Salarda, Jorgia P.

BSN-3E
NURSING CARE PLAN (NCP)

NURSING PLANNING IMPLEMENTATIO

ASSESSMENT EVALUATION
DIAGNOSIS OBJECTIVE OF CARE INTERVENTION RATIONALE N

Short Term Goal: Short Term Goal:

SUBJECTIVE CUES: Acute pain related At the end of 4 hours INDEPENDENT At the end of 4
to inflammation of nursing intervention, the hours nursing
• Mrs. Strong • Assess and • Asked the
tonsils as patient will be able to: • Monitoring intervention,
complains that monitor patient to
evidenced by using pain condition of patient
she is having ✓ Express feeling pain using assess pain
patient’s scale allows is gradually shifting
difficulty in of comfort as pain scale level using
verbalization of objective to its normal state
swallowing. evidenced by a the pain
pain and facial measurement as evidenced by the
• She complains satisfactory pain scale of 0 to
patient verbalized
grimace level of 0 out of of subjective
pain in her throat 10 and
10 pain adequate relief of
• She also stated explained
pain as evidenced
✓ Revert her Body perception
that she that 0 means
temperature and by a pain score of 0
experience no pain, 1 to
respiratory rate out of 10, stable
difficulty in to its normal 4 for mild
vital signs and
swallowing for state pain; 5 to 7
absence of facial
several days. ✓ Absence of for moderate
grimace.
• She also stated facial grimace pain; 8 to 10
that she has a is severe Actions were also
foul-smelling Long Term Goal: pain. indentified on how
breath. manage the pain.
After 3 days of nursing
• Her husband • Monitor
intervention, the patient • To monitor • Monitored
stated that she patient’s
can be able to: the the vital
was snoring as vital signs Long Term Goal:
effectiveness signs and
she sleeps. ✓ Experience no of treatment documented After 3 days
further signs or for the relief
OBJECTIVE CUES: it on the nursing
symptoms of
of pain. The patient’s
 Diagnostic Procedures: infection time chart. intervention, the
monitoring of goal was met as
✓ Vital signs vital signs evidenced by the
✓ Physical
may depend patient experience
assessment on the peak no further signs or
time of the symptoms of
Vital Signs
drug infection.
• Weight: 60 kg administered
• Temp: 38.2
• RR: 25 bpm • • Encouraged
Encourage • Drink plenty
. to increase patient to
of fluid to
fluid intake drink 8 to
✓ Red and swollen prevent throat
10 glasses
tonsils from drying
of fluids a
✓ Feverish to out. When the
day.
touch body is
✓ Shows a responding to
grimacing face an infection,
it needs more
hydration
Lab Values: than usual.
Rapid streptococcal test:
Positive
• • Advised the
Advise • These types
patient to patient to
of food can
avoid hot, avoid hot,
aggravate the
spicy, and spicy, and
pain and can
coarse food coarse food.
cause
bleeding.

• Prepared
• Salt water can
• Encourage warm salt
help in the water for the
patient to
draw out patient to
gargle salt
water and
 water bacteria while gargle.
protecting the
gums.

• To increase
• Elevate the the oxygen • Adjusted the
head of the level head of the
bed and allowing bed and
place patient optimal lung assisted
expansion. patient to a
in semi-
fowler’s semi-
position fowler’s
position.

• Resting will • Checked the

• Place the allow the room for
patient in body to fight unnecessary
complete off the noise and
bed rest bacterial distractions
during infection and that can
severe provide disturb the
episodes of optimal patient
pain comfort to the when she is
patient. asleep so
that she can
rest well.

• Non- • Encouraged
• Encourage
pharmacologi to do tepid
to do tepid
cal measures sponge bath
sponge bath
in case fever to allow in case fever
persists evaporate persist to
cooling. Do cool down
 not use the body.
alcohol as it
can cool the
skin rapidly
and may
cause
shivering.

• Extra activity • Was able to

• Encourage can worsen encourage
patient to the situation. the patient
rest
to rest

DEPENDENT
• Analgesics
• Administer are used to • Administere
analgesic as relieve mild d
prescribed to moderate paracetamol
by the pain and as
attending reduce fever. prescribed
physician by the
attending
physician
and
monitored
patient for
any side
effects.
• Bacterial
• Administer infections are • Administere
antibiotics
 such as treated with d penicillin
penicillin or penicillin or as
cephalospori cephalosporin prescribed
ns as s as a first- by the
prescribed line therapy attending
by the physician
attending
physician
• This helps in
• Explain that reducing • Was able to
surgery complications discuss and
might be and improves explain the
indicated postoperative possible
such as recovery. side effects
Tonsillecto Adults who of the
my and have procedure,
adenoidecto undergone a as
my if patient tonsillectomy prescribed
has had to treat or indicated
repeated recurrent by the
episode of streptococcal attending
tonsillitis, as infections physician.
prescribed experience
by the decrease in
attending the number of
physician. streptococcal
or other
throat
infections or
days with
throat pain.
 NURSING CARE PLAN (NCP)

