Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

College of Nursing

A CASE ANALYSIS

on

ACUTE TONSILLOPHARYNGITIS

In Partial Fulfillment of the Requirements of the Course

Presented to: Mr. Julius Laureta, RN, MAN Clinical Instructor

Presented by: KEENEN ENGEL B. PASCUA BSN IV-AMARYLLIS

CASE STUDY GRADING SHEET FOR NCM

PARAMETERS Introduction & Objectives Personal Data Nursing History of Past and Present Illness Assessment Diagnostic Procedures a. Ideal b. Actual Anatomy & Physiology Pathophysiology Algorithm Explanation Management a. Medical b. Surgical c. NCP with Evaluation d. Preventive Management Drug Study Discharge Planning Updates ORGANIZATION BIBLIOGRAPHY TOTAL PERCENTAGE % 5 5 15 5 ACTUAL GRADE

5 15

5 20 5 5 5 5 2.5 2.5 100

REMARKS: _________________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________

Mr. Julius Laureta, RN MAN Clinical Instructor

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INTRODUCTION

Tonsillopharyngitis is the swelling of the pharynx and the tonsils. Pharyngitis is the swelling and inflammation of the pharynx. The pharynx is the back of the throat, including the back of the tongue. The tonsils participate in systemic immune surveillance. In addition, local tonsillar defenses include a lining of antigenprocessing squamous epithelium that involves Band T-cell responses.

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, dysphagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented by culture or rapid antigen test. Treatment depends on symptoms and, in the case of group A -hemolytic

streptococcus, involves antibiotics. Tonsillopharyngitis is usually viral, most often caused by the common cold viruses but occasionally by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV. In about 30% of patients, the cause is bacterial. Group A -hemolytic streptococcus (GABHS) is most common. Rare

causes include pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea. GABHS occurs most commonly between ages 5 and 15 and is uncommon before age 3. Its usual signs and symptoms are pain with swallowing which is the hallmark and is often referred to the ears. Very young children who are not able to complain of sore throat often refuse to eat. High fever, malaise, headache, and GI upset are common, as are halitosis and a muffled voice. The tonsils are swollen and red and often have purulent exudates. Tender cervical lymphadenopathy may be present. Fever, adenopathy, palatal petechiae, and exudates are somewhat more common with GABHS than with viral tonsillopharyngitis, but there is much overlap. GABHS usually resolves within 7 days. Untreated GABHS may lead to local suppurative complications ( peritonsillar abscess or cellulitis) and sometimes to rheumatic fever or glomerulonephritis. Patient X is a 4 y/o girl from Calingayan, Sinait, Ilocos Sur who was admitted for the first time in Corpuz Clinic and Hospital with a chief complain of fever and sore throat.

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As the student-nurse assigned to care for Pt. X for 2 duty days, I have observed his condition and identified some of his health needs. Although my

contribution to the patients recovery may be insignificant, witnessing my patients condition improving is a very fulfilling experience. But more than the feeling of fulfillment, I felt that I was an instrument of God in trying to bring back wholeness in Xs life no matter how insignificant it may be.

OBJECTIVES
After completing this case study, the student-nurse will be able to obtain appropriate knowledge, skills and attitude in caring for a patient with bone injury particularly to a patient with space occupying lesion. This is manifested by the students ability: 1. To present accurately the patients profile. 2. To obtain a comprehensive past, present and family history of patients illness. 3. To assess the health status of the patient using the cephalocaudal method and organize cues for Nursing Care Plan. 4. To know the different diagnostic examinations (ideal and actual) related to the patients case and understand the purpose and limitation of each examination. 5. To study the results/outcome of the diagnostic procedures that the patient has undergone and explain how these are related to the case of the patient. 6. To discuss the anatomy and physiology of the organ involved in the case. 7. To illustrate through a schematic diagram the pathophysiology of the patients case and explain the mechanism that is involved. 8. To present the medical and surgical management done to the patient. 9. To formulate a practical and realistic plan of care for the patient through: a. systematic organization of the subjective and the objective cues related to the case. b. identifying and prioritizing nursing diagnoses using the PES format (ProblemEtiology-Signs/Symptoms) and according to NANDA. c. analysis of the pathophysiology of the identified diagnosis based on the presentation of the patient d. formulating appropriate nursing objectives following the SMART criteria. Page | 4 Keenen Engel B. Pascua

e. planning for independent, dependent and collaborative interventions and explaining the rationale for every intervention done. f. evaluating the degree of achievement for all the objectives set at the beginning of the intervention. 10. To make a list of the different drugs taken and is presently taking by the patient with their corresponding dosages, mechanisms of action, side/adverse effects and nursing responsibilities. 11. To formulate a Discharge Plan covering the following areas: METHOD (Medications, Exercises, Treatments, Health Teachings, Out-Patient Department and Diet)

