ACUTE TONSILLO PHARYNGITIS EXUDATIVE CASE STUDY 2013

1. Basis of selection of case Group A Beta Hemolytic Streptococci (GABHS) is a common cause of sore throat, usually spread person-to-person. Outbreaks related to infected food have more seldom been reported. The bacteria may originate from the throat or from wounds on the hands of persons handling the food. An outbreak in 2003 involving 153 individuals who fell ill after eating contaminated 'sandwich-layer cakes' was investigated. The average attack rate was 72%. A food-borne tonsillopharyngitis outbreak was reported in 2008. The participants (n = 403) were divided into two groups: the study group (n = 252); those with any two of the following three complaints; sore throat, fever, and dizziness, and the control group (n = 151); those without these complaints. This investigation revealed that 252 people were affected by this outbreak. Group A -hemolytic streptococci were isolated from the throat cultures of 63 affected individuals (25%) and an employee working in the patisserie that made desserts served for lunch. The basis of selection of our study is the alarming number of cases of tonsillopharyngitis among aged groups especially in children. 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. Reflection of Nursing Process 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 II. Present Health or History of present illness. PTA the child has noted to have cough and nasal catarrh and 3 days PTA 3 episodes of vomiting noted with fever up to 38C.The effect of pain on the behavior of the child is that he is irritable and he cannot speak well Past Health 1. Prenatal status The spacing of the pregnancy was one year and it was planned. The mothers attitude and the fathers attitude towards pregnancy were glad. There is a medical supervision and it started at the second month of pregnancy. The health status of the mother is generally good with no complication, vomiting noted, gain weight, and edema of the feet. The medication prescribed to the mother during pregnancy was calcium supplement and undergone UTZ during her pregnancy.

III.

2. Labor and Delivery Gravida 2; Para 2 (G2P2). The duration of the pregnancy is 9 months and the place of pregnancy was at West Visayas State University Medical Center and the type of delivery was normal. The birth weight is 7.9 lbs. 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.)

5. Serious Accidents or Injuries The child doesnt have any record of accidents or injuries. 6. Serious or chronic illnesses The patient has a pneumonia and asthma last 2 months and the child was hospitalized. 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. IV. Developmental History 1. Growth The height of the patient is 106 cm. and its weight is 19.7 kgs. 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 Gross motor skills He walks alone, skips and climbs at the age of 1 year old. Fine motor skills At the age of 2 the child can stack blocks and uses crayons to draw. At the age of 3 the child can already feed self and at the age of 4 years old the child can dress and undress on his own, brush teeth and draw simple shapes. 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-sunexposed 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. MOUTH AND OROPHARYNX Lips symmetric vertically and horizontally at rest and moving. Teeth are stained yellow. Pinkish red, smooth and moist buccal mucosa. Halitosis noted. Gums are light pink in color and no bleeding. Incomplete teeth noted. Tongue is midline, dull red in color and moist. Hard palate and soft palate are pinkish in color. Tonsils projecting beyond limits of tonsillar pillars. Tonsils red, enlarged and covered with exudates. Grade 2 inflammation of tonsils noted. Posterior wall of pharynx is red bulge adjacent to tonsil extending beyond midline. 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. THORAX AND CHEST Elliptical in shape and move symmetrically when breathing. No chest retraction noted. Tachypnea noted with a respiration of 29 bpm. The areola and nipples are brown in color and no discharges noted. Apical pulse auscultated. Crackles noted on anterior lungs. 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. GENITO-ANAL AND GENITO-URINARY Pubic hairs are not present. There is no skin lesions, penile discharges and swelling noted. No hemorrhoids and bleeding. Urinated a minimal amount of yellowish color urine. Defecated to a yellowish brown watery stool.

DIAGNOSTIC TEST LABORATORY TESTS Urinalysis Color Transparency Reaction Specific gravity Pus cells Red blood cell amorphous phosphate squamous epithelial cells bacteria mucus threads Hematology hemoglobin hematocrit

RESULT Pale straw Slightly hazy Neutral 1.020 0-2 hpf 0-2 hpf Few Occasional Occasional Occasional 99 gms/L 0.29 vol. fr

NORMAL VALUE

SIGNIFICANCE

1.0 10-1.025

NORMAL

red blood cell count 3.43 x 1012 /L white count blood cell 3.65 x 103 /L 23 % 18 % 5% 73 % 4% 328 x 109 /L 85.2 fl 98.8 pg

Male: 130-180 g/L Male: 0.40 0.54 vol. fr Male: 4.6 6.2 x 1012 /L 4.5 11 x 103 /L 55-70% 50-70% 2-5% 20-40% 3-9% 150-450 x 109/L Male: 60 100 fl 25.4 34.6 pg

