(Solved) NUR2115 Module 04 Written Assignment Nursing Process Case Study | Homework Solution
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Module 04 Written Assignment Nursing Process Case Study
Module 04 Content
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.
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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: Module 04 Written Assignment
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.
SAMPLE ANSWER;
Assessment:
Objective Data:
- Physical observations: Daniel appears tired, fainting episode, shallow breathing, sweating, high blood pressure, slight fever.
- Laboratory results: Abnormal lab work (specifics not provided).
Subjective Data:
- Daniel’s feeling of fatigue and tiredness.
- His perception of his brother being better at most things.
Collecting Data:
- Perform a thorough physical assessment to monitor vital signs, including blood pressure, temperature, respiratory rate, and heart rate, Module 04 Written Assignment.
- Conduct a head-to-toe assessment to evaluate any signs of distress, such as pallor, diaphoresis, or abnormal skin findings.
- Obtain a detailed medical history from Daniel and his family, focusing on recent changes in health, any underlying conditions, and family history, including any history of fainting episodes or cardiac issues.
- Inquire about Daniel’s recent activity level, sleep patterns, and dietary habits to assess his overall lifestyle.
- Review Daniel’s recent academic performance and any stressors he may be experiencing, including feelings of inadequacy compared to his brother.
Further Evidence Needed:
- Detailed information on the abnormal laboratory results to assess any underlying conditions, such as electrolyte imbalances or metabolic disturbances. Module 04 Written Assignment
- Psychological assessment to explore Daniel’s feelings of inferiority compared to his brother and any potential stressors contributing to his fatigue, including academic pressure or social concerns.
Analysis and Identification of the Problem:
Daniel’s Problems:
- Fatigue and tiredness: Daniel’s recent onset of fatigue, coupled with his fainting episode and shallow breathing, suggests a potential underlying health issue contributing to his fatigue.
- Fainting episode and abnormal laboratory results: Daniel’s fainting episode, along with his abnormal laboratory results and high blood pressure, indicate a need for further investigation into possible cardiac or metabolic abnormalities.
Nursing Diagnoses:
- Risk for Imbalanced Nutrition: Less Than Body Requirements related to fatigue and decreased appetite.
- Risk for Injury related to fainting episodes and altered level of consciousness.
- Anxiety related to health concerns and academic performance. Module 04 Written Assignment.
Planning:
Goals:
- Daniel will maintain adequate nutrition and hydration levels to support his recovery and overall well-being.
- Nursing Interventions: a. Collaborate with the dietitian to develop a nutritional plan tailored to Daniel’s preferences and dietary needs. b. Provide education to Daniel and his family on the importance of balanced nutrition and hydration, emphasizing the consumption of nutrient-rich foods and fluids. c. Monitor Daniel’s dietary intake and hydration status, offering assistance and encouragement as needed to ensure adequate intake. Module 04 Written Assignment
- Daniel will remain safe and free from injury during his hospital stay.
- Nursing Interventions: a. Implement fall prevention measures, such as keeping the bed in the lowest position, ensuring call bell accessibility, and providing non-slip footwear. b. Conduct regular neurovascular checks to assess Daniel’s neurological status and detect any signs of impending fainting episodes. c. Educate Daniel and his family on recognizing warning signs of fainting, such as dizziness, lightheadedness, Module 04 Written Assignment or palpitations, and instruct them on appropriate actions to take, including lying down and elevating the legs.
The effectiveness of these nursing interventions depends on various factors, including Daniel’s compliance, underlying health conditions, and the presence of supportive family and healthcare team. However, by addressing his nutritional needs and ensuring safety measures, these interventions aim to improve Daniel’s overall well-being and reduce the risk of complications during his hospitalization.
