KRISTIAN KARL B.

KIW-IS

I .NURSING CARE PLAN

DAY 2

CUES EXPLANATION OF OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

THE PROBLEM
Subj: STG: Goal Fully Met
‘“nahihirapa Acute pain is After of 4 hours Assessed pain using STG:
Use of a pain scale
n nga siya directly related to comprehensive appropriate pain scale for After of 4 hours
allows objective
lumunok, tissue injury and nursing child’s age and comprehensive nursing
masakit measurement
resolves when intervention, development. intervention, the
daw aang of subjective pain
tissue heals. It may the patient will patient demonstrated
lalamunan perception.
be caused by a demonstrate relief of pain, absence
niya.” As stimulus such as relief of pain, Administered pain of Nonverbal
verbalized Throat pain is common
trauma to body absence of medications as prescribed indications of
by the during the first several
tissues that directly Nonverbal such as acetaminophen discomfort such as
patient’s days (occasionally up
irritates the pain indications of (Tylenol), ibuprofen grimacing, crying,
mother. to 10 days) post
receptors causing discomfort (Advil), or oxycodone. clinging to parent.
surgery. Rectal
inflammation such as Monitor for effectiveness
administration of
grimacing, and side effects.
analgesia is also
crying, clinging
possible for the very
to parent.
young client.
Goal Partially Met
Obj:
Suggested diversional LTG:
Reddened Provides a distraction
LTG: activity such as watching a After 3 days of
tonsils from discomfort.
After 3 days of video, reading a book or comprehensive nursing
Dysphagia
comprehensive listening to music. intervention, Patient
Facial
nursing displays improved well-
grimace
intervention, being such as baseline
Patient will levels for pulse, BP,
Cold promotes
displays Applied an ice collar on respirations, and
vasoconstriction and
improved well- the neck or encourage the relaxed muscle tone or
Nursing.dx decreases swelling that
being such as child to eat popsicles. body posture.
Acute Pain contributes to pain.
baseline levels
related to
for pulse, BP,
inflammatory
respirations,
process as
and relaxed . Instructed patient not
manifested It can cause
muscle tone or to eat rough and spicy
by Reddened vasodilation that
body posture. foods such as rice,
tonsils, could lead to
pepper, peas, corn,
painful and bleeding.
nuts., seasonings, foods
difficulty of
with garlic pepper or
swallowing
chili.
secondary to
Tonsillitis
Talking and coughing
. Instructed patient to
can cause great
refrain
pressure on the area
- talking
which can lead to
- coughing
bleeding.

. Encouraged use of
This helps stimulate
relaxation techniques :
closure of gating
- low rhythmic
mechanism in the
breathing,
spinal cord and blocks
- back rubs
the transmission of
- repositioning.
pain impulses. It also
decreases pain by
promoting relaxation.
 . Minimized Fatigue can decrease
environmental activity the client’s threshold
and noise to promote and tolerance for pain
rest. and thereby heighten
- proper lighting the perception of pain.
- quite environment If the client is well-
- cool ventilation rested, she after
experiences decrease
pain and increase
effectiveness of pain
management
measures.

Advised mother to
continue with the
antibiotics as To completely destroy
prescribed by the the bacteria. This also
doctor even if prevents the resistance
symptoms subside. of the bacteria from
the antibiotic.
Advised mother to
avoid giving sweets and
cold beverage to the Bacteria proliferate
patient. faster in sweet
environment.

Promoted oral fluid

intake
Without proper
nutrition and hydration
the oral mucosa is
more vulnerable to
damage. This will also
Advised mother to prevent dehydration
make patient gargle
with a solution of warm This relieves the
water and salt patient’s sore throat
Although this is only
short-lived.

II. CHARTING:

F> Acute Pain related to inflammatory process as manifested by Reddened tonsils, painful and difficulty of
swallowing secondary to Tonsillitis

D> Received lying on bed with ongoing PNSS 1L @ 600 cc on the R hand. Vital signs prior to operation:
Temp:38.0 C RR: 22bpm Spo2: 98%
CR: 89 bpm Bp: 100/70mmhg, ‘“nahihirapan nga siya lumunok, masakit daw aang lalamunan niya.” As verbalized
by the patient’s mother, Reddened tonsils
Dysphagia and Facial grimace

A>
 Assessed pain using appropriate pain scale for child’s age and development.
 Administered pain medications as prescribed such as acetaminophen (Tylenol), ibuprofen (Advil), or
oxycodone. Monitor for effectiveness and side effects.
 Suggested diversional activity such as watching a video, reading a book or listening to music.
 Applied an ice collar on the neck or encourage the child to eat popsicles.

 Instructed patient not to eat rough and spicy foods such as rice, pepper, peas, corn, nuts., seasonings,
foods with garlic pepper or chili.
 Instructed patient to refrain
 o talking
o coughing
 Encouraged use of relaxation techniques :
o low rhythmic breathing,
o back rubs
o repositioning.
 Minimized environmental activity and noise to promote rest.
o proper lighting
o quite environment
o cool ventilation
 Advised mother to continue with the antibiotics as prescribed by the doctor even if symptoms subside.
 Advised mother to avoid giving sweets and cold beverage to the patient.
 Promoted oral fluid intake
 Advised mother to make patient gargle with a solution of warm water and salt

R> Patient displays improvement in mood and coping as evidence by no facial grimacing, crying, clinging to
parent.