Anemia Anemia Anemia, nutritional deficiency Infection Lower protection to bacteria NORMAL Acute infection NORMAL NORMAL NORMAL Macrocytic anemia due to low vitamin B12 or folic acid

neutrophil segmenter stab lymphocyte monocyte platelet count MCV MCH

MCHC RDW Throat Culture

33.8 g/dl 11.52 Positive

Male: 31 37 g/dl 11.5-14.5 Causative agent GABHS detected

D. Drug Therapy Generic name: Cetirizine Classification: Antihistamine Dosages: (Adults and Children 6 yr and older) = 10 mg/day PO or 5 mg PO bid Therapeutic actions: Potent specific histamine (H1) receptor antagonist; inhibits histamine release and eosinophil chemo taxis during inflammation, leading to reduced swelling and decreased inflammatory response. Indications: Management of seasonal and perennial allergic rhinitis, allergies, hay fever Treatment of chronic, idiopathic uticuria Unlabeled uses: To decrease wheal response and pruritus of mosquito bites; possible use in allergic asthma. Contraindications and cautions: Contraindicated with allergy to any anti histamines, hydroxyzine. Not recommended for children < 2 y.o. Lactation Adverse Effects: CNS: Somnolence, sedation CV: Palpitation, edema, dizziness GI: Nausea, diarrhea, abdominal pain Respiratory: Bronchospasm Other: Fever, rash, fatigue Nursing Considerations: Give w/out regard on meals Provide oral solution form or chewable tablets for pediatric use if needed. Evaluate therapeutic response Patient teaching: Take this drug w/out regards to meals Report difficulty of breathing, hallucinations, tremors, loss of coordination, irregular heartbeat. Generic name: Paracetamol Classification: Analgesic and Anti pyretic Dosages: 250 mg/tab q 4 hr for fever Route: Oral Therapeutic actions: It inhibits prostaglandin synthesis

 Is effective at reducing pain and fever Indications: Treatment of mild to moderate pain Temporary reduction of fever Temporary relief of minor aches Contraindications and cautions: Contraindicated in patients w/ hypersensitivity to paracetamol Contraindicated in patients w/ kidney and liver diseases Adverse Effects: CNS: Headache CV: Chest pain, dyspnea GI: Acute renal failure Nursing considerations: Do not exceed the recommended dosage Reduce dosage w/ hepatic impairment Discontinue drug if hypersensitivity reactions occur Patient teaching: Take the drug only for complaints indicated; it is not an anti-inflammatory agent Report for rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding pattern. Generic name: Paracetamol Brand name: Acetaminophen Classification: Antipyretic Dosages: 12.5 mg/kg q 4 hr Route: IV/Parenteral Therapeutic actions: Inhibits the synthesis of prostaglandin that may serve as mediators of pain and fever, primarily in the CNS. Has no significant anti-inflammatory properties/GI toxicity. Indications: Treatment of mild pain Treatment of moderate to severe pain Contraindications and cautions: Contraindicated in previous hypersensitivity Products containing alcohol should be avoided in patients who have hypersensitivity/intolerance to these compounds. Adverse Effects: Skin eruption Hematological toxicity(thrombocytopenia)leading to cyanosis

 Renal damage Nursing considerations: Assess overall health status Assess type, location, and intensity of pain prior to 30-60 minutes following administration. Assess fever, note presence of associated sign. Patient teaching: Advise patient to consult physician if discomfort or fever is not relieved by routine doses. Report for rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding pattern. Generic name: Zinc Classification: Vitamins and Mineral Dosages: 5 ml OD Route: Oral Therapeutic actions: Serve as cofactor for many enzymatic reactions. Required for normal growth and tissue repair, wound healing, and sense of taste and smell. Indications: Replacement and supplement therapy in patients who are at risk of zinc deficiency. Contraindication and cautions: Hypersensitivity / allergy to any components in the formulation. Use cautiously in renal failure. Adverse effects: Acute toxicity may cause diarrhea, vomiting & lethargy Nursing Considerations: Monitor progression of zinc deficiency symptoms during therapy. Emphasize the importance of follow up exams. Patient teaching: Inform the patient to notify any health care team if he/she feels nausea, vomiting, abdominal pain, tarry stools occur. Generic name: Ampicillin Sulbactam Classification: Antibiotic Dosages: 750 ml IVTT q 6 hr Route: IV/Parenteral

