CASE PRESENTATION

RELATED TO CLIENTS
WITH UPPER
RESPIRATORY
PROBLEMS:
TONSILLITIS
CLINICAL GROUP D

10-05-20
 Table of Contents
01 02 03
Signs and Laboratory Pathophysiol
Symptoms Findings and ogy
Diagnostic
Exams
Interpretatio
04 05
ns
06
Drug Nursing Discharge
Study Care Plans Plan
 Case
Scenario
Marie is a 19 year-old student admitted at a Medical-
Surgical Ward with chief complaints of throat pain,
difficulty of swallowing, and elevated body temperature.
She claimed that she experienced sore throat 3 days prior
to admission, followed by difficulty of swallowing the next
morning, and experienced fever at 38.4⁰C in the
afternoon. Her body temperature ranges from 37.9⁰C to
38.8⁰C. Upon outpatient consultation, the patient’s
temperature was at 38.5⁰C, has white patches on tonsils,
has muffled voice when speaking, headache, and tender,
swollen, lymph nodes on the sides of the neck.
 Case
Scenario
Her parents brought her for consultation because
Marie’s body temperature goes down to normal
only within 4 hours of taking antipyretic
medication, and is only able to consume a small
amount of food for the past 2 days. Her parents
added that this is Marie’s 2nd time to experience
this condition. Upon the advice of the physician,
Marie is to be admitted for further management
and evaluation, and was subsequently admitted to
Medical-Surgical Ward.
01
PRIORITY SIGNS
AND SYMPTOMS
 a. Sore b. Difficulty
throat for 3 swallowing
b.1. Loss of appetite
days prior
to admission
c. Fever that
a.1. Tender, swollen, lymph nodes ranges from
a.2. White patches on tonsils
a.3. Muffled voice when speaking 37.9C to 38.8C
c.1. Headache
 02
LABORATORY
FINDINGS AND
DIAGNOSTIC
RESULTS
INTERPRETATION
 COMPLETE BLOOD COUNT

TEST UNIT NORMAL VALUES RESULTS CLINICAL

SIGNIFICANCE
WBC Count X10^9/L 5.0-10.0 INCREASED Total WBC count is
significantly
increased in patients
with tonsillitis
because it indicates
that the body if
fighting off an
infection.
Differential Count       In patients with
tonsillitis,
Lymphocytes % 0.20-0.35 INCREASED lymphocytes are
      increased because of
the bacteria causing
the infection. The
body is trying to fight
off the bacteria
 
 URINALYSIS

Parameters Results Reference Implication  

Macroscopic exam
The urine is usually described as being
smoky, cola colored, tea colored, or rusty.
Color Dark-colored urine   The color is usually dependent on the  
amount of blood present and the pH of the
urine.
Chemical examination
Leukocyte Trace <trace Infection  

