Acute Tonsillopharyngitis Case Analysis

Manuel S.
Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
-
COLLEGE OF NURSING ALLIED HEALTH SCIENCES
In partial fulfillment of the requirements for

Related Learning Experience at
Nursing Care Management 106A
Communicable Diseases
NURSING CASE ANALYSIS

Diagnosis: Acute Tonsillopharyngitis Non-Exudative
Submitted by:
Guevarra, Lemuel M.
Submitted to:
Clinical Instructor
Dr. Dario Sumande PhD, RN, MAN, USRN
Date Submitted:
08/23/19
ACUTE TONSILLOPHARYNGITIS
Manuel S. Enverga University Foundation
Lucena City
DEPARTMENT OF NURSING AND ALLIED HEALTH SCIENCES
NAME: AD
ADDRESS: SAN ANTONIO, CITY OF PARAŇAQUE
GENDER: MALE
CIVIL STATUS: SINGLE
BIRTHDAY: JUNE 15, 2015
NATIONALITY: FILIPINO
RELIGION: ROMAN CATHOLIC
CHIEF OF COMPLAINT: COUGH
ADMISSION: AUGUST 15, 2019

ADMITTING PHYSICIAN: DR. LORIZA M. SORIANO M.D.
ATTENDING PHYSICIAN: DR. EDNA A. MIRANDA M.D.
HISTORY OF PRESENT ILLNESS

Five days prior to confinement the client started to have cough and cold with fever. No
medication taken and consult done. A day before confinement the client started to have
abdominal pain but without vomiting, with sore throat and headache.
PAST HISTORY:
 January 2019 – measles

 August 2019 – Dengue
PERSONAL AND SOCIAL HISTORY
 Incomplete vaccine
Lucena City
DISEASE: ACUTE TONSILLOPHARYNGITIS NON-EXUDATIVE
DEFINITION
Nonexudative tonsillopharyngitis is an inflammation of the back of the throat (pharynx) and
tonsils that is not accompanied by the accumulation of thick mucous material or pus in or on the
throat tissues. (https://me-pedia.org/wiki/Nonexudative_pharyngitis#Presentation)
CAUSATIVE AGENT
Can be caused by several different viruses and bacterial organisms. Clinically speaking, the most
important causative agent is group A streptococcus (Streptococcus pyogenes).
(https://www.ncbi.nlm.nih.gov/pubmed/2249402)
RESERVOIR
Humans are the reservoir.
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
Lucena City
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.
Complications of Streptococcal Tonsillopharyngitis
Non Suppurative Complications:

• Acute rheumatic fever
• Scarlet fever
• Streptococcal toxic shock syndrome
• Acute glomerulonephritis
Lucena City
• 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.
Lucena City
LABORATORY AND DIAGNOSTIC EXAM (CLIENT BASED)
HEMATOLOGY
8/15/2019
Component Result Normal Range Interpretation
WBC 12.18 x 4,000-10,000 Increased level caused by bacterial infection as
10^9/L manifested by the client’s reddened and inflamed
throat and tonsils. Increased level of WBC rules
out the viral infection due to usually during viral
infection WBC is normal or at low level.
RBC 4.28 4.5 – 6.2 Decreased level sign of anemia related to
10^12/L nutritional deficiency as the client is experiencing
difficulty of swallowing and pain.
Hematocrit 0.34 g/L 0.40 – 0.50 Decreased level is a sign of anemia related to
nutritional deficiency as the client is experiencing
Hemoglobin 113.0 g/L 130 - 180 Decreased level sign of anemia related
MCV 79.2 fL 82 – 98 Decreased level is a sign of iron deficiency
anemia related to nutritional deficiency as the
client is experiencing difficulty of swallowing
and pain.
MCH 26.4% 28 - 33 Decreased level is a sign of anemia related to
Platelet 570 150 - 400 Increased level caused by bacterial infection in
Count 10^9/L the client’s throat and tonsils.
RDW 15 % 11.4 – 14.0 Increased level is a sign of iron deficiency anemia
related to nutritional deficiency as the client is
experiencing difficulty of swallowing and pain.
Mon% 10.50 % 2.0 - 4.0 Increased level caused by bacterial infection in
the client’s throat and tonsils as manifested by
reddened and inflamed throat with no mucous
accumulation.
Eos% 5.60 % 2.0 - 4.0 Increased level caused by bacterial infection in
the client’s throat and tonsils as manifested by
reddened and inflamed throat with no mucous
accumulation.
CLINICAL CHEMISTRY
Urinalysis (Microscopic / Chemical Examination)
Color: Light yellow
Transparency: Clear
Lucena City
Chemical Result Normal Range Interpretation
Analysis
Glucose Negative ≤ 5.5 mmol/L Negative Result
Bilirubin Negative ≤ 5. umol/L Negative Result
Ketone Negative ≤ 0.4 mmol/L Negative Result
Specific 1.010 1.005 – 1.035 Normal
Gravity
Blood Negative ≤ 9/uL Negative Result
Ascorbic 2.8 mmol/L ≤ 5. mmol/L Increased Level
Acid (+2)
Creatinine Negative ≤ 1.0 mmol/L Negative Result
Remarks: False (-) negative result for glucose bilirubin, ketone and blood maybe due to the
presence of ascorbic acid, repeat urinalysis after 24 hours without taking vitamin C is suggested.
Note: No follow up or repeat urinalysis is performed.
MEDICATION (Client Based)
DRUG ACTION INDICATION RATIONALE
BRAND It inhibits Treatment of mild to Treatment for the fever