Therapeutic actions: Bactericidal action against sensitive organism; inhibits synthesis of bacterial cell wall, causing cell death. Indications: Treatment of infections caused by susceptible strains of Shigella, Salmonella, E Coli, gram positive organism Meningitis Contraindications and cautions: Contraindicated w/ allergies to penicillin, cephalosporin, or other allergens. Use cautiously with renal disorder. Adverse effects: CNS: Lethargy, hallucinations, seizures CV: Heart Failure GI: Nausea, vomiting, abdominal pain, bloody diarrhea GU: Nephritis Hematologic: Anemia, prolonged bleeding time Hypersensitivity: Rash, fever, wheezing Local: Pain Nursing considerations: Check IV site carefully for signs of thrombosis or drug reaction Do not give IM injections in the same site; atrophy can occur Patient teaching: Inform patient that they may experience these side effects: Nausea, vomiting, GI upset (eat small frequent meals), diarrhea Tell patient to report pain or discomfort at sites unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, diarrhea, difficulty of breathing Generic name: Salbutamol Brand name: Albuterol Classification: Anti-asthmatic, Bronchodilators Dosages: 2-12 yrs old: for child 10-15 kg use 1.25 mg BID or TID by nebulization; for child more than 15 kg, use 2.5 mg BID or TID by nebulization Route: Inhalation Therapeutic actions: In low doses, acts relatively selectively at beta2 adrenergic receptor to cause bronchodilation and vasodilatation; at higher doses beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical symphatomimetic cardiac effects. Indications: Relief and prevention of bronchospasm in patients w/ reversible obstructive airway disease or COPD

Inhalation: Treatment of acute attacks of bronchospasm Prevention of exercise-induced-bronchospasm Contraindicated with hypersensitivity to albuterol, tachyarrhythmia, tachycardia. Patients w/ diabetes mellitus Adverse effects: CNS: Restlessness, anxiety, fear, CNS stimulation CV: Cardiac arrhythmias, tachycardia, palpitations, anginal pain Dermatologic: Sweating, pallor, flushing Respiratory: Coughing, respiratory difficulties Nursing Consideration: Do not exceed recommended dosage Maintain a beta-adrenergic blocker on standby in case of emergency Patient Teaching: Inform patient that they may experience these side effects: Dizziness, drowsiness, fatigue, headache, nausea, vomiting, change in taste, anxiety, sweating, flushing, insomnia. Tell patient to report chest pain, dizziness, weakness, tremors, or irregular heartbeat, difficulty of breathing, productive cough. E. PATHOPHYSIOLOGY: Anatomy of Upper Respiratory Tract

OVERVIEW: 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. An upper respiratory tract infection, or upper respiratory infection, is an infectious process of any of the components of the upper airway. It is one of the most frequent causes of physician visits with varying symptoms ranging from runny nose, sore throat, cough, to breathing difficulty, and lethargy 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

Get plenty of rest. Drink plenty of water. Gargle with warm salt water several times a day. Drink warm liquids (tea or broth) or cool liquids. Avoid irritants that might affect your throat, such as smoke from cigarettes, cigars, or pipes, and cold air. Avoid drinking alcohol.

Complications of Streptococcal Tonsillopharyngitis Non Suppurative Complications: Acute rheumatic fever Scarlet fever Streptococcal toxic shock syndrome Acute glomerulonephritis PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococci) Suppurative Complications: Tonsillopharyngitis pharyngeal cellulitis or Abscess Otitis Media Sinusitis Necrrotizing Fasciitis Others 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

Group A Beta hemolytic streptococcus

Tonsil/Pharynx

Lymphocytes

IgM

Inflammatory Process

Neutrophils/ Macrophages

Pyrogen Secretions Stimulates fever production

5 Cardinal signs: Warmth Redness Swelling Pain Decreased Function

Histamine/Kinins Secretions (causes vascular permeability & vasodilator)

Dysphagia

Reset Hypothalamus Regulator

Fever

Loss of Appetite

Malaise

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. Predisposing factors are classified as Non Modifiable and Modifiable. Non Modifiable factors include: Age Gender Heredity Modifiable factors include: Environment a. Exposure to different smoke, pollutants or irritants Lifestyle Past Medical History Group A Beta-Hemolytic Streptoccocus as the causative agent can be acquired through ingestion of foods with the microorganism or by airborne droplet as the means of transmission. 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. Pyrogen Secretions are then excreted by the microorganisms, neutrophils, monocytes and other cells that stimulate fever production by acting the hypothalamus. Increasing levels of prostaglandin E2 in the brain induce an area called the hypothalamus to turn up the body's thermostat a notch. Suddenly, the same external temperature feels colder, and various means are employed to restore the subjective impression of warmth. These include involuntary processes such as shivering, which generates heat by movement, and voluntary behavior such as putting on more clothes, finding a warm radiator to sit next to, and so on. 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.

