Nursing Care Plan (Pharyngitis)

 

Assesment Subjective: “Masakit lalamunan ko kapag umuubo at lumulunok ” as

Diagnosis Acute Pain Related to Biological injury agent and reflex muscle spams

Outcome Identification After 3 days the client will be able to demonstrate relief from pain. The client will be

Nursing Care Plan Pharyngitis( Acute Pain ) Planning Intervention Short Term: Independent Nursing Interventions: After 3 days of nursing intervention the Assess for potential types of pain that may be affecting client;   client will be able to demonstrate the to aid in understanding reason for severity of pain

verbalized by the client

As evidenced by Swelling of throat;Pain that worsens with swallowing or Coughing

able to verbalize nonpharmacological methods that provide relief. Follow Prescribed  pharmacological regimen.

relief from pain. The Client will be able to verbalize nonpharmacological Methods that provide relief. Follow Prescribed pharmacological regimen.

Objective: 

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Facial mask of Pain;  pupil dilation Positioning to ease Pain Distraction Behavior  Self-focus; narrowed focus

Long Term: After one week of nursing intervention the client will be able verbalize that the  pain is relieved and controlled. Verbalize sense of control of response to acute situation and positive outlook for the future.

Submandibular and  periauricular lymph nodes are usually enlarged and tender to  palpation.

Evaluation Short Term: After 3 days of nursing intervention the client demonstrated relief from pain. The

associated with client’s condition, and point toward needed interventions for pain management. Nociceptive pain results from actual tissue damage or potentially tissue-damaging stimuli.   Assess client’s perceptions of pain, along with behaviors and cultural expectations regarding pain. ;Client’s perception of and expression of pain are infl uenced by age, developmental stage, underlying problem causing pain, cognitive, and behavioral and sociocultural factors.    Note client’s attitude toward pain and use of pain medications, medications, including any history of substance abuse. ; Client may have beliefs restricting use of medications, may have a high tolerance for drugs because of recent or current use, or 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 

Client also verbalized nonpharmacological Methods that provide relief. Prescribed pharmacological regimen was followed. Long Term: After one week of nursing intervention the client verbalized that the pain is relieved and controlled. The Client also Verbalized sense of control of response to acute situation and  positive outlook for the future. Goal was met

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.

Assesment Subjective: “nahihirapan ako huminga

Diagnosis Ineffective Airway Clearance Related to retained secretions

Outcome Identification After 8 hours, the client will be able to maintain airway

Nursing Care Plan Pharyngitis (Ineffective Airway Clearance) Planning Intervention Short Term: Independent nursing Interventions: After 8 hours of Nursing Intervention,  Assess level of consciousness/cognition and ability to

Evaluation Short Term: After 8 hours of Nursing Intervention, the client-maintained

 

dahil sa tuloy-tuloy na pag ubo ko”  as verbalized by the client

Objective:   

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Difficulty of Breathing Difficulty Verbalizing Alteration in respiratory rate or pattern Wide-eyed look; restlessness

As evidenced by continuous Dry coughing.

 patency. Expectorate/clear secretions readily and Demonstrate behaviors to improve or maintain clear airway.

the client will be able to maintain airway patency. Expectorate/clear secretions readily and Demonstrate  behaviors to improve or maintain clear airway. Long Term: After One Week of Nursing Intervention, The Client will be able to Demonstrate absence or reduction of congestion with breath sounding clear, noiseless respirations, and improve oxygen exchange.

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 protect own airway. ;This information is essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions. Monitor respirations and breath sounds, noting rate and sounds. ;Indicative of respiratory distress and/or

accumulation of secretions. Evaluate client’s cough/gag reflex, amount and type of secretions, and swallowing ability, to ;determine ability to protect own airway. Suction nose, mouth, and trachea prn using correct-size  catheter and suction timing for child or adult, to  ;clear 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

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airway patency. Expectorated and cleared secretions readily and Demonstrated behaviors that improved or maintained clear  airway. Long Term: After One Week of Nursing Intervention, The Client Demonstrated absence or reduction of congestion with breath sounding clear, noiseless respirations, and improved oxygen exchange. Goal was Met.