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Additional subjective data
The overall picture seems clear; however, there might be a certain need for some additional information. The patient should also say how she feels in the mornings and whether her throat is stronger after eating and heartburns. Additionally, it is also important to get to know whether she suffered from supercooling.
Additional objective data
Besides, numerous illnesses might start with a sore throat. For this reason, additional objective data is needed. It is vital to notice whether her movements are free or complicated. It might provide the information needed for better diagnosis and positive outcomes. Thus, the greater part of the objective data has already been collected.
Tests
First, the blood test to understand whether there is any inflammatory state of not is needed. Biochemical blood assay will also provide information about the general state of the patients health. Moreover, it helps to admit the presence of an allergic response. Uroscopy is also crucial to monitor the functioning of various systems and determine the first signs of any severe disease. Finally, throat smear is also crucial as it will show the organisms responsible for the appearance of these symptoms.
List of working differential diagnoses
The given set of complaints might be peculiar to different illnesses. For this reason, several differential diagnoses could be suggested at this stage of examination
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allergic response
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rhinovirus
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Viral Pharyngitis
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adenovirus
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influenza
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Bacterial Pharyngitis
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tonsillitis
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GERD
Medical and nursing diagnoses
There are several nursing diagnoses peculiar to the above-mentioned symptoms. These are acute pain, disturbed sleep pattern, hyperthermia, anxiety, imbalanced nutrition, ineffective airway clearance, knowledge deficit (NANDA, n.d.). All these nursing diagnoses revolve around a sore throat and demand a specific care plan. As for medical ones, the results of the above-mentioned tests will show the problem and state what kind of disease it is. Thus, resting on the given data, the most probable diagnosis is GERD as the patient also suffers from heartburn which is one of the symptoms of this disease.
Plan of care
In case GERD is diagnosed, there is a certain treatment and care plan that should be recommended. First, non-prescription antacids and acid reducers might be recommended to relieve pain that comes from heartburn (“GERD. Treatment and care”, n.d.). It will also result in a decrease of pain in a throat as the acid that comes from the stomach is one of the main causes of it. Thus, there is no need for antibiotics as the symptoms are not caused by any bacteria.
Complementary therapies
The patient might also be recommended some complementary therapies. She should alter her food habits as some products trigger the appearance of these reactions. Moreover, fermented milk products could also be offered as they decrease the risk of heartburn and have a positive impact on all digestive organs.
Health education
There is also the need for information about the main causes that result in the appearance of heartburns and the negative impact GERD might have on the quality of life of an individual.
Patient teaching
The patient should be taught how to struggle with the first symptoms of GERD and how to choose products that will help to avoid any complications or new appearances of these symptoms.
Complementary therapies and the plan of care
Thus, complementary therapies should also be incorporated in the plan of care as they might contribute to the improved outcomes and increase the quality of the patients life.
Healthy People 2020 objectives
Finally, investigating the case in terms of Healthy People 2020, it is possible to conclude that its objectives in food safety (“Food safety”, n.d.) and oral health contribute to the great importance of this situation.
References
Food safety. (n.d.). Web.
GERD. Treatment and care. (n.d.). Web.
NANDA. (n.d.). The complete list of NANDA nursing diagnosis. Web.
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