Assessment Nursing Planning Intervention Rationale evaluation

Diagnosis
Objectives: > Acute pain >with 8 hours of >assess v/s >provide >goal was fully
>”masakit lagi related to nursing record. baseline data for met as evidenced
yung lalamunan inflammation of intervention, the comparison in by verbal report
nya, lalo na pag tonsils secondary pt. will report a rates may that pain has
lumulunok” to tonsillitis. decrease in level indicate decreased from 5
asverbalized by of pain, and body >assess pain worsening to 0 and
the pt’s mother temp will lower characteristics condition. temperature
from 38°c to including location > provides lowered from
Subjective: 37°c. and severity baseline data for 38°c to 37°c.
>initial v/s taken (using faces comparison and
as follows: > with 3 days of scale). reference for >goal wasa fully
T= 38°c nursing >place pt. in appropriate met pt has non-
RR= 40 intervention, the apposition of diagnosis and swollen and non
breaths/min pt. will manifest comport possibly management. tender lymph
CR= 110bpm the following semi fowlers’. >promotes nodes on
>febrile signs of improved >offer more comfort: submandibular
>with swollen condition fluids and semi- Maximize area,
and tender lymph a. non-swollen solid or moist respiratory and pinkish and non
nodes on and non tender foods, as cardiac functions. swollen tonsils,
submandibular lymph nodes on tolerated. can easily
area submandibular >offer ice chips, >Promotes swallow fluids
>with bright red area. as tolerated. adequate and semi solid or
and swollen b. pinkish and >assist pt. in nutrition’s while moist foods,
tonsils non swollen gargling lessening and has stable
>appear irritable tonsils. With saline difficulty in v/s.
>difficulty in c. can easily solution. swallowing.
swallowing. swallow fluids >provide >decrease
and semi solid or divertional swelling of the
moist foods activities such as tonsils.
d. stable v/s. watching tv, >relieves sore
gangling pup-up throat and
or coloring books, reduce swelling.
or playing with >helps pt. to
toys. cope with
>promote rest incompletely
providing a quiet relieved pain.
environment and
limiting visiting
hours
>regulate ivf to >promote energy
prescrive rate. conservation and
lessen metabolic
demands.
>facilitate fluid
electrolyte
replacement and
>Administer balance support
antibiotics as circulating blood
ordered. volume to hasten
>Administer healing process.
analgesic as >treat underlying
ordered. cause of
> explain inflammation.
possible >decrease level
complications of of pain.
conditions if >prevents
inadequately complication of
treated. conditions ensure
>emphasize continuity of
preventive care.
measures such >prevent
as non exposures complication are
to irritants, recurrence of
adequate condition; ensure
nutrition’s and continuity of
hydration and care.
vitamin C
supplementation