Question

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.

Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales

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.

Answer 1

1) subjective data:

Client point of view symptoms:

1) breathing difficulty.

2)sweating.

3)tiredness.

4) weakness.

Objective data: observable and measurable data:

1) fever.

2)high blood pressure.

3)sweat.

4) abnormal lab investigation.

Goals:

1) to prevent complications.

2)to reduce fever.

3) provide comfort.

4)provide psychological support.

5) maintain normal blood pressure.

Diagnosis: asthma.

Nursing diagnosis:

1) ineffective breathing pattern is related to disease condition.

2) impaired skin integrity is related to disease condition.

3) high blood pressure is related to excessive sweating as evidenced by checking vital signs.

4) tiredness is related to excercise as evidenced by observation.

5) fever is related to infection in the body as evidenced by lab investigation.

Planinng:

It is depends on patient symptoms...

1)administer oxygen to maintain breathing pattern.

2)cold sponge should be given to reduce temperature.

3) administration of antibiotics to prevent infection.

4)to provide bed rest to relieve tiredness.

5)to check vital signs Every hour.

6) to maintain intake and output chart.

7) to provide psychological support to the family members.

Implementations:

1) administered oxygen to relieve breathing difficulty.

2)cold sponge is given to Daniel to relieve fever.

3) vital signs are checked every hourly.

4)maintained intake and output chart.

5) provided psychological support to the family members.

6) provided bed rest to relieve tiredness.

7) administered antibiotics to prevent infection.

Evaluation:

Patient relieved from fever , tiredness,breathlesness.