NUR 2115 Module 4 Assignment Nursing Process Daniel Case Study- Rasmussen College
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NUR 2115 Module 4 Assignment Nursing Process Daniel Case Study- Rasmussen College/NUR 2115 Module 4 Assignment Nursing Process Daniel Case Study- Rasmussen College/NUR 2115 Module 4 Assignment Nursing Process Daniel Case Study- Rasmussen College/NUR 2115 Module 4 Assignment Nursing Process Daniel C...
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Rasmussen College
Fundamentals of Professional Nursing
Module 4 Assignment Nursing Process Case Study
1. What is the objective data?
• Daniel is a 16-year-old boy who is an identical twin.
• Daniel, his brother, and their two sisters live with their parents in the Midwest.
• He fainted while getting ready for a game.
• He was running a slight fever, diaphoretic, lethargic, hypertensive, and breathing
shallow while in the ER.
• He did have some abnormal lab work.
• Daniel’s grades have been slipping.
2. What is the subjective data?
• Daniel believes his brother is much better at most everything.
• Daniel has been feeling more tired than usual.
• Daniel felt achy.
3. What further evidence would you need to gather in your patient interview?
I would want to wake up Daniel for the patient interview because, even though he is still a
pediatric patient, I believe that he is old enough to speak for himself and is the best source to
find out how he has been feeling and what has been going on. I would also need to wake him
up to determine if he is alert and oriented. If he isn’t arousable, then we would have a bigger
issue to worry about.
I would first ask if he’s taking any medications, if he has any significant health history, or family
health history. I would then inquire when exactly Daniel’s symptoms began. I would ask if he
experiences his symptoms after anything specific, such as practice or a game, or if they are
generally ongoing and always there.
I would ask him how he likes school and his sports, what his favorite subject is, etc. to assess if
these might be causing him a lot of stress or if he feels like he is under a lot of pressure. I would
ask the family members to step out of the room to provide privacy and encourage trust
between myself and the patient. At this time, I would ask if he is sexually active, if he has been
experimenting with any drugs, if he feels safe at home, and if he has any thoughts of hurting
himself or others. While conversing with Daniel, l would also pay attention to his body language
and affect.
I would also inquire about his eating habits and if he is drinking enough water, especially since it
is known that adolescents don’t always have the best eating habits and since he is an athlete,
it’s important that he is fueling his body appropriately [Sch151]. Additionally, I would want to
know how much sleep he’s getting and if he has experienced any weight loss.
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