Cues

Nursing Diagnosis Altered breathing pattern related to acute tonsillophar yngitis as evidenced by presence of exudates.

Outcome Criteria

Interventions

Rationale

Evaluation

Discharge Planning Medication: >Medications should be taken regularly as prescribed, on exact dosage, time, & frequency, making sure that the purpose of medications is fully disclosed by the health care provider. It should be taken with the assistance of the folks for safety. Environment: > Should have an easy access to necessities, should be well ventilated. Provide quiet and peaceful environment for comfort and relaxation of patient. Treatment: >Encourage the patient to complete the full days of medication therapy Home care: Get plenty of rest. Drink warm liquids or cool liquids. Encourage patient to gargle

Subjective: Budlayan mag ginhawa kag gasakit pagid akon tutunlan. As verbalized by the patient. Objective: Vital Signs: T- 38 C P- 88 bpm R- 30 bpm Dyspnea Cough Presence of exudates Restlessness

After 30 minutes of nursing intervention, the patient will be able to maintain airway patency and clear secretions.

Independent: Monitor vital signs Assess for any signs and symptoms of altered breathing pattern and refer for any untoward signs and symptoms. Evaluate clients cough/gag reflex and swallowing ability Elevate head of bed and/or have client sit

Goals Met: To obtain baseline data. Early recognition of untoward signs and symptoms. After 30 minutes of nursing intervention, the patient was able to maintain airway patency and clear secretions readily.

To determine ability to protect own airway.

To promote physiological and psychological

up on chair.

ease of maximal inspiration.

with warm saline water. If febrile, perform TSB, give antipyretic medication.

Observe for signs and symptoms of infection

To identify infectious process and promote timely intervention. Helps to prevent/reduc e fatigue.

Health Teaching: >Teach patient of frequent and proper hand washing (to prevent spreading of infection to others). >PROMOTE PROPER HYGIENE/PREVENTIONOF INFECTION. Since the immune system is compromised, every effort should be maintained to prevent infection. Frequent hand washing is the best way to control infection. Wash hands thoroughly with warm, soapy water, especially before eating or preparing food and after using the toilet. Carry an alcohol-based hand sanitizer during times when water is not available.

Encourage/ provide opportunities for rest; limit activities to level of respiratory tolerance Advice to increase fluid intake

To prevent drying of secretions

Collaborative:

 Administer medications To relax (antibiotics, smooth bronchodilator respiratory s) as ordered musculature and mobilize Assist with secretions. use of respiratory Various devices and therapies/mod treatments. alities may be required to acquire and maintain adequate airways, improve respiratory function and gas exchange. Perform chest physiotherapy To get rid of after PAI. airway secretion and to help patient breathe more freely.

>ADHERE TO TREATMENT REGIMEN Adherence to the treatment regimen is essential in order to prevent relapse. Most common cause of relapse is loss to compliance. Medications should be administered at proper time and proper dosage. >Avoid irritants, such as pollutants and cigarette smoke. > Advice patients folks to cook food for diet thoroughly. Out Patient: >OPD such as follow-up check-up as ordered by the physician should be greatly encouraged for the patient to determine the patients development and for the physician to know if the medication and treatment ordered will be continued or not.

Diet: >Advice patients folks to prepare healthy nutritious food. Avoid foods that can cause allergic reactions to patient. >High Protein- Protein is for tissue repair since patient has some tissue damage, giving high protein diet aids in healing. >High in Vitamins- Vitamins protects the patient from infection. >MEETING NUTRITIONAL AND FLUID NEEDS Bear in mind the food preferences of the child when planning for menus. Presenting the food in an attractive manner increases the interest of the patient. Increase intake of protein-rich foods for further healing and food rich in fiber and Vitamin C. Encourage patient to increase fluid intake

Support system: > Encourage family to engage in patients treatment. > Have the family attend to spiritual, physical and emotional needs of the patient at home.

F. Prioritizing Nursing Diagnosis 1. Altered breathing pattern related to acute tonsillopharyngitis as evidenced by presence of exudates. 2. Acute pain related to inflammation of tonsillopharyngeal as evidenced by difficulty of swallowing. 3. Imbalance nutrition less than body requirements related to difficulty of swallowing. 4. Hyperthermia related to acute infection by microorganisms. 5. Knowledge deficit related to not familiar with the sources of infection.