Additional Data
I would like to ask the patient additional questions to obtain more subjunctive data for the diagnosis to be appropriate. I want to know if she had similar symptoms before and how long they lasted. As the woman has an allergy, I wonder if some of the mentioned symptoms are observed at certain times of the year. I am also concerned about her previous reoccurring respiratory tract infections or traumas. Finally, I want to know if she smokes or lives in an area with highly polluted air. I also want to get some additional objective data. For example, if the woman has nasal polyps that can be connected with nasal congestion. Maybe she suffers from infection because of dentition issues.
Tests
I would like to make the patient take a throat culture test to check if the symptoms are caused by streptococcal infection. Rather often a sore throat and fever are explained by it. I also want to order a blood test for mononucleosis if the first one turns out to be negative. A complete blood count may be needed if the reason for symptoms remains unidentified because it provides the most extended information (Martel & Cherney, 2015).
Diagnoses
Before making a final decision regarding the patient’s diagnosis, I want to develop a list of differential diagnoses. It can include the following:
- Pharyngitis
- Retroviral syndrome
- Allergic rhinitis
- Mononucleosis
- Airway obstruction
Considering the patient’s symptoms, I believe that the most appropriate medical diagnosis is pharyngitis. Nursing diagnosis for it includes:
- Acute pain. The inflamed throat is mainly characterized by it.
- Ineffective airway clearance. Secretions and their consistency prevent the patient from breathing easily.
- Imbalance nutrition. The woman is likely to eat less because of the pain she experienced while swallowing.
- Knowledge deficit. The patient should be able to obtain all required information regarding her condition (Michaelmjc, 2012).
Plan of Care
First of all, I want to help the patient to cope with pain, so I will administer an analgesic. I will add saline gargles and ask the woman to drink more, monitoring her actions and condition. I will offer a soft diet and educate the patient considering her issue. If a streptococcal infection is identified, I will encourage the patient’s family to take a test. I will prescribe antibiotics if bacterial pharyngitis is proved because, in this situation, possible adverse reactions tend to be less critical than complications caused by the disease. In the case of strep infection, alternative treatment is not likely to be effective. However, some benefits of changes in nutrition (vitamins) and herbs intake (garlic or ginger tea) can have positive effects.
Health Education
I will focus patient education on the causes of a sore throat and symptomatic treatment so that the woman will be able to identify the issue and provide initial care. I will also discuss treatment peculiarities and side effects. Additionally, I will teach her to maintain reexamination and reduce risks for her child. Even though various complementary therapies are possible, I will incorporate only those that can be easily maintained at home for the woman not to face difficulties.
Connection to Healthy People 2020
Healthy People 2020 does not discuss pharyngitis in particular. However, it can be considered in the framework of antibiotic prescribing because research shows that a lot of individuals obtain unnecessary antibiotic treatment that has potential harm to their health. Professionals tend to monitor this issue to define how they can reduce antibiotic intake and related expenditures (CDC, 2016).
References
CDC. (2016). Measuring outpatient antibiotic prescribing. Web.
Martel, J., & Cherney, K. (2015). Pharyngitis. Web.
Michaelmjc. (2012). Nursing diagnosis for pharyngitis. [Web log comment]. Web.