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ASSESSMENT
Findings include T 102F (38.8C). An acutely swollen and reddened area of the soft palate is noted in her mouth, half occluding the orifice from the mouth into the pharynx. Yellow exudate is present. CBC reveals an elevated WBC of 16,000/mm3. A diagnosis of peritonsillar abscess is made. (continued)
DIAGNOSIS
The following nursing diagnoses are identified for Ms.Wunderman. Acute pain related to swelling Risk for ineffective airway clearance related to pain and swelling Deficient fluid volume related to fever and difficulty in swallowing fluids
EVALUATION
When Ms. Ironhorse contacts Ms. Wunderman by telephone 2 days after her visit to the emergency department, she reports complete relief of symptoms. She is afebrile, taking fluids without difficulty, and has had no difficulty breathing. She has not experienced any pain.
EXPECTED OUTCOMES
The expected outcomes for the plan of care are that Ms. Wunderman will: Have minimal or no pain. Maintain a patent airway as demonstrated by normal respiratory rate and rhythm. Maintain optimal fluid intake as evidenced by consumption of fluids and semiliquid foods, moist mucous membranes, normal skin turgor, and normal temperature.