Enerolisa Paredes, NUR 405, Nurse Care Plan 04/08/2017

Enerolisa Paredes

LEHMAN COLLEGE

DEPARTMENT OF NURSING

PEDIATRIC NURSE CARE PLAN

NUR 405

PROFESSOR MARTINEZ

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Enerolisa Paredes, NUR 405, Nurse Care Plan 04/08/2017

INTRODUCTION- I

Acute tonsillopharyngitis is an inflammatory process of the oropharynx. It

can become a particularly horrible throat infection involving Mycoplasma

pneumoniae and Chlamydia pneumoniae organisms that often occur in children. It

can also come to pass in patients who are given antibiotics for simpler infections and

founder to take the prescribed regimen (dose and time).

Viruses. The adenoviruses are the most common cause of tonsillopharyngitis,

especially types 1, 2, 3, and 5, which are the types that infect small children most

frequently. Other respiratory viruses are less common causes of tonsillitis; the

parainfluenza viruses probably are the most frequently isolated in this group. Herpes

simplex virus also is recognized as an occasional cause of tonsillopharyngitis, as is

Epstein-Barr virus. The most frequent causes of the common cold, the rhinoviruses and

coronaviruses, involve the tonsils.

Bacteria. Group A Streptococcus is the most important and frequent cause of

tonsillopharyngitis. It is frequently associated with acute rheumatic fever and acute

glomerulonephritis. Appropriate treatment of streptococcal pharyngotonsillitis prevents

the occurrence of rheumatic fever.

Epidemiology. Prevalence. The average incidence of all acute URIs is five to

seven per child per year. It is estimated that children have one streptococcal infection

every 4 to 5 years. Group A streptococci is isolated in 30-36.8% of children with

pharyngitis.

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Age Occurrence. Pharyngitis is infrequent in the first 2 years of life, when all

URIs are most frequent. Most cases of pharyngitis occur in school-age children, when the

incidence of all infections is still high but less than in the first 2 years.

Etiology. Viruses are isolated in about 50% of children less than 2 years old but

infrequently after that. Group A streptococcus is isolated most frequently in school-age

children, while M. pneumoniae is most often in teenagers.

Contact. All respiratory agents are spread by close contact or large droplets, with

the exception of influenza, which also is spread by small droplets and the airborne route.

A history of a household, school, or outside contact with another patient who has

tonsillopharyngitis due to a known agent, especially the group A Streptococcus, increases

the likelihood that the index infection has the same etiology.

OBJECTIVES- II

General Objectives:

To improve myself on formulating Nursing Care Plans.

Specific Objectives:

1. To know what can cause Acute Tonsilopharyngitis.

2. To know the anatomy and physiology of the body organ involved in Acute

Tonsilopharyngitis.

3. To understand the pathophysiology of Acute Tonsilopharyngitis.

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4. To relate my patient chief complaint on her condition having Acute

Tonsilopharyngitis.

5. To relate the medications and medical procedures done to JM on her condition of

having Acute Tonsilopharyngitis.

ANATOMY AND PHYSIOLOGY- III

The upper respiratory tract primarily refers to the parts of the respiratory

system lying outside of the thorax or above the sternal angle. Another definition

commonly used in medicine is the airway above the glottis or vocal cords. Some specify

that the glottis (vocal cords) is the defining line between the upper and lower respiratory

tracts; yet even others make the line at the cricoid cartilage.

Upper respiratory tract infections are amongst the most common infections in the

world.

NOSE: Physically a nose is an organ on the face. Anatomically, a nose is a

protuberance in vertebrates that houses the nostrils, or nares, which admit and expel air

for respiration in conjunction with the mouth. Behind the nose is the olfactory mucosa

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and the sinuses. Behind the nasal cavity, air next passes through the pharynx, shared with

the digestive system, and then into the rest of the respiratory system. In humans, the nose

is located centrally on the face; on most other mammals, it is on the upper tip of the

snout.

NASAL CAVITY: A large fluid filled space above and behind the nose in the

middle of the face.

PHARYNX: The part of the neck and throat situated immediately posterior to

(behind) the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx,

and trachea.

