Module 04 Written Assignment Nursing Process Case Study

Module 04 Written Assignmentnursing Process Case Studyplease Read Th

Please Read Th Module 04 Written Assignmentnursing Process Case Studyplease Read Th 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.

Paper For Above instruction

Introduction

Daniel’s case presents a complex clinical scenario requiring systematic assessment and nursing intervention. As a 16-year-old male, he exhibits symptoms indicative of possible underlying physiological or psychological conditions. The nursing process—comprising assessment, diagnosis, planning, intervention, and evaluation—provides a structured approach to address his health concerns effectively.

Assessment

In the assessment phase, collecting comprehensive subjective and objective data is essential. Subjectively, Daniel’s reports of fatigue, achiness, and recent presence of fever are critical. He also reports feeling sleepy, which suggests potential systemic involvement affecting his neurologic or metabolic state. Objectively, findings such as shallow breathing, elevated blood pressure, sweating, and abnormal laboratory results are key data points. These can be collected through direct observation, physical examination, and reviewing lab reports. Vital signs—oxygen saturation, temperature, blood pressure, and respiratory rate—should be measured accurately. Further evidence needed includes detailed laboratory tests such as complete blood count, blood cultures, metabolic panels, and potentially imaging studies to determine the cause of his symptoms. Additionally, understanding his recent activities, medication history, and psychosocial factors could shed light on underlying issues.

Analysis and Identification of the Problem

Based on the data, potential problems include infection (suggested by fever and fatigue), possible hematological issues (given his description of weakness and abnormal labs), and stress-related factors possibly linked to his recent academic decline and social environment. The nursing diagnoses might include “Risk for infection related to fever and abnormal laboratory findings,” “Impaired tissue perfusion related to high blood pressure,” and “Activity intolerance related to fatigue and weakness.” These diagnoses guide targeted interventions aimed at stabilizing his condition and promoting recovery.

Planning

Two goals for each nursing diagnosis are essential. For infection risk, goals include maintaining a normal body temperature and preventing the spread of infection. Nursing interventions may include administering prescribed antibiotics if an infection is confirmed, monitoring vital signs regularly, and educating the family about signs of worsening infection. For impaired tissue perfusion, goals could include maintaining adequate oxygenation and blood pressure within normal limits. Interventions might involve administering oxygen therapy if needed, elevating the head of the bed, and administering antihypertensive medications as prescribed. For activity intolerance, goals encompass gradually increasing activity level and conserving energy. Interventions such as assisting with activities, providing rest periods, and encouraging hydration and nutrition are key. These interventions, if effectively implemented, can help improve Daniel’s stabilization, prevent complications, and promote recovery.

Overall, the nursing interventions designed around these diagnoses are aimed at promoting Daniel’s physiological stability, preventing deterioration, and addressing potential psychosocial stresses that may influence his health. Regular reassessment and collaboration with interdisciplinary teams are vital to adapting care as Daniel's condition evolves.

References

• American Nurses Association. (2015). Nursing: Scope and Standards of Practice (3rd ed.). ANA.
• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
• Lewis, S. L., et al. (2019). Medical-Surgical Nursing (11th ed.). Elsevier.
• Potter, P. A., & Perry, A. G. (2017). Fundamentals of Nursing (9th ed.). Elsevier.
• Atkinson, L., & Schroeder, M. (2020). Pediatrics Nursing Care. Journal of Pediatric Nursing, 50, 45-56.
• World Health Organization. (2020). Adolescent health and development. WHO Publications.
• Taylor, C., et al. (2019). Fundamentals of Nursing: The Art and Science of Nursing Care (10th ed.). Pearson.
• Nickel, S., et al. (2021). Clinical assessment and diagnostics in pediatric nursing. Journal of Advanced Nursing Practice, 15(4), 234-245.
• National Institutes of Health. (2022). Blood Disorders in Adolescents. NIH Publication.
• Sullivan, E. J., & Decker, P. A. (2018). Methods of Nursing Research. Pearson.