Nursing Care Plan

Pharyngitis( Acute Pain )

Assesment Diagnosis Outcome Identification Planning Intervention Evaluation
Subjective: Acute Pain Related to After 3 days the client will be Short Term: Independent Nursing Interventions: Short Term:
“Masakit lalamunan ko kapag Biological injury agent able to demonstrate relief After 3 days of nursing intervention the  Assess for potential types of pain that may be affecting client; After 3 days of nursing intervention the
umuubo at lumulunok” as and reflex muscle spams from pain. The client will be client will be able to demonstrate the to aid in understanding reason for severity of pain client demonstrated relief from pain. The
verbalized by the client As evidenced by Swelling able to verbalize relief from pain. The Client will be able associated with client’s condition, and point toward Client also verbalized nonpharmacological
of throat;Pain that nonpharmacological methods to verbalize nonpharmacological needed interventions for pain management. Methods that provide relief.
Objective: worsens with swallowing that provide relief. Methods that provide relief. Nociceptive pain results from actual tissue damage or Prescribed pharmacological regimen was
 Facial mask of Pain; or Coughing Follow Prescribed Follow Prescribed pharmacological potentially tissue-damaging stimuli. followed.
pupil dilation pharmacological regimen. regimen.  Assess client’s perceptions of pain, along with behaviors and
 Positioning to ease Pain cultural expectations regarding pain. ;Client’s perception of Long Term:
 Distraction Behavior Long Term: and expression of pain are infl uenced by age, After one week of nursing intervention the
 Self-focus; narrowed After one week of nursing intervention developmental stage, underlying problem causing pain, client verbalized that the pain is relieved and
focus the client will be able verbalize that the cognitive, and behavioral and sociocultural factors. controlled. The Client also Verbalized sense
pain is relieved and controlled.  Note client’s attitude toward pain and use of pain medications, of control of response to acute situation and
 Submandibular and
Verbalize sense of control of response to including any history of substance abuse. ;Client may have positive outlook for the future.
periauricular lymph
acute situation and positive outlook for beliefs restricting use of medications, may have a high
nodes are usually
the future. tolerance for drugs because of recent or current use, or Goal was met
enlarged and tender to
palpation. may not be able to take pain medications at all if
participating in a substance abuse recovery program.
 Obtain client assessment of pain to include location,
characteristics, onset, duration, frequency, quality, and
intensity. Identify precipitating or aggravating and relieving
factors ;in order to fully understand client’s pain
symptoms.
 Provide nonpharmacologic pain management; Quiet
Environment
 Identify specifi c signs/symptoms and changes in pain char -
acteristics requiring medical follow-up. ;Provides
opportunity to modify pain management regimen and
allows for timely intervention for developing
complications.
Dependent Nursing Interventation
 Administer analgesics, as indicated, to maximum dosage, as
needed, ;to maintain “acceptable” level of pain. Notify
physician if regimen is inadequate to meet pain control goal.
Combinations of medications may be used on prescribed
intervals.

Nursing Care Plan

Pharyngitis (Ineffective Airway Clearance)
Assesment Diagnosis Outcome Identification Planning Intervention Evaluation
Subjective: Ineffective Airway Clearance After 8 hours, the client will be Short Term: Independent nursing Interventions: Short Term:
“nahihirapan ako huminga Related to retained secretions able to maintain airway After 8 hours of Nursing Intervention,  Assess level of consciousness/cognition and ability to After 8 hours of Nursing Intervention, the client-maintained
dahil sa tuloy-tuloy na pag As evidenced by continuous patency. Expectorate/clear the client will be able to maintain protect own airway. ;This information is essential for airway patency. Expectorated and cleared secretions readily
ubo ko” as verbalized by the Dry coughing. secretions readily and airway patency. Expectorate/clear identifying potential for airway problems, providing and Demonstrated behaviors that improved or maintained clear
client Demonstrate behaviors to secretions readily and Demonstrate baseline level of care needed, and influencing choice airway.
improve or maintain clear behaviors to improve or maintain of interventions.
Objective: airway. clear airway.  Monitor respirations and breath sounds, noting rate and Long Term:
 Difficulty of Breathing sounds. ;Indicative of respiratory distress and/or After One Week of Nursing Intervention, The Client
 Difficulty Verbalizing Long Term: accumulation of secretions. Demonstrated absence or reduction of congestion with breath
 Alteration in respiratory After One Week of Nursing  Evaluate client’s cough/gag reflex, amount and type of sounding clear, noiseless respirations, and improved oxygen
rate or pattern Intervention, The Client will be able secretions, and swallowing ability, to ;determine exchange.
to Demonstrate absence or reduction ability to protect own airway.
 Wide-eyed look;
of congestion with breath sounding  Suction nose, mouth, and trachea prn using correct-size Goal was Met.
restlessness
clear, noiseless respirations, and catheter and suction timing for child or adult, to ;clear
improve oxygen exchange. airway when excessive or viscous secretions are
blocking airway or client is unable to swallow or
cough effectively.
 Encourage deep-breathing and coughing exercises or
splint chest/incision to maximize effort.;Observe for
signs of respiratory distress
 Provide information about the necessity of raising and
expectorating secretions versus swallowing them, ;to
report changes in color and amount in the event that
medical intervention may be needed to prevent or
treat infection.
 Encourage/provide opportunities for rest; limit
activities to level of respiratory tolerance. ;This
prevents/reduces fatigue.
Independent nursing
Dependent:
 Administer medications as indicated, ;to relax smooth
respiratory musculature, reduce airway edema, and
mobilize secretions.