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.
Full Answer Section
Subjective Data:
- Ask Daniel:
- How are you feeling overall?
- How long have you been feeling tired?
- Have you noticed any other symptoms (chills, headache, cough, muscle aches)?
- Is anything making your symptoms worse or better?
- How is your sleep quality?
- Are you stressed or having any emotional concerns?
- Does anything hurt?
- Ask Daniel's mother and brother:
- Have you noticed any changes in Daniel's behavior or mood?
- Has he experienced any other symptoms you haven't mentioned?
- Is there any family history of medical conditions?
Further Evidence:
- Depending on the initial assessment, further investigations might be needed such as chest X-ray, EKG, additional blood tests, or specific scans based on suspicion of underlying conditions.
Analysis and Identification of the Problem:
Possible Nursing Diagnoses:
- Fatigue related to underlying medical condition (as evidenced by tiredness, fainting, sleepiness, and possibly abnormal lab results)
- Anxiety related to recent health changes (as evidenced by possible sleep problems, worry about performance, and potential pressure from comparing himself to his brother)
- Acute pain related to muscle aches (as reported by Daniel)
Note: These are initial diagnoses based on limited information. Further assessment and analysis are needed to confirm or refine the diagnoses.
Planning:
Goal 1: Manage Daniel's fatigue and identify the underlying cause.
- Nursing Intervention 1: Monitor vital signs and oxygen saturation frequently.
- Rationale: Early detection of changes in vital signs can indicate worsening of the underlying condition or potential complications.
- Nursing Intervention 2: Encourage adequate sleep and rest periods.
- Rationale: Rest helps the body recover and can improve energy levels.
Goal 2: Reduce Daniel's anxiety and provide emotional support.
- Nursing Intervention 1: Create a calm and supportive environment, listen to his concerns, and offer reassurance.
- Rationale: A calm environment and a listening ear can help reduce anxiety and promote a sense of security.
- Nursing Intervention 2: Encourage open communication with family and friends, especially his brother Jeff.
- Rationale: Social support can help Daniel cope with emotional stress and feel less alone.
Goal 3: Manage any pain and discomfort Daniel might be experiencing.
- Nursing Intervention 1: Assess pain location, severity, and any aggravating or relieving factors.
- Rationale: Understanding the characteristics of pain helps in choosing appropriate pain management strategies.
- Nursing Intervention 2: Implement non-pharmacological pain relief measures such as warm compresses, massage (if appropriate), and distraction techniques.
- Rationale: These measures can help to reduce pain without potential side effects of medications.
Effectiveness of Interventions:
These interventions are likely to be helpful in managing Daniel's symptoms and improving his well-being. Regular monitoring and reassessment will be crucial to evaluate the effectiveness of the interventions and adjust them as needed. Additionally, collaborating with the physician and other healthcare professionals will be essential for diagnosing the underlying cause of Daniel's symptoms and determining the most appropriate treatment plan.