Question

Module 04 Written Assignment Nursing Process - Case Study
Please read the following case study and complete the questions below.

Daniel is a 16 year old boy who is an identical twin. He and his brother Jeff are very close and do most things together. While Daniel excels at sports he believe his brother is much better at most everything. Daniel, his brother, and their two sisters live with their parents in the Midwest. Recently Daniel has been feeling more tired than usual. He thought it was because of his schedule and school work, which he is fairly good at. He gets mostly Bs, but his grades have been slipping of late. One day he fainted while getting ready for a game. His coach called his parents to let them know Daniel was taken to the Emergency Room. While there the doctor decided to admit Daniel to the hospital for observation. At the time he was running a slight fever, his breathing was shallow, and he was sweating. He was also very sleepy and his blood pressure was high. He did have some abnormal laboratory work, but his doctor was not too concerned at present. Daniel also stated that he felt achy.

You are assigned to take care of Daniel today and when you walk into his room, his mother and brother Jeff are there. Daniel appears to be sleeping. In your written assignment, respond to the following questions applying the nursing process:

Assessment: What type of objective and subjective data can you collect with what you know? How will you collect these data? What further evidence do you need?

Analysis and Identification of the Problem: What do you believe Daniel's problem(s) are? What might be the nursing diagnoses? Use the following for identification.

Planning: Identify two goals and one nursing intervention for each, based on your nursing diagnoses.

While you will not be able to implement or evaluate, how well do you think your nursing interventions might help with Daniel's care.

Answer 1

Assessment:

Objective data:

• sweating
• fever
• high blood pressure
• shallow breathing

Subjective data:

• Ache
• tiredness
• breathing difficulty

These data can be collected by asking questions to Daniel and from his brother, mother. We can evidence it by observing Daniel.

Analysis and identification of the problem:

• Dehydration may be a cause as the physical activity would result in this.
• Hypoglycemia may be a cause as he does not meet his energy needs.

Nursing diagnosis:

Fluid volume deficit related to loss of sweating as evidenced by increased physical activity.

Hypoglycemia related to increased energy needs as evidenced by sweating.

Nursing goal and intervention:

To maintain a normal temperature.

• Encourage to drink plenty of fluids.
• Give adequate rest.

To maintain normal blood pressure and glucose level.

• Maintain intake and output chart.
• Monitor the BP level.
• Provide a balanced diet.

Monitoring of his vital signs and documentation helps to compare the improvement in his health. Health education to Daniel and the planning of his daily schedule help him to avoid tiredness. Adequate diet and plenty of fluids to meet his energy needs.