Professional Documents
Culture Documents
TONSILLO
PHARYNGITIS
EXUDATIVE
CASE STUDY
2013
1. Basis of selection of case
2. Clarity of Objectives
GENERAL OBJECTIVES:
After 2 hours of case presentation the students will be able to obtain the
knowledge to enlarge skills and to develop the attitude towards caring of the patient
with cases regarding tonsillopharyngitis.
SPECIFIC OBJECTIVES:
Specifically, this aims to:
KNOWLEDGE
1. Explain the pathophysiology of tonsillopharyngitis.
2. Identify the main cause of the disease.
3. Name the signs and symptoms of the disease manifested of the client.
SKILLS
1. Carry out independent and dependent intervention being done to the client
appropriately and with care.
2. Perform comprehensive nursing interventions base on the client priority needs.
3. Demonstrate proper approach used in clients with tonsillopharyngitis.
ATTITUDES
1. Establish rapport to client and folks.
2. Encourage the folks to cooperate to the intervention being performed.
3. Avoid promising words that might worsen the clients condition.
3.1 ASSESSMENT
A. Patients Profile
NAME: J. L.S.
AGE: 6 years old
SEX: Male
DATE OF BIRTH: June 21, 2007
ADDRESS: Pavia, Iloilo
OCCUPATION: None
RELIGION: Roman Catholic
NATIONALITY: Filipino
CHIEF COMPLAINT: Fever and cough
DIAGNOSIS: URTI, ATP-E
PHYSICIAN: Dr. F.A
B. Nursing History
I. Reason for seeking care
Fever and cough
3. Postnatal status
She stayed at the hospital for 3 days. The baby was breastfed and the
baby was discharged with the mother.
4. Childhood Illnesses
The child doesnt have experienced any childhood illnesses (mumps,
chickenpox, measles, etc.)
7. Operations or Hospitalizations
The child has been hospitalized for 5 days due to pneumonia and asthma
last 2 months ago.
8. Immunizations
The child has a complete immunization.
9. Allergies
The child is allergic to pollens and dust.
10. Medications
When the child has been admitted he was given an antibiotics and PAI.
2. Milestones
When the child reached 8 months, he learns to pick up toys by himself
within reach and when he reached 1 year old he learns to stand up alone
and take his first step. The child said his first word dada when he
reached 8 months. He developed bowel and bladder control at the age of
4-5 years old.
3. Current Development
Language skills
At the age of 3 the child can talk and speak clear and understand some
words.
Toilet training
The child learns to control his bowel/ bladder at the age of 4 years old and
knows the terms used in toileting.
4. Nutritional History
The child has been breastfed by his mother and solid food was introduced
to him at the age of six months.
5. Family History
In their family there is only hypertension in the mother side. His father
consumes 8 packs of cigarette per year.
C. Assessment Findings
Physical Assessment
GENERAL SURVEY
S.J. is a 6 years old male pupil, well developed and appears to be at stated age.
Not well cleaned but wears appropriate clothes. Oriented to time, place, person, and
able to respond to questions and environmental stimuli appropriately. Comprehends
directions. Difficulty or discomfort making laryngeal speech sounds or varying
volume, quality, or pitch of speech.
SKIN
Skin color differences among body areas and between sun-exposed and non-sun-
exposed areas. Presence of scars noted. Darker skin around knees and elbows. Cool to
warm temperature. Turgor resilience. Bilateral symmetry.
HEAD
Hair is black in color, thick and distributed evenly. Head erect and midline. Skull
normocephalic, symmetric and without deformities. Scalp is intact and without lesions
or mass noted. Facial features symmetric. No bruits.
EYES
Eyebrows are smooth, black in color and distributed evenly and in line with each
other. Superior eyelid covering a portion of iris when open. With mote noted. Eyelashes
are black, evenly distributed, present on both lids and turned outward. Conjunctiva
clear and inapparent. Sclerae white and visible above irides only when eyelids are wide
open. Irides are clearly visible and similar in color. Pupil is round, regular and equal in
size, reactive to light and accommodation.
EAR
Auricles in alignment. Moderate cerumen noted on ear canal. Conversational
hearing appropriate. Able to hear whispered voice. Has a good auditory activity and
obeys to verbal commands.
