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.
Expert Solution Preview
Introduction:
As a medical professor, the nursing process is a crucial part of medical education. It involves a systematic approach to patient care that is patient-centered and evidence-based. In this case study, we are presented with the case of Daniel, a 16-year-old boy who was admitted to the hospital for observation after fainting. In this assignment, we will apply the nursing process to this case study, including assessment, analysis, identification of the problem, planning, and evaluating nursing interventions.
Assessment:
Objective data that can be collected include Daniel’s vital signs, laboratory results, and observation of his breathing pattern, fever, and blood pressure, as well as noting signs of dehydration such as dry mouth or skin. Subjective data can be obtained through interviewing Daniel and his family to get more information on Daniel’s medical history, any pre-existing conditions, current symptoms, and any medication or drug allergies.
Further evidence that is needed includes a detailed medical history, more in-depth physical examination, and consultation with other healthcare professionals such as a cardiologist or neurologist.
Analysis and Identification of the Problem:
Daniel’s problem(s) could be related to his fainting episode, recent fatigue, fever, abnormal laboratory results, and high blood pressure. Potential nursing diagnoses could include Risk for Injury related to Syncope, Fatigue related to potential medical conditions, Risk for Infection related to fever, and Risk for Hypertension related to high blood pressure.
Planning:
Goal 1: Reduce the risk of falls and injuries caused by syncope by maintaining a safe environment and educating the patient and family on preventing future episodes. This can be achieved by eliminating slipping or tripping hazards.
Intervention: Teach the patient and family on proper fall prevention techniques such as sitting down slowly and holding onto a support surface, staying hydrated, and disclosing when feeling lightheaded or dizzy.
Goal 2: Facilitate healing and reduce the risk of infection by monitoring and assessing vital signs, administering any prescribed medications, and providing hygienic care.
Intervention: Monitor vital signs to detect fever and infection early, provide proper hygiene, such as hand-washing, and assist with medications.
Evaluation:
The nursing interventions mentioned would form a part of a larger care plan, which is evaluated regularly by healthcare professionals. These interventions can help improve the patient’s overall health and condition. However, it is important to note that evaluating a nursing intervention would require careful and regular monitoring.