Post-streptococcal glomerulonephritis – may

Blood Trace <trace occur 2-3 weeks after infection. This causes  
haematuria (bloody urine)
Is excreted through the urine due to kidney
Protein Trace <trace  
impairment
 03
PATHOPHYSI
OLOGY
NARRATIVE PATHOPHYSIOLOGY
Tonsillitis is an infection of your tonsils, two masses of tissue at the back of
your throat. Your tonsils act as filters, trapping germs that could otherwise enter
your airways and cause infection. They also make antibodies to fight infection.
But sometimes, they get overwhelmed by bacteria or viruses. This can make them
swollen and inflamed.
Based on the scenario, we have identified the predisposing and precipitating
factors that could trigger the disease. Under the predisposing factors is age.
Tonsillitis most often occurs in children, but rarely in those younger than age 2.
While under the precipitating factors is the invasion of the pathogen may it be a
viral or bacterial infection. The most common bacterium causing tonsillitis is
Streptococcus pyogenes (group A streptococcus), the bacterium that causes strep
throat. The viruses that cause the common cold are often the source of tonsillitis,
but other viruses can also cause it such as Adenoviruses, Epstein-Barr virus,
Herpes simplex virus, and measles virus.
NARRATIVE PATHOPHYSIOLOGY
Once the pathogen invaded the mucous membrane our first line of defenses is
activated. Our white blood cells are activated and they infiltrate the site of the
infection. They fight against that pathogen and kills it. After that there will be an
accumulation and deposition of cellular debris and products of inflammatory
response which results the white and yellow spots or it is called tonsillar
exudate.
NARRATIVE PATHOPHYSIOLOGY
After also the invasion of pathogen in the mucous membrane our
inflammatory system releases cytokines. Cytokines are small secreted
proteins released by cells have a specific effect on the interactions and
communications between cells. With the invasion of the pathogen in the
mucous membranes, the activation of cytokines are precursor by the antigen
presenting cell-macrophage. The activation of cytokine-producing cells
triggers them to synthesize and secrete their cytokines. The cytokines, in
turn, are then able to bind to specific cytokine receptors on other cells of the
immune system. This in turn leads to the increase of vascular permeability of
vascular walls within the local infection. This leads to the leakage of protein
and fluid into the surrounding tissue. This affects the localization of the
tonsillar tissue, nasal tissue and regional lymph nodes especially the anterior
cervical lymph nodes. This can cause swelling and irritation on both the
tonsillar and nasal tissue and may cause enlargement on the regional lymph
nodes.
NARRATIVE PATHOPHYSIOLOGY
The swelling and irritation of the tonsillar tissue may cause tonsillar edema
that may lead to a variety of symptoms such as dysphagia, difficulty of
breathing, throat irritation and snoring. Muffled voice may be present
secondary to throat irritation. In the nasal tissue, the accumulation of
secretions within the area may cause nasal congestion and coryza. Which
may lead to the production of cough as the discharges within the nasal area
may irritate the back of the throat. Also, cytokines inadvertently causes
cellular injury and hemolysis that may present as petechiae and erythema in
the tonsillar tissue. Lastly, these systemic inflammatory cytokines disrupt the
hypothalamic regulation which causes fever which in turn may be
accompanied by an occasional headache.
 04
DRUG
STUDY
 Drug Cefuroxime
Name Profurex
2nd Generation Drug
Cephalosporin Class
• Injection, Powder for Reconstitution:
750 mg, 1.5 g.
Drug • Injection, Solution: 750 mg/50 ml, 1.5
g/50 ml. Oral
Availability • Suspension (Ceftin): 125 mg/5 ml, 250
mg/5 ml.
• Tablets (Ceftin): 250 mg, 500 mg

600mg thru IV Dosage

 Cefuroxime binds to one or more of the
Mechanism of penicillin-binding proteins (PBPs)
which inhibits the final transpeptidation
Action step of peptidoglycan synthesis in
bacterial cell wall, thus inhibiting
• biosynthesis and arresting cell wall
Pharyngitis
assembly resulting in bacterial cell
• Tonsillitis death.
• Acute Otitis Media
• Acute Bacterial Maxillary Sinusitis Indicatio
• Impetigo
• Gonorrhea ns
• UTI
• Perioperative Prophylaxis

Contraindicat Hypersensitivity to
ions cephalosporins.
 • Use cautiously in patients
Cautions hypersensitive to penicillin
• Severe renal impairment,
history of penicillin allergy
Frequent:
• Discomfort with IM administration
• Oral candidiasis (thrush) Side
• Mild diarrhea Effects
• Mild abdominal cramping
• Vaginal candidiasis

Occasional: Rare:
• Nausea • Allergic reaction (rash, pruritus,
• Serum sickness-like reaction urticaria),
(fever, joint pain; usually occurs • thrombophlebitis (pain, redness,
after second course of therapy and swelling at injection site).
resolves after drug is
discontinued).
 • Antibiotic-associated colitis, other
superinfections (abdominal cramps,
severe
• watery diarrhea, fever) may result
from altered bacterial balance.
Adverse • Nephrotoxicity may occur, esp. in
Effects pts with preexisting renal disease.
• Pts with a history of allergies, esp. to
penicillin, are at increased
• risk for developing a severe
hypersensitivity reaction (severe
pruritus, angioedema, bronchospasm
anaphylaxis).
 Before:
• History: Hepatic and renal impairment, lactation,
pregnancy, allergies, particularly cephalosporins,
penicillin.
During
• Monitor daily pattern of bowel activity, stool
Nursing consistency
• Monitor I&O, renal function tests for
Responsibil nephrotoxicity
ities • Monitor frequently for thrombophlebitis
• Be alert for superinfection
• Discontinue if hypersensitivity reaction occurs.
After:
• Advice patient or SO to report signs of
superinfection
• Caution patient that drinking alcohol should be
avoided during and several days after the therapy
• Advise patient to report discomfort at the I.V.
insertion site.
 Drug
Co-Amoxiclav
Name
Drug
Antibiotics
Class
Drug • Tablet
• Oral liquid medicine
Availability • Injection

