Nursing Care Plan for Tonsilitis

Nursing Care Plan: Tonsillitis ASSESSMENT • Subjective Cues: Ms. Cruz complains of pain in her throat. • She stated that she is having difficulty in swallowing • She said it was difficult to swallow for several days. • • Objective Cues: She has reddened and swollen tonsils She shows a grimacing face. NURSING DIAGNOSIS PLANNING INTERVENTION OBJECTIVE OF CARE Dependent After 3 hours of • Administer analgesics • “Acute pain nursing as prescribed such as the related to interventions, acetaminophen and. inflammation of patient will be able monitor for tonsils as to: effectiveness or side evidenced by verbalize adequate effects. relief of pain as patient’s verbalization of evidenced by a • Administer • pain pain and facial satisfactory antibiotics such as level of 0 out of 10, grimace” penicillin or stable vital signs, and cephalosporins as absence of facial prescribed. grimace. Independent • Assess and monitor • pain using appropriate pain scale. Vital Signs: Temperature: 38.5°C (Fever) Respiratory Rate: 23 Lab Values: Rapid streptococcal test: Positive • Monitor the patient’s • vital signs and characteristics of pain RATIONALE IMPLEMENTATION Analgesics are used • to relieve mild to moderate pain and reduce fever. Bacterial infections • are treated with penicillin or cephalosporins as a first-line therapy. EVALUATION After rendering the Administered paracetamol as appropriate nursing prescribed and interventions to the monitored the patient, the goal of care was met. The patient for any side patient verbalized effects. adequate relief of pain as evidenced Administered by a pain score of 0 penicillin as out of 10, stable vital signs, and prescribed. absence of facial grimace. Monitoring using a • pain scale allows objective measurement of subjective pain perception. Asked the patient to assess pain level using the pain scale of 0 to 10 and explained that 0 means no pain, 1 to 3 means mild pain; 4 to 5 is moderate pain; 8 to 10 is severe pain. To monitor • effectiveness of treatment for the Monitored the vital signs and characteristics of at least 30 minutes after administration of medication. relief of pain. The time of monitoring of vital signs may depend on the peak time of the drug administered. pain 30 minutes after giving the medicine and documented it on the patient’s chart. • Encourage patient to increase fluid intake. • Drinking plenty of • fluids will prevent the throat from drying out. When the body is responding to an infection, it needs more hydration than usual. Encouraged patient to drink 8-10 glasses a day. • Encourage patient to • gargle with salt-water. Salt water can draw • out water and bacteria while protecting the gums, so gargles may be effective for improving gum and dental health. Prepared warm saltwater for the patient to gargle. • Avoid hot, spicy, and • coarse food such as chips or crackers. These types of food • can aggravate the pain and can cause bleeding Advised the patient to avoid eating hot, spicy, and coarse food. • Elevate the head of • the bed and place patient in semiFowler’s position. To increase the • oxygen level by allowing optimal lung expansion. Adjusted the head of the bed and assisted patient to a semi-Fowler’s position. • Place the patient in • complete bed rest during severe episodes of pain. Resting will allow • the body to fight off the bacterial infection and provide optimal comfort to the patient. Checked the room for any unnecessary noise and distractions that can disturb the patient when she is asleep so that she can rest well.