NAME : prostaglandin moderate pain, and acute pain of the
Paracetamol synthesis temporary reduction client who has acute
GENERIC of fever and tonsillopharyngitis non
NAME : temporary relief of exudate. Client has an
minor aches elevated temperature of
CLASSIFI 37.8 degrees Celsius
CATION : during admission as
Analgesic and Anti symptom of underlying
pyretic condition which is
infection in the throat
FREQUENCY/ and tonsils.
DOSAGE:
250 mg/tab q 4 hr
for fever PO
Lucena City
BRAND Inhibits the Treatment of mild to Treatment for the fever
NAME : synthesis of moderate pain, and acute pain of the
Paracetamol prostaglandin temporary reduction client who has acute
GENERIC that may serve as of fever and tonsillopharyngitis non
NAME : mediators of pain temporary relief of exudate. Client has an
and fever, minor aches elevated temperature of
CLASSIFI primarily in the 37.8 degrees Celsius
CATION : CNS. during admission as
Analgesic and symptom of underlying
Anti pyretic Has no condition which is
significant anti- infection in the throat
FREQUENCY/ inflammatory and tonsils. Client
DOSAGE: properties/GI experience difficulty in
180mg TIV toxicity. swallowing and pain
that’s why PO was
shifted to TIV.
BRAND In low doses, Inhalation: Treatment During assessment

