Help to recognize 2 actual diagnosis and 1 risk

[mahaX1]

SCENARIO:

A 10-year girl was brought to the clinic with complaints of high grade fever of 40 C, throat pain and difficulty of swallowing. Upon inspection, redness and swelling of bilateral tonsils were noted accompanied with tender lymph nodes on the sides of the neck. RR 31 bpm, HR 109 bpm and SpO2 96.  

I want a help to recognize 2 actuals diagnosis and 1 risk

is Impaired swallwoing R\T throat pain amb tender lymph nodes and swelling and redness of tonsils  right??

 

[Hannahbanana, BSN, MSN]

When you look at this child, what do you see?

A fever, a very sore throat, a parent, inability to take PO well, fear, pain, do you worry about her airway, how long has she been sick, does her parent/guardian know about signs to look out for ...? Look in your NANDA-I for nursing diagnoses that include findings on these factors.

You make a nursing dx the same way a physical therapist makes a diagnosis or a physician makes a diagnosis: by observing symptoms and coming to a conclusion and deciding on a plan of care. You will be making a nursing plan of care based on your nursing observations and decisions.

What do you see, nurse? What does nursing have to do, independent of what a physician prescribes (which the nurse or others have to implement anyway)?

[amoLucia]

I'd also be looking at that temp - 40 degrees C equals 104 F.

That scares me. My kid sister was a febrile convulsive as a child - and she didn't need to hit 104 before full-blown seizures. One of the most significant memories (and understanding of seizures) occurred when I watched her seize once (she was about 4 yo and I was 8). I still see her in my mind's eye flopping like a rag doll in my Dad's arms. Have never forgotten it.

[Hannahbanana, BSN, MSN]

Well, since we didn’t answer the homework question but only led her to a better way to work on it herself (teach a man to fish and all that) , I guess she’s not coming back. Sigh.