NOSE
Nose in midline and no discharge or polyps, mucosa pink. Conforms to face to
color. Nares oval and symmetrically positioned. No sinus tenderness to palpation.
Correctly identifies odor.
NECK
Neck is straight and symmetrical. Trachea is in midline. No jugular vein
distention or carotid artery prominence. Carotid pulse is palpable. Thyroid is palpable,
firm, smooth and not enlarged. Thyroid and cartilage move with swallowing.
Tenderness noted below the mandible. No bruits noted. Perform limited range of
motion.
BACK
Spinal column in proper alignment. Slightly cold back was observed. Crackles
are heard upon auscultation.
ABDOMEN
Flat, rounded and symmetrical. Uniform in color, no pigmentation and rashes
noted. No abdominal scars and masses. Active bowel sounds audible in all four
quadrants. Abdomen is soft.
UPPER EXTREMITIES
Arms are fair in color and symmetrical. Scars noted. No tenderness upon
palpation of the muscles and joints. The patient can perform passive range of motion.
Radial and brachial pulses are palpable. With D5IMB 500 cc x 66 cc/h infusing at right
basilic vein. Good capillary refill noted. Full range of motion.
LOWER EXTREMITIES
Legs are fair in color. Muscles are firm and skin is slightly dry. Palms are not
pale. Full range of motion. The popliteal and dorsalis pedis pulses can be felt upon
palpation. The client has good capillary refill.
E. PATHOPHYSIOLOGY:
Respiration provides the body with a means of gas exchange. It is the process whereby
oxygen from the air is transferred to the blood and carbon dioxide is eliminated from
the body. The nervous system controls the movement of the respiratory muscles and
adjusts the rate of breathing so that it matches the needs of the body during various
levels of activity.
The respiratory center consists of two dense, bilateral aggregates of respiratory neurons
involved in initiating inspiration (the drawing of air into the lungs.) and expiration
(expelling air from the lungs) and incorporating afferent impulses into motor responses
of the respiratory muscles. The first, or dorsal, group of neurons in the respiratory
center is concerned primarily with inspiration. These neurons control the activity of the
phrenic nerves that innervate the diaphragm and drive the second, or ventral, group of
respiratory neurons. They are thought to integrate sensory input from the lungs and
airways into the ventilator response. The second group of neurons, which contains
inspiratory and expiratory neurons, controls the spinal motor neurons of the
intercostals and abdominal muscles.
The respiratory system consists of the air passages and the lungs. Structurally, the
respiratory system is divided into two: the upper respiratory tract and the lower
respiratory tract.
The upper respiratory tract includes nose or nostrils, the sinuses, nasal cavity,
pharynx, and larynx. These structures direct the air we breathe from the outside to the
trachea and eventually to the lungs for respiration to take place.
The lower respiratory tract begins with the trachea which enters the thoracic
cavity and subsequently divides into two main bronchi, one supplying each lung. The
bronchi then divide repeatedly forming airways of ever decreasing diameter (see
below). The smallest bronchi are called terminal bronchioles; these are the last of the
purely conducting portion of the lungs.
The upper respiratory tract warms, humidifies, and filters the air; in this process
it is exposed to the wide variety of pathogens that may lodge and grow in various areas
depending on the susceptibility of the host. Pathogens may lodge in the nose, pharynx
(particularly the tonsils), larynx, or trachea, and may proliferate, if the defenses of the
host are depressed. The spread of the infection depends on the resistance mounted by
the host and on the virulence of the organism.
Acute tonsillopharyngitis is the swelling of the pharynx and the tonsils. Pharyngitis
is an acute inflammation of the pharynx, which is the back of the throat, including the
back of the tongue, is one of the most commonly identified clinical problems. Although
it is usually viral in origin, pharyngitis may also be caused by bacterial infection. Group
A beta-hemolytic Streptococcus (GABHS) (strep throat) is the most common cause of
bacterial pharyngitis. Tonsillitis is an acute inflammation of the palatine tonsils.
Although it is sometimes viral in origin, tonsillitis is usually due to streptococcal
infection.
