WESLEYAN UNIVERSITY-PHILIPPINES
Mabini Extension, Cabanatuan City
COLLEGE OF NURSING
Chelsy Jhene A. Dizon (BSN 2-7)
NCP
ASSESSMENT DIAGNOSTIC PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Acute Pain related Short-term Goal: Independent: Independent:
“Nahihirapan to inflammation of Within the shift, patient will report a Assess pain level using numeric pain scale Regular pain assessment Short-term
monitors effectiveness of
akong the tonsillar area as decrease in throat pain from 6/10 to every 4 hours. interventions.
Goal: Patient
lumunok.” evidenced by ≤3/10 on a numeric pain scale. Encourage warm saline gargles 3–4 Warm saline gargles reduce reported reduced
Reports throat patient’s times/day. throat discomfort and throat pain from 6/10
pain. verbalization of Long-term Goal: Provide soft, bland, cool foods and bacterial load. to 2/10 within the
Objective Data: throat pain and Within 1 week, patient will adequate oral fluids. Soft/cool foods minimize shift.
irritation and ensure
difficulty in demonstrate improved swallowing Teach relaxation and distraction techniques nutritional intake.
Oropharyngeal swallowing. ability, tolerate soft foods without (e.g., deep breathing, quiet rest). Relaxation techniques Long-term
redness and discomfort, and verbalize relief of Dependent: promote comfort and reduce Goal: After 1 week,
swollen tonsils pain. Administer prescribed analgesics (e.g., perceived pain. patient tolerated soft
Difficulty Paracetamol 500 mg PO q6h prn) for pain Dependent: foods without
Analgesics (Paracetamol)
swallowing relief. relieve pain and improve
discomfort, was able
Afebrile Administer antibiotics (e.g., Amoxicillin comfort. to swallow fluids
(Temp: 36.8 500 mg PO q8h for 7–10 days) if bacterial Antibiotics (Amoxicillin) normally, and
°C) tonsillitis is confirmed. eradicate bacterial infection, verbalized pain
V/S WNL Collaborative: reducing inflammation. relief.
Collaborative:
(BP: 118/80, Refer to physician if pain worsens, Early referral prevents
PR: 82, RR: swelling increases, or airway obstruction is complications such as
20) suspected. peritonsillar abscess or
Collaborate with dietitian for appropriate airway obstruction.
soft diet meal planning during recovery. A multidisciplinary approach
ensures adequate nutrition
and faster recovery.
