NURSING CARE PLAN

DATE ASSESSMENT NURSING NEED PLAN INTERVENTION EVALUATION

AND DIAGNOSIS
TIME
OF
SHIFT

Aug Subjective Impaired oral H Within 5 hours of 1. Establish rapport Within 5 hours of
09, data: mucous E nursing intervention, R: Establishing rapport develops a nursing intervention, the
2022 “Nurse, membrane A the patient will be cordial relationship between the patient was able to:
malisudan ko og related to L able to: client and the attending nurse,
7am-3 kaon tapos sakit infectious T which leads to better GOAL MET
communication and patient care.
pm akong tutunlan process as H - Understand
inig mutulon.” evidenced by the etiology - Passed food/fluid
2. Monitor the vital signs, saturation
as verbalized by inflamed P and levels at regular intervals
from mouth to
the patient tonsillitis E management R: To identify the complication and stomach safely.
R of tonsillitis provide essential intervention. - Maintained
Objective Data: Rationale: C - Improve his adequate
- Reddened Tonsillitis is E condition and 3. Give and instruct the prescribed hydration as
tonsil an P recurrence of medication by the doctor to the evidenced by
- T: 376.3 C inflammation T the infection patient such as antibiotics for the good skin turgor
- PR: 108 bpm of the tonsils I will be infection even if symptoms subside. and moist
- RR: 25 cpm caused by an O avoided R: To completely destroy mucous
infection. In N bacteria. This also prevents the membranes.
tonsilitis, the resistance of the bacteria from
tonsils are / the antibiotic.
enlarged, red,
and often H 4. Instruct the patient to avoid
coated (either E eating sweets and cold
partly or A beverages.
entirely) by a L R: Bacteria proliferate faster in
substance T sweet environment
that is yellow, H
gray, or 5. Encourage the patient to do a
white. M tepid sponge bath in case fever
Tonsillitis A persists.
usually N R: Tepid sponge bath decreases
occurs as A the body’s temperature through
part of G conduction.
pharyngitis E
(throat M 6. Promote oral fluid intake
infection). E R: Without proper nutrition and
Tonsillitis N hydration the oral mucosa is
usually T more vulnerable to damage. This
begins with will also prevent dehydration.
sudden sore
throat and 7. Advise patient to gargle with a
painful solution of warm water and salt
swallowing. R: This relieves the patient’s
sore throat. Although this is only
short-lived.
Source:
https://www.n 9. Educate the patient regarding
hs.uk/conditio the importance of compliance to
ns/tonsillitis/# given medication.
:~:text=Tonsill R: for the patient to gain more
itis%20is%20 understanding about the
an%20infecti treatment being given to him.
on%20of,adul
ts%20can%2 10. Instruct the patient or the
0get%20it%2 family to limit the patients
0too. exposure to persons with
respiratory infection
R: To reduce the potential spread
 of droplets between patients and
to avoid worsening of the
patient’s condition.

Physical Assessment: