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Objective: Patient seen lying on flat on bed, pale looking Temp: PR: RR: Bluish discoloration of the skin. Capillary refill (5 secs)
Nursing Diagnosis Ineffective airway clearance related to inflammation of the tonsils as evidence by abnormal breathing sound
Planning At the end of 2 hours nursing intervention the patient will had adequate breathing pattern
Intervention Independent Position patient to semi fowler position with proper body alignment for optimal breathing pattern Routinely check the patients position
Rationale
Evaluation Patient secretion are mobilized and airway is maintain free of secretion as evidence by clear breath sound, eupnoea, normal skin color, ability to effectively cough up secretion following treatment and deep breaths RR=
So he does not slide down in bed causing the abdomen to compress the diaphragm To facilitate removal of secretion So patient will understand the rationale and appropriate techniques to keep the airway clear of secretion To maintain hydration To decrease oral flora
Instruct patient how to cough effectively Demonstrate and teach coughing and deep breathing and splinting technique
Encourage oral fluid intake Assist with oral hygiene Instruct patient or
To give information
Planning At the end of 1 hour nursing intervention the patient will relieve the pain and inflammation
Intervention Independent Assess the degree of pain Monitor pain score 1-10 Provide anticipatory instruction on pain causes appropriate prevention and relief measures
Rationale
Evaluation Pt. verbalized adequate relief of pain or ability to cope with incompletely relieve of pain.
Explain cause of pain/or discomfort Instruct patient to report pain Anticipate need for analgesics or additional method of pain reliever. Respond immediately to complaint of pain Perception of time may become distorted. To help pt. express as factually as possible the effect of pain relief measure. So that relief measure maybe instituted.
Evaluate pt. respond to pain and medication or therapeutics aimed at abolishing or reliving the pain. Eliminate additional stressor or sources of discomfort whenever possible. Dependent Give analgesic as ordered. Apply heat or cold compress as ordered
Nursing Diagnosis
Planning
Intervention
Rationale
At the end of 30 mins. Assess of presence of Nsg. Intervention the risk factors pt. Measure temperature of frequent intervals Increase fluid intake Give tepid sponge bath Apply cold compress Dependent Administer medication as ordered. To provide hydration