Clinical Manifestations:
Pharyngitis
A bacterial pharyngitis may occur by itself or as a complication of the common cold or
flu. The bacteria most commonly responsible is the Group A beta-hemolytic
Streptococcus. Less frequently the infection is caused by pneumococcus, staphylococcus
pyogenes or hemophilus influenzae. As an acute bacterial pharyngitis develops, the
child complains of a sore throat which may become severe very rapidly, making it
difficult to swallow (dysphagia). The child may develop chills, and at times his/her
temperature may reach 104F to 105F. He may complain of earache. This is usually a
result of pain in the throat being referred to the ears; however, an acute ear infection can
complicate pharyngitis. Since a baby or young child cannot complain of a sore throat,
irritability, and fever are the first manifestations of pharyngitis. The child is flushed and
looks ill. Hemolytic Streptococcal pharyngitis can be associated with a skin rash. The
throat appears bright red and there may be small yellow pustules and stringy mucus on
the pharyngeal wall.
Tonsillitis
A child who develops acute tonsillitis due to hemolytic streptococci complains of an
excruciatingly sore throat and has difficulty in swallowing (dysphagia). The child
appears flushed and on occasion develops a rash. He may have chills, and his
temperature usually rises to 103F or higher. Frequently the child complains of earache
to pain being referred from the throat to the ears. The tonsils are usually larger than
normal and are visible during inspection. They are bright red. In acute tonsillitis
enlarged lymph nodes frequently appear as tender lumps in the upper neck, just below
the angle of the jaw.
Risk Factors:
A Risk factor is something that increases your chance of getting a disease or a condition.
These risk factors increase your chance of getting a sore throat:
Age
Exposure to someone who has a sore throat or any other infection involving the
throat, nose, or ears.
Situations that cause stress, such as travelling, working, or living in close contact
with people
Exposure to cigarette smoke, toxic fumes, industrial smoke, and other air
pollutants.
Having other medical conditions that affect your immune system, such as, HIV
and AIDS or cancer.
Stress
Hay fever or other allergies.
Bacterial or viral infection
Diagnostic Tests:
Throat Swab is obtained and examined for streptococcus antigen using the
Latex Agglutination (LA) antigen test or enzyme immunoassay (ELISA) testing.
These tests allow rapid identification of the antigen but are not highly sensitive.
When the test is positive, treatment for strep throat is initiated. If the test is
negative, the swab is culture to ensure that streptococcus organisms are not
present.
Complete Blood Count (CBC) may be done in severely ill patients or to rule out
other causes of pharyngitis. The WBC count is usually normal or low in viral
infections and elevated in bacterial infections.
Mono spot test (if mononucleosis is suspected).
Treatment
Medications
Antipyretic
Bronchodilator
Antihistamine
Pinicillin
Vitamins
Home Care
Prevention
Vaccination
There is no vaccine against GAS available for clinical use, although
development of this preventive measure is under investigation. An important
area of uncertainty is whether vaccine-induced antibodies may cross-react with
host tissue to produce nonsuppurative sequelae in the absence of clinical
infection.
Foodborne Illness
Streptococcal contamination of food has been implicated in foodborne
outbreaks of pharyngitis, and foodborne transmission of GAS pharyngitis by
asymptomatic food service workers with nasopharyngeal carriage has been
reported. Factors that can reduce foodborne transmission of GAS pharyngitis
include thorough cooking, complete reheating, and use of gloves while handling
food.
Prophylaxis
Continuous antimicrobial prophylaxis is only appropriate for prevention
of recurrent rheumatic fever in patients who have experienced a previous
episode of rheumatic fever.
Ingestion of food with microorganism
Airborne Droplets
Tonsil/Pharynx
Lymphocytes IgM
Inflammatory Process
5 Cardinal signs:
Warmth
Redness
Neutrophils/ Swelling Histamine/Kinins Secretions
Pyrogen Secretions
Macrophages (causes vascular permeability &
Pain
Stimulates fever production Decreased vasodilator)
Reset Hypothalamus Regulator
Fever Loss of Appetite Dysphagia
Malaise
Function
The tonsils and pharynx as part of the upper respiratory tract helps in warming,
humidifying, and filtering the air; in this process it is exposed to the wide variety of
pathogens that may lodge and grow in various areas depending on the susceptibility of
the host. Pathogens may lodge in the nose, pharynx (particularly the tonsils), larynx, or
trachea, and may proliferate, if the defenses of the host are depressed. The spread of the
infection depends on the resistance mounted by the host and on the virulence of the
organism.