625mg/cap, 1 cap BID

to complete 7 days Dosage
 An antibiotic that combines amoxicillin
and clavulanic acid. It destroys bacteria
by disrupting their ability to form cell
walls. Clavulanic acid blocks the
Mechanism of chemical defense, known as beta-
Action lactamase that some bacteria have
against penicillin’s.
 
Co-amoxiclav is active against bacterial
infections that have become resistant to
amoxicillin

Given to treat bacterial Indicatio

infections. ns
  History of hypersensitivity to beta-
lactams, e.g. penicillins and
Contraindication cephalosporins
s  Previous History of amoxicillin-
clavulanate associated with
jaundice/hepatic dysfunction
• Renal impairment.
• Erythematous rashes common
in glandular fever
• Cytomegalovirus infection
• Acute or chronic lymphocytic Cautions
leukemia
• Hepatic impairment
• Pregnancy
• Cholestatic jaundice
  Nausea
Side  Vomiting
Effects  Headache
 Diarrhea
• Skin rash
• Itching or hives
• Has problems breathing or Adverse
seems short of breath or is
wheezing Effects
• Their face, throat, lips or tongue
start to swell.
 Before:
• Obtain a history before initiating therapy
to determine previous use of and
reactions to penicillins or
Nursing cephalosporins. Persons with a negative
history of penicillin sensitivity may still
Responsibil have an allergic response.
ities • Observe for signs and symptoms of
anaphylaxis (rash, pruritus, laryngeal
edema, wheezing).
• Obtain specimens for culture and
sensitivity prior to therapy. First dose
may be given before receiving results.
 DURING:
• Administer at the start of a meal to enhance absorption
and to decrease GI side effects.
• Do not administer with high fat meals; clavulanate
absorption is decreased.
• Capsule contents may be emptied and swallowed with
liquids.
Nursing AFTER:
• Teach parents or caregivers to calculate and measure
Responsibil
doses accurately. Reinforce importance of using
ities measuring device supplied by pharmacy or with product,
not household items.
• Advise patient to report the signs of superinfection (furry
overgrowth on the tongue, vaginal itching or discharge,
loose or foul-smelling stools) and allergy.
• Instruct patient to notify health care professional
immediately if diarrhea, abdominal cramping, fever, or
bloody stools occur and not to treat with anti-diarrheals
without consulting health care professionals
 Drug Acetaminophen
Name Paracetamol
Drug
Analgesics
Class
Drug
Availability

1-tab q 4 for temp Dosage

above 37.8
 Appears to inhibit prostaglandin synthesis
Mechanism of in the CNS and, to a lesser extent, block
pain impulses through peripheral action.
Action Acts centrally on hypothalamic heat-
regulating center, producing peripheral
vasodilation

Mild pain or fever

Indicatio
ns
Contraindicat
Severe hepatic impairment or
ions severe active liver disease
  Sensitivity to acetaminophen;
 Severe renal impairment;
 Alcoholic hepatic disease, hepatic
Cautions
impairment, or active hepatic
disease; chronic malnutrition
 Hypovolemia