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PATIENT PROFILE
Name Age Sex Address Birthday Religion Father Mother Date of admission Diagnosis Shenna Anne Dinong Yadao 4 years old Female Calingayan, Sinait, Ilocos Sur March 24, 2007 Roman Cathilic Jeffrey Yadao Mylene Yadao June 20, 2011 Acute Tonsillopharyngitis

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PAST HISTORY According to the patients mother, the patient was born via NSD. She received her BCG at birth as well as Hep B and completed the dose at July 10, 2007. She also completed the DPT and OPV vaccines. And also she had MMR vaccine on December 14, 2007. She has no know allergies as claimed by the mother. Her appetite in their house was low but she can drink up to 3 bottles of coca-cola 8oz.

PRESENT ILLNESS
Prior to the admission, June 19, 2011, she got a fever of 38.5. The mother gave her paracetamol syrup. She stayed at home for the time being but because of her fever not decreasing, June 20, 2011, she rushed her to Corpuz Clinic and Hospital for medical chek-up. The chief complain was fever and later they found out that it was an acute tonsillopharyngitis. Then she was admitted to the said hospital.

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ASSESSMENT (PEARSON)

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June 21, 2011

Patient X, 4 y/o female, child, Roman Catholic lives in Calingayan, Sinait, Ilocos Sur She is conscious, coherent and well-oriented. Responds appropriately to stimuli s/a pain and during interaction. According to Erik Ericksons Psychosocial Development is

June 22, 2011

Patient X, 4 y/o female, child, Roman Catholic lives in Calingayan, Sinait, Ilocos Sur She is conscious, coherent and well-oriented. Responds appropriately to stimuli s/a pain and during interaction. According to Erik Ericksons Psychosocial Development is

at the Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others. If given this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others and make decisions. Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative.
No episodes of vomiting noted. Patient urinated 5 times with straw colored urine. Patient defecated once with well-formed, aromatic and brownish in color. No eye and nasal discharges noted. Fair in appearance Patient lies on bed most of the time and sits sometimes. The mother of the patient gives her a bath in the morning.

at the Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others. If given this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others and make decisions. Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative.
No episodes of vomiting noted. Patient urinated 3 times with straw colored urine. Patient defecated once with well-formed, aromatic and brownish in color. No eye and nasal discharges noted. Fair in appearance Patient moves a lot from bed to bed The mother of the patient gives her a bath in the morning. Page | 9

Keenen Engel B. Pascua

Activity and Rest

Eimination

Psychosocial

She is being supervised by his mother and assist her in her needs Body temperature: 37.8 C febrile. No known food and drug allergy. With D5 0.3 NaCl L regulated at 60 ugtts/min Vital signs: PR: 91 bpm RR: 20 cpm Temp: 37.8 C She has normal breathing pattern, rate and depth. Capillary refill is 2 sec. She feels pain upon swallowing. She has decreased appetite She is under soft diet for his age. Preferred foods are any meat and vegetables. Increased fluid intake

She is being supervised by his mother and assist her in her needs Body temperature: 37.3 C afebrile. No known food and drug allergy. With D5IMB L regulated at 60 ugtts/min Vital signs: PR: 94 bpm RR: 22 cpm Temp: 37.3 C She has normal breathing pattern, rate and depth. Capillary refill is 2 sec. With good appetite as claimed. She is under soft diet for his age. Preferred foods are any meat and vegetables. Increased fluid intake

Nutrition

Oxygenation

Safety

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DIAGNOSTICS
Actual Diagnostic Examination
Complete Blood Count
Substance test ed Hemoglobin Hematocrit WBC count Result Reference rang e 120-160 .4-.48 4.5-11 Implication Nursing Responsibilities

Neutrophils Lymphocytes Monocytes Platelet coun t

135 g/L .41 4.2 x 109 / L .63 .23 .12 189 x 109 / L

This

indicates infection

recent

.54 - .70 .25 - .33 .3-7 150 350

It is one of the most commonly requested routine blood tests to check the function of the blood forming organs. The result of this test further confirms or rules out established diagnosis. It is the initial test performed in the study of blood cell diseases. The test is conducted in the pathology laboratory by a registered medical technologist or a pathologist.