NASOPHARYNX: The uppermost part of the pharynx. It extends from the base

of the skull to the upper surface of the soft palate; it differs from the oral and laryngeal

parts of the pharynx in that its cavity always remains patent (open).

OROPHARYNX: Reaches from the Uvula to the level of the hyoid bone. It

opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall,

between the two palatine arches, is the palatine tonsil.

LARYNX: Commonly called the voice box, is an organ in the neck of mammals

involved in protecting the trachea and sound production. It manipulates pitch and volume.

The larynx houses the vocal folds, which are an essential component of phonation. The

vocal folds are situated just below where the tract of the pharynx splits into the trachea

and the esophagus.

DATA COLLECTION

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HEALTH HISTORY

Source and reliability of data: Mother. She was very reliable and

willing to cooperate.

Date of exam 04/08/2017

Name: Ms. JM

Age: 10

Sex: Female

Ethnicity: Hispanic

Language: Spanish and English

Date of birth: 05/06/2017

Religion: Roman Catholic

Education: 4th grade

Chief complaint: Sore throat, fever, runny nose, and nasal congestion.

Past medical history: Asthma (1 y.o. to present), Eczema (1 y.o. to present).

Surgical interventions history: None at the present.

General estimate of health prior to this consultation: Besides having asthma, which is in

good control, patient is in good health.

Immunization History: Up-to-date.
Developmental Level: Patient is able to apply logic thinking, and has the ability to focus

attention. Patient is a problem solver, as per mother said. She has a lot of friends and is very

well adapted.
Allergies: No known history.
Accidents and/or Injuries: No known history.
FAMILY HEALTH HISTORY: Anemia, Colon Cancer, Diabetes, Hypertension and obesity.
Family Genogram:

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Patient/Parents experience of illness: Mom states that she try to control the fever with over the

counter medication, but she felt impotent when the symptoms persist and she decided to go to the

urgent care.
Previous experience with the health care system: She use to go to Montefiores emergency room,

but now she attend to Essen Urgent Care and is very satisfied with the services she and her

daughter receive in that office.

Current Life Situation: Patient lives with mother and grandmother in an apartment studio; mom is

not working because she had an accident. Patient spends all weekends with the father that does

not work either. Mom said that both of them are looking for jobs.
Habits of Sleep: Patient use to sleep around 8 to 9 hours every day.
Diet: Mom said that patient has a healthy diet base on fruit, vegetables, rice, chicken and beans.
Play and Recreation: Patient practice softball everyday for more than 2 hours. Sometimes she

dance at home.
Smoking: No history
Alcohol: No history.
Client Profile: MJ is a 10 years old girl who loves to play softball and dance. She is one of the

best at school, as per mother said. She is good at everything, said the mother. When she started

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something never stop until is done. She enjoys playing with the grandmother and loves to eat at

restaurants. She also love music and likes to read books.

Home environment: Patient lives on a studio with the mother and grandmother. Mom provides

everything she needs because the father is not working at this moment.

REVIEW OF SYSTEMS

GENERAL PARAMETER OF HEALTH

Patient reports, fever, runny nose shivering, sore throat and nasal congestion.

SKIN: No birth marks, color changes, dryness, moles, moisture, pruritus (itching),

bruising, rashes, or petechial lesions. Denies easy bleeding

HAIR: Denies recent hair loss, change in texture or lice.

NAILS: No change in shape, color, brittleness.

HEAD: Denies headaches, head injury, dizziness or vertigo.

NEUROLOGICAL

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MENTAL STATUS: Denies somnolence, disorientation, mood changes, anxiety,

memory disturbance, phobias, hallucinations, depression, inability to meet

responsibilities

CEREBRAL DISTURBANCES: No seizures, vertigo or dysphasia.

MOTOR DISTURBANCES: No altered gait, coordination difficulty, tremors,

paresis or paralysis

SENSORY DISTURBANCES: No anesthesia or paresthesia.

EYES: No strabismus, vision changes, blurring, diplopia, pain, redness, swelling,

discharge or cataracts.

Last Vision Exam: 2017, patient uses glasses.

EARS: No earaches, infections, discharge. No tinnitus, vertigo or cerumen (wax).

