QUESTION
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.
Additional Resource
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
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QUESTION
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.
Additional Resource
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Assessment:
Objective data that can be collected include Daniel’s vital signs (blood pressure, temperature, heart rate, respirations, oxygen saturation), physical examination findings (such as shallow breathing, sweating, and achy feeling), laboratory results, and the doctor’s observations and concerns. Subjective data can be collected through talking to Daniel, his mother, and brother Jeff, as well as reviewing his medical history. To collect this data, the nurse can take vital signs, perform a physical examination, review lab results and medical history, and conduct interviews with Daniel and his family. Further evidence that may be needed includes a thorough history of Daniel’s symptoms, including when they began and any precipitating factors, as well as a more in-depth examination of his family history and any previous medical conditions.
Analysis and Identification of the Problem:
Based on the available information, it is possible that Daniel may be experiencing a respiratory or cardiovascular problem, as well as a possible infection. Possible nursing diagnoses include:
Acute pain related to muscle and joint discomfort
Impaired physical mobility related to muscle and joint discomfort
Ineffective airway clearance related to shallow breathing
Risk for impaired tissue perfusion related to high blood pressure
Planning:
Goals:
Daniel will report a decrease in muscle and joint discomfort
Daniel will maintain effective airway clearance
Nursing Interventions:
Administer pain medication as prescribed
Encourage deep breathing and coughing techniques
Monitor vital signs and oxygen saturation
Provide positioning and mobility strategies
Monitor blood pressure and provide appropriate interventions
Assessment:
It is likely that these nursing interventions will be effective in addressing Daniel’s symptoms and improving his overall care. The pain medication will help to alleviate his discomfort, while deep breathing and coughing techniques will help to improve his airway clearance. Monitoring vital signs and oxygen saturation will help to ensure that he is receiving enough oxygen and that his condition is stable. Providing positioning and mobility strategies will help to improve his mobility and reduce his discomfort. And monitoring blood pressure and providing appropriate interventions will help to address his hypertension.