 Check doctors order.  Check patients identity by asking her name.  Explain the procedure to the patient to promote cooperation.  Teach patient some relaxation techniques like deep breathing exercises to ease anxiety.  Always observe proper aseptic technique when obtaining blood sample.  Forward the blood to the laboratory immediately when it was obtained by a person other than the Med. Tech. for better and more accurate result.  Notify the physician as soon as the results are released.

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Ideal Diagnostic Examinations A). Rapid strep test? The rapid strep test is a quick and accurate diagnostic tool used to determine whether or not strep bacteria are present in the patient's throat. The same test may be used to evaluate for the presence of Streptococci in other infected areas (such as wound infections) How is a rapid strep test done? Obtaining a specimen is the same whether your doctor will do a throat culture or rapid test for strep. A cotton swab (similar to a Q-tip) is quickly rubbed over both tonsils as well as the back wall of the mouth (the posterior pharynx). It is important to avoid contact with other structures inside the mouth such as the tongue or cheeks. The swab is then placed in a specialized container and the rapid test performed. Many people find that obtaining the swab produces a gagging sensation. However, since the entire swabbing process lasts less than five seconds this inconvenience is minimal.

B). Throat Swab Culture A throat swab culture is a laboratory test done to isolate and identify organisms that may cause infection in the throat. How is a Throat Swab Culture done? You will be asked to tilt your head back and open your mouth wide. The health care provider rubs a sterile cotton swab along the back of your throat near the tonsils. You need to resist gagging and closing the mouth while the swab touches this area. The health care provider may need to scrape the back of the throat with the swab several times. This helps improve the chances of detecting bacteria.

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Why the Test Is Performed The test is performed when a throat infection is suspected, particularly strep throat. A throat culture can also help your doctor determine which antibiotics will work best for you.

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PATHOPHYSIOLOGY

Ingestion of food with microorganism

Airborne Droplets

Group A beta haemolytic streptococcus

Tonsil/Pharynx

Lymphocytes

IgM Inflammatory Process

Neutrophils / Macrophages

Histamine/Kinins Secretion (causes vascular permeability and vasodilator)

Pyrogen secretion Stimulates fever production Dysphagia

Reset Hypothalamus Regulator Loss of appetite Fever

Malaise

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MANAGEMENT

Actual Medical Management  for CBC  for urinalysis  IVF of D5 0.3 NaCl L x 60 uggts/min  paracetamol 9ml IV q 4 PRN for temperature greater than or equal to 38.5 C (can be shift to oral paracetamol 125mg/5ml 3 ml q4 PRN for temperature greater than or equal to 37.8 C)  give penicillin sodium 350,000 units IV q 4 ANST (antibiotic)  monitor vital signs every 2 hours  TSB for fever

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Cues Subjective: nasakit jay karabukob as verbalized by the patient haan unay makakaan tattay gapota agsakit kano karabukob na as verbalized by the mother. Objective: With tolerable pain when swallowing

Nursing diagnosis P> Acute pain E>related to swelling of the uvula S>as evidenced by tolerable pain when swallowing

Analysis Inflammation

Planning June 21, 2011

Intervention Independent Assess the etiology and precipitatin g contributor y factors Perform routine comprehens ive pain assessment , including location, characteris tics, onset/dura tion, frequency, quality, severity of the pain. Accept childs

Rationale

Evaluation GOAL MET

8:00 am swelling After 30 minutes of nursing intervention, nerve the patient compressi will be on relieved from pain as evidenced by acute pain verbalization of relived from pain.

To determine the possible cause of pain and to know the appropriate nursing care plan

June 21, 2011 8:30 am After 30 minutes of nursing interventio n, the patient was relive from pain as evidenced by verbalizati on of relived from pain.