Parents clean the ear weekly with the aid of Q-tips.

NOSE & SINUSES: Hyaline discharge, frequent colds, no pain or obstruction,

nasal congestions, denies nosebleeds. No allergies.

MOUTH & THROAT: Sore throath, hyperemic, no difficulty chewing, dysphagia

to solids, no bleeding gums, hoarseness. Teeth are in good condition, patient

brushes her teeth after each meal. Reports sore throat 4 to 5 times a year.

o Last dental checkup: 02/2017

Tonsillectomy: No history.

NECK: No pain, swollen or tender glands, enlargement, limited movement, lumps

or stiffness.

BREASTS: No pain, swelling, enlargement, limitation of movement or dimpling.

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o Axillae: No tenderness, lumps or swelling

o Pre-adolescents/adolescents when did breasts develop? No signs

o BSE none at the present.

RESPIRATORY: No croup, asthma (since 3 years old), no SOB, wheezing,

coughing or sputum production. No hemoptysis, exposure to environmental

hazards. No history or CRX.

Last Mantoux test reports on 2011 was negative.

CARDIOVASCULAR: No murmur, CHD, palpitations, cyanosis or exertional

dyspnea. Patien does not have any activity limitations an is able to keep up with

peers.

PERIPHERAL VASCULAR: No coldness, pedal pulses(+++).

GASTROINTESTINAL: Good appetite, denies food intolerance, allergies,

dysphagia, abdominal pain, N&V, diarrhea, constipation. No history of ulcers,

appendicitis, colitis, rectal bleeding, change in stools, stool color, Frequency of

BM (once a day).

GENITOURINARY: No urgency, nocturia, dysuria, polyuria or oliguria, no blood

in urine, enuresis, toilet trained at 2 years old.

o Female: No menstrual history, vaginal itching, discharge, abnormal

bleeding. Patient is not sexually active.

o Sexuality Sex education awareness? Mom wants to wait to speak about

sexuality with her daughter.

MUSCULOSKELETAL: No tenderness, cramps, swelling, weakness or

deformity. No stiffness, joint pain or swelling. No back pain.

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HEMATOLOGIC: No bleeding tendency, bruising or lymph node swelling.

o Blood transfusions: No history.

ENDOCRINE: Denies diabetes or symptoms (polyuria, polydipsia, polyphagia),

thyroid disease, heat/cold intolerance, changes in skin pigmentation or texture.

PHYSICAL EAMINATION- OBJECTIVE DATA

VITAL SIGNS

B/P: 122/83 mmHg

Pulse/Heart Rate: 78/min

RR: 16/min

Temp: 98.5 C

Weight: 151 pounds

Height: 56 inches

Pulse Oximeter: 96

GENERAL SURVEY

Patient looks alert, oriented on time, space and person. Appears stated age, looks

ill, obese, clean and neat.

Head, Eyes, Ear, Nose, Hair, Mouth, Throat

Head skull is normocephalic.

Hair long length hair, quantity is normal, evenly distributed, black color

and there is presence no flakes.

Eyes the conjunctive is pinkish, eye lashes are black, eyebrows are also

black and it is evenly distributed, pupil size is 3mm and corneas are clear

and no lesions noted upon inspection.

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Ears - there is presence of ear wax in the ear canal, its upper portion is in

line with the outer part of the eye and he has a good hearing acuity.

Nose the mucosa is pinkish in color and the nasal septum is at the

midline.

Mouth lips are symmetrical, pale, dry and without lesions. Oral mucosa

is pink and the frenulum under the tongue is at the center.

Throat no inflammations noted but slight pain noted upon inspection.

Neck

Its color is similar to other body parts. No lumps or goiter noted upon

inspection. No palpable lymph nodes noted upon palpation but pain of

5 out of 10 was noted noted.

Chest, Breast and Axilla

Chest and Lungs it is symmetrical, same in color and equal in size

and shape. Crepitus or tactile fremitus noted upon auscultation.

Breast It is symmetrical. The aroela is brownish in color. No masses

and tenderness noted upon percussion.

Axilla no palpable lymph nodes noted upon palpation.

