Nursing Care Plan

Case Scenario:

A 19-year-old senior high male came to the school clinic complaining that he notices while he was eating his
lunch, he felt that he was having difficulty swallowing his food and the second thing he notices is that he is
experiencing sore throat. He suspected that it was the cause that he is eating more on sweets and cold drinks
because he started experiencing it 4 days ago, but now cannot take it anymore due to exudate and having earache.
So while examining the patient, the nurse has found out that the patient’s throat is swelling and experiencing
redness. On the checking of the vital signs, body temperature 38.7°C (fever); pulse rate of 87 (normal); respiratory
rate of 21 (abnormal) and blood pressure of 130/80mmHg (high blood).

Nursing Care Plan: Acute Pharyngitis

Pathophysiology

ASSESSMENT NURSING PLANNING IMPLEMENTATIO RATIONALE EVALUATION

DIAGNOSIS N
Subjective Data:  Acute After 2-3 hours of
pain Independent: Independent: 1. To Patient will be
 The patient related to
nursing 1. Provide warm provide a soothing able to report:
complains that upper airway intervention patient saline gargle effect on painful  Relieve from
he is irritation will be able to: 2. Serve lukewarm throat pain and
experiencing secondary to  Verbalized water for drinking 2. Cold beverages discomfort
difficulty in an infection. pain is 3. Apply an ice may be difficult to  Follow the
swallowing food relieved collar on the neck swallow when prescribed
and sore throat.  Acute pain  Reduced 4. Promote non throat is inflamed pharmacologi
 Fever due to pharmacologica l 3. Cold promotes
discomfort cal regimen
inflammation  Appears at pain management vasoconstriction  Demonstrate
Objective Data: of the rest such as diversional and decreases relaxation skills
 Sore throat pharynx AEB activities, comfort swelling that and diversional
 Odynophagia sore throat measures and use contributes to pain. activities
 Otalgia and of relaxation 4. Relaxation and  Appears at
 Fever and chills odynophagia exercise diversional rest
 Mouth . 5. Encourage activities distracts
breathing
adequate rest pain stimuli and
 On the physical
period attention therefore
examination
reduces tension or
seen a redness
Dependent: pain.
and swelling of
1. Administer 5. To prevent
the throat and
analgesic as fatigue that can
lymph nodes.
ordered impair ability to
 The lab result
2. Administer manage or cope
(RADT) shows
antipyretic as with pain
the patient is
ordered
positive in a
3.Reinforce
result of
completing the
streptococcus.
course of antibiotic

Vital Signs: Interdependent: Dependent:

 Body 1. Collaborate with 1. To relieve pain
 Temperature dietary 2. To lower
38.7°C management to temperature
 Pulse rate of 87 avoid hot and 3. To prevent
 Respiratory rate spicy, less resistance with the
of 21 seasoned and drug
 Blood pressure unsweetened
of 130/80mmHg coarse food Interdependent
2. Coordinate with 1. It can aggravate
medical technology the pain and can
department for cause bleeding.
throat culture 2. To determine
which pathogen is
present and for
appropriate
treatment