NAME : acts relatively of acute attacks of bronchospasm is noted
Albuterol selectively at bronchospasm due to inflamed throat
beta2 adrenergic at as sign for acute
GENERIC receptor to cause tonsillopharyngitis
NAME : bronchodilation although it has no
Salbutamol and accumulated mucous
vasodilatation; at and was treated
higher doses through the use of
Bronchodilators beta2 selectivity bronchodilator.
FREQUENCY/ is lost, and the
DOSAGE: drug acts at beta2
1neb Q8 receptors to
cause typical
symphatomimeti
c cardiac effects.
BRAND Preferentially Effectively treats 2nd generation
NAME : binds to one or pharyngitis (Acute cephalosporin are used
Cefuroxime more of the tonsillopharyngitis treat infection caused
GENERIC penicillin- non – exudate) by group A beta
NAME : binding proteins hemolytic streptococci
(PBP) located on the infectious agent or
CLASSIFI cell walls of bacteria causing
CATION : susceptible tonsillopharyngitis of
Antiinfective; organisms. This the client.
Antibiotic; Second- inhibits third and
Generation final stage of
Cephalosporin bacterial cell
wall synthesis,
FREQUENCY: thus killing the
Q8 bacterium.
Dosage / route
Lucena City
TIV Partial cross-
allergenicity
between other
beta-lactam
antibiotics and
cephalosporins
has been
reported.
BRAND Anti Use as anti Upon assessment the
NAME : inflammatory inflammatory or client’s throat and
Hydocortisone (glucocorticoid) immunosuppressive tonsils are inflamed in
GENERIC action: Stabilizes agent largely order to treat the
NAME : leukocyte replaced by synthetic inflammation caused
Hydrocortisone lysosomal glucocorticoids that by the bacterial
Sodium Succinate membranes; have minimal infection,
CLASSIFI inhibits hydrocortisone was
mineralocorticoid
Cation : Mucous phagocytosis and used to effectively
activity.
Membrane Agent; release of allergic treat the inflammation
Anti inflammatory substances; caused by the disease,
suppresses acute
FREQUENCY: fibroblast tonsillopharyngitis non
BID formation and exudate.
72g TIV Q6 collagen
deposition;
reduces capillary
dilation and
permeability; and
increases
responsiveness of
cardiovascular
system to
circulating
catecholamines
BRAND Semisynthetic Effectively treats Antibiotic treatment
NAME : third-generation infection pharyngitis. shifts from Cefuroxime
Ceftriaxone cephalosporin (Acute (2nd gen cephalosporin)
GENERIC antibiotic. This tonsillopharyngitis To Ceftriaxone (3rd
NAME : inhibits third and non – exudate) Gen cephalosporin)
CLASSIFI final stage of both thru IV due to
CATION : bacterial cell wall Ceftriaxone has a
Antibiotic; Third- synthesis, thus broader spectrum of
Generation killing the killing bacteria
Cephalosporin bacterium. effectivity.
FREQUENCY:
OD
Dosage / route
1.8g IV
Lucena City
BRAND Serve as cofactor Replacement and Increased in RDW of
NAME : for many supplement therapy deficiency . As
Zinc Sulfate enzymatic in patients who are at manifested in the
GENERIC reactions. risk of zinc client’s lab result
NAME :Zinc Required for deficiency, or with RDW is 15% and was
Sulfate normal growth anemia. considered as high.
and tissue repair, Zinc was given as
wound healing, replacement and
CLASSIFI and sense of taste supplement therapy to
CATION and smell. correct anemia as one
Vitamins and of the complication of
Minerals acute
tonsillopharyngitis non
FREQUENCY: exudate.
OD
DOSAGE /
ROUTE:
5ml PO
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Independent: Goals Met:
“napansin ko Altered • Monitor • To obtain
After 3
po parang breathing vital signs baseline data.
hours of After 30 minutes
madalas at ang pattern
nursing of nursing
paghinga at related to intervention, intervention, the
parang acute the patient • Assess for • Early
patient was able
nahihirapan inflammation will be able any signs and recognition of
to maintain
ang aking and swelling to maintain symptoms of untoward signs and
airway patency.
anak” as in the tonsils airway altered breathing symptoms.
verbalized by and pharynx patency pattern and refer
the the mother as manifested for any untoward
by dyspnea, signs and
Objective:
restlessness symptoms.
• Vital Signs: and RR of
34BPM
T- 37.8 °C
• Evaluate
P- 125 bpm client’s cough/gag
reflex and
R- 34 bpm
Lucena City
• Dyspnea swallowing • To
ability determine ability to
protect own airway.
• Cough
• Elevate
head of bed
• Restlessness and/or have client
• To promote
sit up on chair.
physiological and
psychological ease
of maximal
inspiration.
• Observe
• To identify
for signs and
infectious process
symptoms of
and promote timely
infection
intervention.
• Helps to
• prevent/reduce
Encourage fatigue.
/ provide
opportunities for
rest; limit
activities to level
of respiratory
tolerance
• Advice to
increase fluid
intake • To prevent
drying of secretions
Lucena City
Collaborative:
• • To relax
Administe smooth respiratory
r medications musculature and
(antibiotics, mobilize secretions.
bronchodilators)
as ordered
• Various
therapies/modalities
• Assist may be required to
with use of acquire and
respiratory maintain adequate
devices and airways, improve
treatments. respiratory function
and gas exchange.
REFERENCES
 http://medical-dictionary.thefreedictionary.com/pharyngitis
 http://medical-dictionary.thefreedictionary.com/exudation
 The 1988 Holmes Definition for CFS

Acute Tonsillopharyngitis Case Analysis

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Acute Tonsillopharyngitis Case Analysis

Încărcat de

Drepturi de autor:

Formate disponibile

Manuel S.

Enverga University Foundation

COLLEGE OF NURSING ALLIED HEALTH SCIENCES

In partial fulfillment of the requirements for

NURSING CASE ANALYSIS

DEPARTMENT OF NURSING AND ALLIED HEALTH SCIENCES

CHIEF OF COMPLAINT: COUGH

ADMISSION: AUGUST 15, 2019

HISTORY OF PRESENT ILLNESS

 January 2019 – measles

Complications of Streptococcal Tonsillopharyngitis

Non Suppurative Complications:

MEDICATION (Client Based)

DRUG ACTION INDICATION RATIONALE

BRAND It inhibits Treatment of mild to Treatment for the fever

BRAND In low doses, Inhalation: Treatment During assessment

NURSING CARE PLAN

S-ar putea să vă placă și