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.
Full Answer Section
Subjective Data:
- (Speak to patient when awake)
- Feeling tired than usual
- Feeling achy
- Sleepiness
- History of school and sports participation
- Relationship with family and brother
- Any recent illnesses or exposures
- Medications or supplements consumed
Data Collection:
- Vital signs monitoring - temperature, pulse, respirations, blood pressure
- Physical examination - assess skin, heart sounds, lung sounds, and any pain or tenderness
- Review laboratory results and discuss with doctor
- Interview Daniel when awake - ask open-ended questions to gather comprehensive information about his symptoms and concerns
- Talk to Daniel's mother and brother to gather additional information about his history, recent events, and behavior
Further Evidence:
- Imaging studies like chest X-ray or CT scan depending on suspected diagnosis
- Additional blood tests based on initial results
- Electrocardiogram (ECG) to assess heart rhythm
- Sleep study if excessive sleepiness is a concern
Analysis and Identification of the Problem:
Possible Nursing Diagnoses:
- Risk for Ineffective Tissue Perfusion: High blood pressure, sweating, and altered mental status raise concern for decreased blood flow to vital organs.
- Fatigue: Lethargy, decreased energy, and fainting suggest underlying fatigue.
- Altered Tissue Perfusion related to [insert specific cause] as evidenced by [specific assessment findings]: Tailor this diagnosis after gathering more information and ruling out specific causes.
- Potential Stress and Anxiety related to [insert specific factors] as evidenced by [specific assessment findings]: Schoolwork, competition with brother, and recent hospitalization might contribute to stress.
- Knowledge Deficit related to [insert specific topic] as evidenced by [specific lack of knowledge]: Lack of understanding about his condition and treatment plan could negatively impact recovery.
Planning:
Nursing Diagnosis 1: Risk for Ineffective Tissue Perfusion
Goal 1: Maintain adequate blood pressure within normal range.
- Intervention 1: Monitor vital signs frequently and report any significant changes to the doctor.
- Intervention 2: Assist with positioning and activities to promote optimal blood flow.
- Intervention 3: Provide education on the importance of maintaining blood pressure control.
Goal 2: Improve oxygenation and tissue perfusion.
- Intervention 1: Administer oxygen as prescribed by the doctor.
- Intervention 2: Encourage deep breathing exercises and mobilization as tolerated.
- Intervention 3: Monitor for signs of respiratory distress and report any concerns to the doctor.
Nursing Diagnosis 2: Fatigue
Goal 1: Improve quality and quantity of sleep.
- Intervention 1: Establish a regular sleep schedule and promote a relaxing bedtime routine.
- Intervention 2: Create a quiet and comfortable sleep environment.
- Intervention 3: Educate Daniel on healthy sleep hygiene practices.
Goal 2: Increase energy levels and reduce fatigue.
- Intervention 1: Encourage a balanced diet with adequate hydration.
- Intervention 2: Assist with activities of daily living (ADLs) as needed and gradually increase activity level as tolerated.
- Intervention 3: Monitor for signs of overexertion and encourage periods of rest.
Rationale for interventions: Each intervention is targeted to address the specific needs identified in the nursing diagnoses. By monitoring vital signs, promoting optimal blood flow, and educating the patient, we aim to minimize the risk of complications from high blood pressure. Similarly, encouraging sleep hygiene practices and managing activity levels can significantly improve energy levels and reduce fatigue.
Evaluation: The effectiveness of these interventions will be assessed by monitoring for improvements in Daniel's blood pressure, oxygenation, sleep quality, and energy levels. Regular assessment and communication with the doctor are crucial to adapt the plan based on his progress and response to treatment.