FIRST CITY PROVIDENTIAL COLLEGE

Narra, Francisco Homes, City of San Jose Del Monte, Bulacan

Patient Initials:S.M.A Date Admitted:April 23,2024

Age:18 yrs old Admitting Diagnosis:Acute Tonsillopharyngitis

NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Sleep deprivation Short Term Goal:
“Kulang po ako sa related to Within 30 mins, the patient
tulog dahil sa sakit ng discomfort from will report a reduction in
lalamunan ko” as pain as evidence pain from a numerical pain
verbalized by the by inflammation of scale of 7/10 to 4/10,
patient tonsil allowing for increased
duration and quality of
Objective: sleep for at least four
 Pale lips consecutive hours
 Hoarse voice
 Sore throat: Long Term Goal:
patient rated pain Within 24hrs, the patient
7/10 will demonstrate improved
 Lethargic sleep patterns, achieving at
least 6-8 hours of
uninterrupted sleep per
night, as evidenced by self-
report and objective
assessment measures,
leading to restoration of
energy levels and overall
well-being.
Independent:
 Encourage the patient to
practice techniques (deep
breathing exercises,
progressive muscle relaxation)
before bedtime and as needed
throughout the day to reduce
anxiety and pain perception,
ultimately improving sleep
quality.
Dependent:
 Dependent on physician's
orders, administer prescribed
pain medication
Collaborative:
 Collaborate with the
healthcare team to adjust
medication dosages or explore
alternative pain management
strategies as needed
Short Term Evaluation:
 to reduce anxiety and Within 30 mins, the
pain perception, patient will report a
ultimately improving reduction in pain from a
sleep quality. numerical pain scale of
4/10, allowing for
increased duration and
quality of sleep for at
least four consecutive
hours
Long Term Evaluation:
 to alleviate discomfort Within 24hrs, the patient
and promote better will improved sleep
sleep. patterns, achieving at
least 6-8 hours of
uninterrupted sleep per
 to optimize pain relief night, as evidenced by
and facilitate restful self-report and objective
sleep assessment measures,
leading to restoration of
energy levels and overall
well-being.