Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: S. Age:14 years old Gender: Female Date Handled: February 22, 2021
Medical Diagnosis: Tonsilitis Chief Complaint: Pwede si Mama na lang sumagot for me please? Addressing Pain by evasion to answer the question
Assessment Nursing Diagnosis Planning Intervention RATIONALE EVALUATION

Subjective: Acute pain r/t STG Independent: At the end of 8 hours of nursing
“Pwede si Mama tonsilitis At the end of 5 ˃ provide support to the intervention the patient
na lang sumagot minutes of nursing patient described the pain 1/10 in the
for me please?” intervention the ˃ teach patient to do deep pain scale.
Suggesting a pain patient will breathing
that she is feeling demonstrate use of ˃ monitor vital signs
relaxation skills. ˃encourage verbalization of
therefore
LTG feeling about the pain/ take
recommending her At the end of 8 pain scale -serve as baseline
mother to answer hours of nursing
the questions intervention the Dependent: -to monitor the status of the
needed to be client will described ˃ administer pain reliever as patient
answered 1/ 10 in the pain ordered
scale
Objective:
Quiet
Grumpy -to lessen the pain with the
Withdrawn help of medication
Faint symptoms
Oral physical
examination:
Presence of blood
in a corner of one
of the tonsillar
fossa
Presence of
developing large
clot overlying one
of the tonsil beds
which might
require an
operation