CASE SCENARIO

A 19-year-old girl presents to the emergency department (ED) with three days of sore throat. She has had associated
headache, nausea, subjective fevers and malaise. Today her headache has been getting worse throughout the day, so she
presented to hospital. She saw her GP 24 hours ago and was started on cefalexin 500 mg four times daily. She has recently
travelled interstate to compete in a triathlon, but has not travelled internationally. She has no known infectious contacts. She
has no known medical diagnoses and takes no regular medications.

NURSING CARE PLAN

PLANNING
ASSESSMEN NURSING IMPLEMENTATIO EVALUATIO
OBJECTIV INTERVENTIO RATIONALE
T DIAGNOSI N N
E OF CARE N
S

Ineffective Assess for signs Early signs of

Airway and symptoms
hypoxia
Clearance in of inadequate
oxygenation. include confusio
relation to
nausea n, irritability,
headaches,

pallor,
tachycardia, and
 Place the tachypnea.
child prone or
Promotes
side-lying
position. drainage
of blood and

unswallowed
saliva from the

mouth that can

potentially be

aspirated.
Discourage the

intake of milk,
These dairy
ice cream, and
products may
pudding.
coat the throat
causing the child

to cough out and
clear the throat.

Encourage the
child to drink
 fluids Hydration
adequately.
loosens thick

secretions or
maintains the

secretions moist
to facilitate easy

removal.

Have a suction
equipment
available at the Suctioning
bedside.
removes clots at
the surgical site

and is done only

during an airway

obstruction due
to risk of

bleeding in the
operative site.
 Teach and
demonstrate
Promotes lung
breathing
exercises. expansion,
enhanced air

exchange and
prevents the risk

of pneumonia.