Rare: Side
Hypersensitivity reaction Effects
 Early Signs of Acetaminophen
Toxicity:
 Anorexia, nausea, diaphoresis,
Adverse fatigue within first 12–24 hrs.
Later Signs of Toxicity:
Effects
 Vomiting, right upper quadrant
tenderness, elevated hepatic
function tests within 48–72 hrs.
after ingestion
 Before:
 Assess onset, type, location, duration of pain
 Assess for fever.
 Assess alcohol usage.
 Check that the patient is not taking any other
Nursing medication containing paracetamol.
During
Responsibil
 Assess for clinical improvement and relief of pain,
ities fever
After:
 If symptoms persist for more than three days,
patients should consult the prescribing practitioner.
 Make sure patients are aware they must not exceed
the recommended dose.
05
Nursing Care Plans
Acute Pain
 NURSING SCIENTIFIC
CUES OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS BASIS

Subjec- Acute pain Tonsillitis Short Term: Independent: Independent: Short Term:
tive: r/t swelling occurs when After 1-2 1. Establish rapport. 1. This allows you to After 1-2 hours
“It iya but- of tonsil the tonsils hours of create trust and of appropriate
ol sige it tissues as become appropriate harmonious nursing
paginul- evidenced inflamed or nursing relationship with interventions,
ulon. Mga by reports infected by interventions, client. the client stated
tulo na ka- of pain bacteria. the client will: 2. Assess pain using 2. Use of a pain scale decreased level
adlaw   • state appropriate allows objective of pain and
tapos Throat pain decreased pain scale. measurement appeared more
ginsundan occurs due to level of pain   of subjective pain relaxed or
pa hin the • appear   perception. comfortable.
makuri na inflammation more 3. Observe child for 3. Provides additional  
pagtutulon and edema of relaxed or nonverbal indicatio information about  
.” As the tonsillar comfortable ns of pain such pain. The child may Short term
verbalized tissue which as crying, find discomfort in goals met.
by mother makes grimacing, speaking.
of the swallowing irritability.
client. and talking
 
Objective: difficult, and Long Term: 4. Assess for signs of 4. Throat pain often Long Term:
• tender forces the After 1-2 dehydration. causes them to After 2-3 days
and child to days of   refuse food and of appropriate
swollen breathe appropriate   drink because nursing
tonsils through nursing   swallowing is interventions,
• palpable the mouth. interventions,   painful. Note the client:
lymph   the client will: mucous • stated being
glands   • be free membranes.  free from pain
on the   from pain 5. Suggest diversional  5. Provides a and difficulty
sides of   and activity such as distraction swallowing
the neck   difficulty watching a video, from discomfort. • had adequate
• white   swallowing reading a book or   nutritional
patches Reference: • have listening to music.   intake and
on Pathophysiolo adequate     hydration as
tonsils gy – nutritional 6. Apply an ice collar 6. Cold promotes evidenced by
Concepts of intake and on the neck or vasoconstriction an not refusing to
Altered hydration encourage the client d decreases eat and drink.
Health States to eat popsicles. swelling  
7th Edition by   that contributes to  
Carol Mattson   pain. Long term
Porth, page   goals met.
321
7. Encourage patient to 7. It is important to
eat and drink. maintain adequate
  nutrition to help the
  immune system
  fight off disease.
8. Educate patient to 8. These foods
avoid hot, spicy, sour, aggravate the pain
dairy products and and can cause
coarse food such as bleeding.
chips or crackers.  
   
Dependent: Dependent:
1. Administer 1. Paracetamol helps
paracetamol as to ease pain,
ordered. headache and high
  temperature.
 
 Collaborative: Collaborative:
1. Inform dietary 1. These foods are
department for client’s easy to swallow and
diet such as provide relief too. 
soft foods like plain
pasta, rice, yogurt
and puddings.
 
 
 
