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PRIORITIZED NURSING PROBLEM FOR PHARYNGITIS

Nursing Diagnosis Nursing Intervention Rationale
1. ACUTE PAIN Independent

Assess the need for pain relief. Preventing the pain is one thing
Acknowledge reports of pain that a patient experiencing it can
immediately. consider. Early intervention may
Get rid of additional stressors or decrease the total amount of
sources of discomfort whenever analgesic required.
possible. One’s perception of time may
Provide rest periods to promote become distorted during painful
relief, sleep, and relaxation. experiences. Pain can be
Determine the appropriate pain aggravated with anxiety and fear
relief method. especially when pain is delayed.
Nonopioids (acetaminophen), a An immediate response to
nonselective NSAID, or a reports of pain may decrease
selective NSAID (e.g., anxiety in the patient.
cyclooxygenase [COX]-2 Demonstrated concern for the
inhibitor) patient’s welfare and comfort
Opioid analgesics fosters the development of
Local anesthetic agents trusting relationship.
1. Cognitive-behavioral Patients may experience an
strategies as follows: exaggeration in pain or a
- Imagery decreased ability to tolerate
- Distraction techniques painful stimuli if environmental,
- Relaxation exercises, intrapersonal, or intrapsychic
biofeedback, breathing factors are further stressing
exercises, music therapy them.
One’s experiences of pain may
become exaggerated as a result
of exhaustion. Pain may result in
fatigue, which may result in
exaggerated pain. A peaceful
and quiet environment may
facilitate rest.
Patients with acute pain should
be given a nonopioid analgesic
around-the-clock unless
contraindicated.
NSAIDs work in peripheral
tissues. Some block the synthesis
of prostaglandins, which
stimulate nociceptors. They are
effective in managing mild to
moderate pain.
Opioids may be administered
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2. RISK FOR Maintain or teach asepsis for
INFECTION dressing changes and wound
care, peripheral IV and central
venous management, and
catheter care and handling.
Wash hands and teach patient
and SO to wash hands before
contact with patients and
between procedures with the
patient. Instances when to wash
hands:
- Before putting on gloves and
after taking them off.
- Before and after touching a
patient, before handling an
invasive device (foley catheter,
IV catheter, and so on)
regardless of whether or not
orally, intravenously,
systemically by PCA systems, or
epidurally (either by bolus or
continuous infusion).
Intramuscular injections are not
reliably absorbed. Opioids are
indicated for severe pain,
especially in the hospice or
home setting.
Local anesthetics block pain
transmission and are used for
pain in specific areas of nerve
distribution.
The aid of an imagined event or
a mental picture involves use of
the five senses to divert oneself
from painful stimuli. Increasing
one’s concentration, these
techniques help an individual
decrease the pain experience.
Breathing modifications and
nerve stimulations are some of
the methods. The aim of these
techniques is to lessen the stress,
tension, subsequently decreasing
the pain.
Aseptic technique decreases the
changes of transmitting or
spreading pathogens to the
patient. Interrupting the
transmission of infection along
the chain of infection is an
effective way to prevent
infection.
Friction and running water
effectively remove
microorganisms from hands.
Washing between procedures
reduces the risk of transmitting
pathogens from one area of the
body to another. Wash hands
with antiseptic soap and water
for at least 15 seconds followed
by alcohol-based hand rub. If
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gloves are used.
- After contact with body fluids
or excretions, mucous
membranes, nonintact skin, or
wound dressings.
- If moving from contaminated
body site to another site during
the care of the same individual.
- After contact with inanimate
surfaces and objects in the
immediate vicinity of the
patient.
- After removing sterile or
nonsterile gloves.
- Before handling medications
or preparing food.
Encourage intake of protein-
rich and calorie-rich foods
Encourage fluid intake of 2,000
to 3,000 mL of water per day,
unless contraindicated.
Encourage coughing and deep
breathing exercises; frequent
position changes.
Recommend the use of soft-
bristled toothbrushes and stool
softeners to protect mucous
membranes.
Limit visitors
Provide surgical mask to
visitors who are coughing and
provide an explanation why.
Instruct:
- Cover mouth and nose during
coughing or sneezing.
- Use tissues to contain
respiratory secretions with an
immediate disposal to a no-
touch receptacle; wash hands
with soap and water afterward.
3. DEFICIENT Render physical comfort for the Based on Maslow’s theory, basic
KNOWLEDGE patient. physiological needs must be
Grant a calm and peaceful addressed before the patient
hands were not in contact with
anyone or anything in the room,
use an alcohol-based hand rub
and rub until dry. Plain soap is
good at reducing bacterial counts
but antimicrobial soap is better,
and alcohol-based hand rubs are
the best.
Helps support the immune
system responsiveness.
Fluids promote diluted urine and
frequent emptying of bladder –
reducing the stasis of urine, in
turn, reduces risk for bladder
infection or urinary tract
infection.
Helps reduce stasis of secretions
in the lungs and the bronchial
tree. When stasis occurs,
pathogens can cause upper
respiratory tract infections and
pneumonia.
These may compromise the
integrity of the mucous
membranes and provide a port of
entry for pathogens.
Restricting visitation reduces the
transmission of pathogens.
Educating visitors on the
importance of preventing droplet
transmission from themselves to
others can help reduce the risk of
infection
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environment without
interruption.
Provide an atmosphere of
respect, openness, trust, and
collaboration.
Include the patient in creating
the teaching plan, beginning
with establishing objectives and
goals for learning at the
beginning of the session.
Consider what is important to
the patient.
Involve patient in writing
specific outcomes for the
teaching session, such as
identifying what is most
important to learn from their
viewpoint and lifestyle.
Explore reactions and feelings
about changes.
Support self-directed, self-
designed learning.
Help patient in integrating
information into daily life.
Give adequate time for
integration that is in direct
conflict with existing values or
beliefs.
Provide clear, thorough, and
understandable explanations
and demonstrations.
Give information with the use
of media. Use visual aids like
diagrams, pictures, videotapes,
audiotapes, and interactive
Internet websites,
Check the availability of
supplies and equipment.
When presenting a material,
start with the basics or familiar,
simple, and concrete
information to less familiar,
complex ones.
Focus teaching sessions on a
single concept or idea.
Pace the instruction and keep
education. Ensuring physical
comfort allows the patient to
concentrate on what is being
discussed or demonstrated.
A calm environment allows the
patient to concentrate and focus
more completely.
Conveying respect is especially
important when providing
education to patients with
different values and beliefs about
health and illness.
Goal setting allows the learner to
know what will be discussed and
expected during the session.
Adults tend to focus on here-
and-now, problem-centered
education.
Allowing the patient to identify
the most significant content to be
presented first is the most
effective.
Patient involvement improves
compliance with health regimen
and makes teaching and learning
a partnership
Assessment assists the nurse in
understanding how the learner
may respond to the information
and possibly how successful the
patient may be with the expected
changes.
Patients know what difficulties
will transpire in their own
environments, and they must be
encouraged to approach learning
activities from their priority
needs.
This technique aids the learner
make adjustments in daily life
that will result in the desired
change in behavior.
Informatiom that is in direct
conflict with what is already
held to be true forces a
reevaluation of the old material
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sessions short and is thus integrated more