In the case of the patient, the causative agent GABHS lodged in the tonsils and
the pharynx. As a normal response of the body, lymphocytes, the smallest of the white
blood cells, will be stimulated by the bacteria to divide and form cells that produce
proteins called antibodies. Antibodies can attach to bacteria and activate mechanisms
that result to the destruction of the bacteria. Antibodies are also called Immunoglobulin
(Ig) because they are globulin proteins involved in immunity. Immunoglobulin M is
often the first antibody produced in response to a foreign antigen (components of
bacteria, viruses, and other microorganisms that cause disease).
The actions of the lymphocytes and the IgM will signal the start of an
inflammatory process.
Stage I:
Injured tissues and the leukocytes in this area secrete histamine, serotonin and
kinins that constrict the small veins and dilate the arterioles in the area of injury. These
blood vessels changes cause redness, and warmth of the tissues. This increased blood
flow increases delivery of nutrients to injured tissue. Blood flow to the area increases
(hyperemia) an edema (swelling) forms at the site of the injury or invasion. Capillary
leak also occurs, allowing blood plasma to leak into the tissues. This response causes
swelling and pain.
Stage II:
In this stage, neutrophilia occurs. Exudates in the form of pus occur, contain with
dead WBCs, nephrotic tissue, and fluids that escape from the damage cells. The
neutrophil attack and destroy organisms and remove dead tissue through phagocytosis.
When an infection stimulating inflammation lasts longer than few days, the bone
marrow cannot produce and release enough mature neutrophils into the blood to keep
pace with the growth of organisms. In this situation, the bone marrow begins to release
immature neutrophils, reducing the number of circulating mature neutrophils. This
reduction of mature neutrophils limits the helpful effects of inflammation and increases
the risk for sepsis.
Like pain and swelling, fever plays a vital part in defending the body against
infection. Many bacteria reproduce most effectively at normal body temperature. So by
raising body temperature the rate at which the bacteria can divide is slowed down.
Fever has the opposite effect on most immune cells, causing them to divide more
quickly. So fever both slows down the spread of the infection and accelerates the
counterattack by the immune system.
All injuries and infections, as stated above cause a fever. This might only
manifest itself in a localized heat, and does not always produce an overall increase of
the body temperature.
Due to fever the patient has loss his appetite which is also a result of dysphagia or
difficulty to swallowing that pleads to body malaise.
Nursing Outcome Interventions Rationale Evaluation Discharge Plann
Diagnosis Criteria
Medication:
Altered Independent: Goals Met: >Medications should be
breathing After 30 Monitor vital To obtain regularly as prescribed,
pattern minutes of signs baseline data. After 30 dosage, time, & frequency, m
wa related to nursing minutes of sure that the purpose of me
t acute intervention, Assess for any Early nursing is fully disclosed by the
n tonsillophar the patient will signs and recognition of intervention, care provider. It should
As yngitis as be able to symptoms of untoward the patient with the assistance of th
by evidenced maintain altered signs and was able to safety.
. by presence airway patency breathing symptoms. maintain
of exudates. and clear pattern and airway Environment:
secretions. refer for any patency and > Should have an easy a
untoward clear necessities, should be w
ns: signs and secretions ventilated. Provide quie
symptoms. readily. peaceful environment fo
m and relaxation of patien
m Evaluate To determine
clients ability to Treatment:
cough/gag protect own >Encourage the patient
reflex and airway. complete the full days o
swallowing medication therapy
ability Home care:
of To promote Get plenty of rest
Elevate head physiological Drink warm liqu
of bed and/or and liquids.
ess have client sit psychological Encourage patien
up on chair. ease of gargle with warm
maximal water.
inspiration. If febrile, perform
give antipyretic
medication.
Diet:
>Advice patients folks t
healthy nutritious food.
foods that can cause alle
reactions to patient.
Support system:
> Encourage family to en
patients treatment.