NURSING PLANNING IMPLEMENTATIO

ASSESSMENT EVALUATION
DIAGNOSIS OBJECTIVE OF CARE INTERVENTION RATIONALE N
Short Term Goal:
SUBJECTIVE CUES: Ineffective airway At the end of 4 hours INDEPENDENT
• According to clearance related nursing intervention, the • Assess • Maintaining • The airway At the end of 4
Mrs. Strong, she to obstruction or patient will be able to: airway for the airway is patency was hours nursing
frequently thickened ✓ No longer patency always the assessed intervention,
suffered from secretions as breathe through condition of patient
first priority
allergic rhinitis. evidenced by the mouth is shifting to its
cough and colds ✓ Express feeling normal state as
• She also • Identificatio • Identification • Was able to
of comfort when evidenced by stable
verbalized that n of the and identify vital signs, no
breathing
when the allergens elimination is allergens
✓ Maintain vital longer breathe
Allergic Rhinitis signs to its easiest for through mouth, and
begins, she starts normal state dust mite express feeling of
to have cough ✓ Know and allergens; comfort when
and colds understand pollen is breathing and
• She also stated about the more difficult through her
that she disease and to avoid physical
experienced treatment appearance.
because daily
abdominal pain Actions were also
activities
Long Term Goal: indentified on how
last August, must be maintain effective
which changed altered to do
After 7 days of nursing airway clearance.
her mood and so; an easy
intervention, the patient
decreased her intervention She was also able
will be able to:
energy. is to keep the to know and
✓ Experience no windows understand what
further signs or closed, which the disease all
OBJECTIVE CUES:
symptoms of the is easily about is and how to
Diagnostic Procedures:
infection accomplished manage and what
✓ Vital signs the treatment is.
✓ Demonstrate in air-
✓ Physical
behaviours, conditioned
assessment
lifestyle changes homes and
 Vital Signs showing must be done
• Weight: 44.4 kg increased throughout
• Height: 151 cm energy the year.
• Temp: 35.7 ✓ Sleep 8 hours a
day
• RR: 15 bpm • Abnormal • Was able to
• PR: 96 bpm • Auscultate
breath sounds auscultate
lungs for
. can be heard lungs to
presence of
✓ She sneeze normal or
as fluid and check for
repeatedly mucus presence of
adventitious
✓ Itch her nose and breath
accumulate. normal or
eyes This may adventitious
sounds
✓ Presence of indicate breath
runny nose ineffective sounds
airway
clearance.
• Assess
• Respirations
respirations. • A change in was
Note the usual assessed and
quality, rate, respiration was able to
pattern, may mean note the
depth, respiratory quality, rate,
flaring compromise. pattern,
of nostrils, An increase depth,
dyspnea on in respiratory flaring
exertion, rate and of nostrils,
evidence of rhythm may dyspnea on
splinting, be a exertion,
use of compensatory evidence of
accessory response to splinting,
muscles, airway use of
and position obstruction. accessory
for
muscles,
breathing. and position
 for
• Monitor • Mucus color breathing.
patient for from yellow
cough and to green may • Was able to
production indicate the monitor
of sputum, presence of patient’s
noting infection. cough and
amount, Tenacious, production
color, thick of sputum,
character, secretions noting
and require more amount,
patient’s effort and color,
ability to energy to character,
expectorate expectorate and
secretions, through patient’s
and the coughing, and ability to
ability to may actually expectorate
cough. create an secretions,
obstruction and the
stasis that ability to
leads to cough.
infection and
respiratory
changes

• Elevate the • To increase • Was able to

head of the oxygen level elevate the
bed and by allowing head of the
position the optimal lung bed and
patient in expansion. positioned
Semi the patient
Fowler’s in Semi
Fowler’s
 • Encourage • To decrease • The patient
to increase the viscosity was able to
fluid intake of the intake warm
discharges fluid to
maintain
adequate
hydration
• Encourage
• Extra activity
patient to • Was able to
rest can worsen
encourage
shortness of
the patient
breath. to rest

• Encourage • Encourage a • Established

patient to routine
rapport and
thoroughly cleaning of
ask patient
clean their the house, in a kind
house furniture, and
way. Was
equipment w able to
hich may
encourage
house dust
patient to
and other thoroughly
pollens.
clean their
house.

DEPENDENT
• Administer • Expectorants • Prepare all
medication help thin and the needed
as loosen mucus equipment
prescribed so patients and
by the can cough it medication
up more
 attending easily. This for
physician can help the administerin
body rid itself g the
of excessive medications
mucus more
quickly.
• Prepare the
• Teach the
• Use nasal needed nasal
patient on
spray as spray and
ordered by how to use
administer it
the nasal sprays
to the
attending by blowing
patient. Was
physician the nose first
able to teach
then
the patient
administering
and parent
the
on how to
medication.
use it
Belleza, R. M. N. (2021, February 11). Allergic Rhinitis. Nurseslabs. https://nurseslabs.com/allergic-rhinitis/

Wayne, G. B. (2019, March 20). Ineffective Airway Clearance Nursing Care Plan. Nurseslabs. https://nurseslabs.com/ineffective-

airway-clearance/