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