NURSING CARE PLAN

Date/Shift Assessment Need Nursing Diagnosis Objective of Nursing Intervention

Care

10-02-20 Subjective cues: P Altered comfort: pain After 5 hours of Independent:

7/3 “ga sakit akong S related to throat nursing  Provide Comfort meaures (eg. Touch, repositioning, use of
8am tutunlan dong Y inflammation. interventions, heat/cold packs, nurses presence, quiet environment, and
maglisud kog C the patient will calm activities).
tun” as H R. Tonsillitis is an be able to: R. To promote nonpharmacological pain management.
verbalized by O infection at the  Encourage verbalization of feeling about pain.
patient. L tonsils. Streptococcus  Lessen pain R. Relieve feeling of discomfort.
O is the most common discomfort  Encourage adequate rest periods.
Objective cues: G infecting organism by relaxation R. To prevent fatigue.
 Increased I although tonsillitis skills and  Work with patient to prevent pain, therapeutic interventions,
tension C can be caused by divertional response, and length of tie before pain recurs.
NEED hemophilus influenza activities. R. To maintain acceptance level of pain notify physician if regimen
 Restlessness and other organism is inadaquete to meet pain control goal.
Rest and sleep the client with  Accept patients description of pain acknowledge the pain
 Enlarge and tonsillitis. Report experience and convey acceptance of clients response to pain.
inflammed Maslow’s throat pain difficulty R. Pain is a subject experience it cannot be felt by others.
tonsil both hierarchy in swallowing oflagin  Encourage divertion activities (Socialization with others).
with (referred pain to the R. To distract attention and reduce tension.
exudates ear) and generalized  Admister analgesics as indicated, to maximum dosage, as
 Pain scale of malaise-examination needed.
6/10 discloses an acutely
R. To maintain accptance level of pain.
 Difficulty on inflammed mucous
swallowing  Identify specific signs/symptons and changes in pain
membrane around the
 Fever tonsillar area with or characteristics requiring medical follow-up.
 Vomiting without the presence R. To determine patients conditions
 Odynophagi of purulent exudate.
a REF: NANDA
SOURCE:
 V/S taken as Medical Surgical
follows: Nursing 6th edition
T- 37.2 by Joyce M. Black
P- 92 page 1678.
R- 22
Bp- 110/90