Assessment Subjective: Nahihirapan sya huminga as verbalized by the mother.

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=

This promote better lung expansion and improve air exchange

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

significant others on indication for frequency and side effects of medication

about the drugs

Dependent Administer medication as ordered

Assessment Subjective: Objective

Nursing Diagnosis Acute pain related to swelling of the tonsils

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

To promote healing. Cold compress may

reduce local edema.

Assessment Subjective: Objective

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation Pt. maintaine body temperature within a normal range.

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