Heart

Cadiac rate is 83 beats per minute during my care. No S3 and S4 heart

sound noted upon auscultation.

Abdomen

It is symmetrical and the umbilicus is at the center. No lesions noted upon

inspection.

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Back

Symmetrical to the head, straight and there are no lesions but sores are

noted upon inspection. He has a skin color similar to other body parts.

Upper and lower extremities

They are symmetrical to their opposites. Finger nail are non-cyanotic and

no clubbing noted upon inspection. Skin color is similar to other body

parts.

Skin

Color of the skin is light brown, its moisture is dry, warm to touch and she

has a good skin tugor.

LABORATORY DATA:

Rapid strep: Negative

Throat culture: Done. Sent to laboratory.

MEDICATIONS

Albuterol (Proventil, Ventolin). Neb. (0.083%)

Short-acting beta2-agonists are bronchodilators. They relax the muscles lining the

airways that carry air to the lungs; treatment of choice for acute exacerbation of asthma.

Fluticasone (Flovent). Aerosol inhaler. 88 mcg twice daily

Corticosteroids reduce inflammation in the airways that carry air to the lungs and reduce

the mucus made by the bronchial tubes. Inhaled steroids should be given after beta-2-

adrenergic agonist.

Amoxicillin 500 mgrs/8hrs daily.

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Derivative of ampicillin and has similar antibacterial spectrum (certain gram-positive and

gram-negative organisms); similar bactericidal action as penicillin; acts on susceptible

bacteria during multiplication stage by inhibiting cell wall mucopeptide biosynthesis;

superior bioavailability and stability to gastric acid and has broader spectrum of activity

than penicillin; less active than penicillin against Streptococcus pneumococcus;

penicillin-resistant strains also resistant to amoxicillin, but higher doses may be effective;

more effective against gram-negative organisms (eg, N meningitidis, H influenzae) than

penicillin.

DISCHARGE INSTRUCTIONS:

Seek care immediately if:

Your child suddenly has trouble breathing or turns blue.

Your child has swelling or pain in his jaw.

Your child has voice changes, or it is hard to understand his speech.

Your child has a stiff neck.

Your child is urinating less than usual or has fewer diapers than usual.

Your child has increased weakness or fatigue.

Your child has pain on one side of his throat that is much worse than the other

side.

Contact your child's healthcare provider if:

Your child has throat pain, trouble swallowing, fever, or other symptoms that are

not getting better or are getting worse.

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Your child has a rash on his body. He may also have reddish cheeks and a red,

swollen tongue.

Your child has new ear pain, headaches, or pain around his eyes.

Your child pauses in his breathing when he sleeps.

You have questions or concerns about your child's condition or care.

Follow up with your child's healthcare provider as directed:

Write down your questions so you remember to ask them during your visits.

Manage your child's pharyngitis:

Have your child rest as much as possible.

Give your child plenty of liquids so he does not get dehydrated. Give him

liquids that are easy to swallow and will soothe his throat.

Soothe your child's throat. If your child can gargle, give him of a teaspoon of

salt mixed with 1 cup of warm water to gargle. If your child is 12 years or older,

give him throat lozenges to help decrease his throat pain.

Use a cool mist humidifier to increase air moisture in your home. This may

make it easier for your child to breathe and help decrease his cough.

Help prevent the spread of pharyngitis:

Wash your hands and your child's hands often. Keep your child away from other people

while he is still contagious. Ask your child's healthcare provider how long your child is

contagious. Do not let your child share food or drinks. Do not let your child share toys or

pacifiers. Wash these items with soap and hot water.

When to return to school or daycare:

Your child may return to daycare or school when his symptoms go away.

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REFERENCES

Herdman, H. T., & Kamitsuru, S. (2014). Nursing diagnoses 2015-2017 definitions and
classification. Oxford: Wiley.

Hockenberry, M. J. & Wilson, D. (2011). Wongs Nursing Care of Infants and Children
(9th ed.). Philadelphia, PA: FA Davis Company.

Jarvis, C. (2012). Physical examination and health assessment (6th ed). Saunders.

McKinney, E. S. (2012). Maternal-child nursing (4th Ed.). St. Louis, Missouri:

Elsevier/Saunders.