When teaching, build on slowly
patient’s literacy skills. Patients are better able to ask
Identify patient’s understanding questions when they have basic
of common medical information about what to
terminology, such as “empty expect.
stomach,” “emesis,” and
“palpation.” Different people take in
Use the teach-back technique to information in different ways.
determine the patient’s Adequate preparation is
understanding of what was especially important when
taught: teaching in the home setting.
- The nurse gives information in This method allows the patient
a caring manner, using plain to understand new material in
language. relation to familiar material.
- Ask the patient to explain in Clearly focuses teaching allows
his or her own words. the learner to concentrate more
- Rephrase the information if completely on material being
unable to repeat it accurately. discussed.
- Again ask the patient to teach- Learning requires energy, so
back the information using his shorter, well-paced sessions
or her own words until the reduce fatigue and allow the
nurse is comfortable that is patient to absorb more
understood. completely.
- If the patient still does not In patients with low literacy
understand, consider other skills, materials should be short
strategies. and have culturally sensitive
Provide preadmission self- illustrations.
instruction materials to prepare Patients are expected to read and
patient for postoperative understand labels on medicine
exercises. containers, appointment slips,
Encourage questions and informed consents.
Provide immediate feedback on The teach-back technique
performance. consists of specific steps in a
Allow repetition of the repetitive order to evaluate the
information or skill. recipient’s knowledge of the
Render positive, constructive content discussed. Patients who
reinforcement of learning are not able to do this method
Incorporate rewards into after multiple cycles is
learning process considered cognitively impaired.
Note progress of teaching and Providing patients with
learning. preadmission information about
Help patient identify exercises has been shown to
community resources for increase positive feelings and the
continuing information and ability to perform prescribed
support. exercises.
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Approach individuals of color Questions facilitate open
with respect, warmth, and communication between patient
professional courtesy.
and health care professionals and
allow verification of
understanding of given
information.
Immediate feedback allows the
learner to make corrections
rather than practicing the skill
wrongly.
Repeated practice allows patient
gain confidence in self-care
ability.
A positive approach by the
patient will help him or her feel
good about learning
accomplishments, gain
confidence, and maintain self-
esteem.
Rewards help to make learning
fun and exciting.
Documentation allows additional
teaching to be based on what the
learner has completed
Learning occurs through
imitation, so persons who are
currently involved in lifestyle
changes can help the learner
anticipate adjustment issues.
Community resources can offer
financial and educational
support.
Instances of disrespect and lack
of caring have special
significance for individuals of
color.
References: