Acute Tonsillopharyngitis’ Pathophysiology

Etiology
• viral, most often caused but occasionally by Epstein-
Predisposing Factors by the common cold Barr virus, herpes simplex
viruses (adenovirus, virus, cytomegalovirus, or HIV.
• Age rhinovirus, influenza, In about 30% of cases, the
• Gender coronavirus, respiratory cause is bacteria
• Environment syncytial virus)

Sign and Symptoms

• Pain with swallowing is
the hallmark and is often
referred to the ears
Culture rapid antigen-test • High fever
• Malaise
• Headache

Tender cervical
lymphadenopathy may Acute Tonsillopharyngitis
be present
 C. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:
Ineffective airway
Goal: • Teach the mother The patient needs to Goal met. The
Subjective: client was able to
After an 8-hour shift, the to perform proper cough to be able to
“Nahihirapan sya clearance related expel mucous
huminga dahil sa client’s secretions would be coughing technique remove the mucus
to and was able to
plema.”
lessened. to the patient. maintain
as verbalized by thick tenacious
the client’s Objectives: adequate
yellowish hydration.
mother.
1. After 30 minutes, • Apply Chest Chest physiotherapy is
secretions.
Objective: the client will be Percussion to the important in loosening
able to expel Client. and mobilizing
Hooked in D5 Analysis:
IMB 500cc x 62- mucous by:a.Doing secretions. Indications
63mgtts/min.
proper coughing for chest physiotherapy
Increased amount
Temp. 39 C techniqueb.Applyin • Position the include sputum
and viscosity of
g Chest percussion client for Postural retention not responsive
RR: 20 cpm secretions and/or
inability to clear 2. c.Chest Drainage. to spontaneous or
PR 110 bpm
Drainaged.Adminis directed cough,
secretions through
(+) cough tration of drugs 2. • Administer abnormal chest x-ray
the normal cough
mechanism may The client will be Antibiotics as
able to maintain ordered findings consistent with
lead to pooling of
adequate hydration infiltrates or
secretions in
lower by:a.Increasing oral deterioration in
airways.Pooling fluid • Increase the oxygentaion. The
of secretions leads intakeb.Regulating number of fluid patient is placed in the
to infection and intravenous fluid. being drunk by the proper position to drain
inadequate gas patient. the involved lung
exchange. segments.)An increased
respiratory rate leads to
an increase in
insensible fluid loss
during exhalation and
can lead to dehydration.

• Regulate the IV Administration of this

fluid as ordered. fluid generally causes
dilution of plasma
solute concentration
and forces water
movement into cells to
reestablish intracellular
and extra cellular
equilibrium; cells then
expand or swell.
 Ineffective To monitor newborn • Monitor axillary Regular temperature
Subjective: “
thermoregulation: closely to maintain temperature at monitoring will identify
May lagnat sya” Goal met.
hyperthermia temperature and prevent least every 8 adequate or inadequate
as verbalized by Mother
related to disease hyperthermia and cold hours; thermoregulation
the mother.
process. stress
demonstrates
effective
• Providse TSB To lower down body
bath. temperature. maintenance of
Objective:
neutral thermal

Hooked in D5 environment

IMB 500cc x 62- • Maintain thermal To maintain stable within 24 hours.

neutral body temperature. Temperature
63mgtts/min.
environment. decreases from
Temp. 39 C 39 degrees
RR: 20 cpm centigrade to
37.5 degrees
PR 110 bpm
centigrade.
(+) cough