 
References:
 Nursing Care Plans:
Guidelines for
individualizing Client
Care 7th Edition by
Doenges, Moorhouse
and Murr
 Nursing Diagnoses
NANDA International
(2005) page 440
05
Nursing Care Plans
Impaired Swallowing
05
Nursing Care Plans
Imbalanced Nutrition
 Nursing Scientific
Cues Objectives Intervention Rationale Evaluation
Diagnosis Rationale
Independent: Independent:
SUBJECTIVE: Imbalanced The activation Short Term: Short Term:
“Maul-ol an but- nutrition less of cytokine- Within 8 hours of 1. Assess weight, age, body 1. Provides comparative After 8 hours of
ol ni Marie ngan than body producing nursing build, strength, activity/rest baseline. nursing
nagkukuri hiya requirements cells leads to interventions, the level, and so forth. interventions, the
pagtulon. Di na related to the discharge patient will: 2. Determine ability to chew, 2. Factors that can affect goal has been met.
hiya inability to of protein as swallow, taste. Note ingestion and/or digestion The patient
ginaganahan ingest or well as fluid  Verbalize denture fit; presence of of nutrients. verbalized
pagkaon” As digest food or into the understanding of mechanical barriers; understanding of
verbalized by absorb surrounding causative factors lactose intolerance, cystic causative factors
the mother of nutrients as tissue. This when known and fibrosis, pancreatic disease. when known and
the patient. evidenced by affects the necessary 3. Ascertain understanding of necessary
loss of localization of interventions. individual nutritional needs. 3. To determine what interventions.
OBJECTIVE: appetite and the tonsillar information to provide
 Throat pain difficulty of and nasal Long Term: 4. Discuss eating habits, client/SO. Long Term:
 Difficulty of swallowing. tissues and Within 7 days of including food preferences, 4. To appeal to clients After 7 days of
swallowing regional lymph nursing intolerances/aversions. likes/desires. nursing
 Loss of nodes. interventions, the 5. Note total daily intake. interventions, the
appetite Therefore patient will Maintain diary of calorie 5. To reveal changes that goals have been
 Only able to causing for demonstrate intake, patterns and times should be made in client’s met. The patient
consume a them to swell nutritional intake of eating. dietary intake. demonstrated
small and become adequate to meet nutritional intake
amount of enlarged. The metabolic needs as Dependent: adequate to meet
food for the swelling and evidenced by: 1. Assess drug interactions, metabolic needs as
past 2 days irritation of the disease effects, allergies, 1. These factors may be evidenced by:
 Weight: 54 tonsillar tissue  Stable weight use of laxatives, diuretics. affecting appetite, food
kg also lead to and muscle- 2. Administer pharmaceutical intake, or absorption.  Stable weight and
 Age: 19 difficulty in mass agents as indicated: 2. For better nutritional muscle-mass
years old swallowing measurements, Digestive drugs/enzymes, intake absorption. measurements,
that eventually  Positive nitrogen Vitamin/mineral (iron),  Positive nitrogen
results to loss balance, supplements, Medication. balance,
of appetite.  And tissue Collaborative:  And tissue
regeneration. 1. Consult dietitian/nutritional regeneration.
team as indicated. 1. To implement
interdisciplinary team
2. Refer to home health management.
resources and so on. 2. For initiation/ supervision
of home nutrition therapy
when used.
05
Nursing Care Plans
Hyperthermia
05
Nursing Care Plans
Readiness for Effective Therapeutic Regimen
 06
Discharg
e Plan
 Discharge Plan (METHODS format)
MEDICINES

● Co-Amoxiclav (Antibiotic). This is to help treat bacterial infection.

● Analgesics such as acetaminophen for pain relief.

● Advise client to continue prescribed medication to ensure optimum recovery.

EXERCISE

● Advice patient to gradually resume to usual activities as tolerated.

TREATMENT

● Instruct client to increase fluid intake.

● Instruct client to have complete bed rests.

● Instruct client to gargle with warm salt water. This may help decrease throat pain.
 Discharge Plan (METHODS format)
HEALTH EDUCATION

● Demonstrate and educate parents and patients about good hand hygiene to avoid

the spread of microorganisms.

● Encourage rest to help the immune system work.

OUTPATIENT DEPARTMENT (CHECK-UP)

● Instruct client to continue follow-up check up to the doctor.

● Instruct client to write down questions so she remember to ask them during her

visits.
 Discharge Plan (METHODS format)
DIET

● Instruct client to drink plenty of water.

● Recommend client to consume soft foods and nonirritating liquids for the first

few days.

● Instruct client to avoid dairy products. Dairy products coat the throat and may

cause the patient to cough which will further irritate the throat and cause pain,

especially after surgery.

SPIRITUALITY

● Advise client and parents to maintain good and safe environment.

 Thank
You!
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