Assessment of children involves observational skills and may require enlisting the aid of parent/caregiver to clarify cues and verbalizations.

Pain is subjective and cannot be experienced by others

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With slight swelling with slight swelling at the uvula

description of pain

May signal worsening of condition or development of complications

With facial grimacing

Investigate changes in frequency or description of pain Observe for guarding, rigidity and restlessnes s

Nonverbal expressions may signal pain or changes in pain severity

Influences degree of pain manifestation Nonpharmacological pain management promotes relaxation, may reduce level of pain and enchance coping.

Note location or type of trauma

Provide comfort measures such as

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repositionin g, warm compress

Helps distract childs attention from pain and reduces tension.

Encourage diversional activities; e.g., music therapy, Helps reduce fatigue playing and enhances coping quiet games capability COLLABORATIVE Encourage rest periods

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Cues SUBJECTIVE: haan unay makakaan tattay gapota agsakit kano karabukob na as verbalized by the mother. OBJECTIVE: V/S BT 37.8 C PR 91 bpm RR 20 cpm With tolerable pain upon swallowing. With decreased

Nursing diagnosis P> Risk for imbalance nutrition, less than body requiremen ts E> related to inability to eat comfortabl y leading to decreased appetite

Analysis Pain when swallowin g

Planning June 21, 2011 8:30

Intervention INDEPENDENT Determine ability to chew, swallow, and taste

Rationale

Evaluation GOAL MET June 21, 2011 9:00

After 30 minutes of nursing Decreased intervention, appetite the patient will ingest nutritionally adequate Risk for diet for her imbalance age and d activity level nutrition, less than body requireme nt

After 30 minutes of nursing interventio Determine childs n, the current patient Identifies individual nutritional nutritional needs and ingested status. nutritionall provides y adequate comparative diet for baseline. Elicit her age and informatio Baseline information activity n from level to determine child/pare adequacy of intake. nt Knowledge of childs regarding specific typical likes/dislikes may be daily food helpful in meeting intake, childs nutritional determinin needs during a time g foods when appetite is
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These factors can affect ingestion/desire to eat

Keenen Engel B. Pascua

appetite

and beverages normally consumed. Note types of snacks. Discuss eating habits and food preferenc es (likes and dislikes) Note characteri stics of stool

supressed or child has no interest in food.

Provides information about digestion/bowel function and may affect choice/timing of feeding

This may help meet the nutritional needs of the child and the child will experience decreased pain when taking in food.

Advise mother to give her child soft

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diet

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Cues SUBJECTIVE: medyo nabara isuna ading as verbalized by the mother OBJECTIVE: V/S BT 37.8 C PR 91 bpm RR 20 cpm With dry and warm skin.

Nursing diagnosis P> Hyperthermia E> related to infection S> as evidenced by skin warm to touch and with a body temperatur e of 37.8

Analysis Ifectious agents Monocytes

Planning June 21, 2011 8:30

Intervention INDEPENDENT

Rationale

Evaluation GOAL MET June 21, 2011 12:30

After 4 hrs. Of Pyrogenic nursing Cytokines interventions, the patient will Ant. maintain core Hypothalam temperature us within normal range. Elevated thermoregu latory set point Increased heat conservatio n (Vasoconstriction/ Behavior changes) Increased Heat production (involuntary muscular

Promote surface cooling by means of tepid sponge bath.

To decrease temperature by means through evaporation and conduction

Maintain bed rest.

After 4 hrs. Of nursing interventions, the patient maintained core temperature within normal range.

Provide high calorie diet.

To reduce metabolic demands and oxygen consumption To meet metabolic demands.

Wrap extremities with

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Keenen Engel B. Pascua

contraction Fever

blankets. Increase fluid intake

To minimize shivering.

To prevent dehydration as well as cooling the body.

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PREVENTIVE MANAGEMENT

PREVENTIVE AND PROMOTIVE MANAGEMENT

For faster recovery, the patient should do the following: y y y y Follow doctors order with his/her prescribed home medications. Get plenty of rest. 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. y Drink at least 6 to 8 glasses (8 oz.) of fluid a day to replace fluids lost when you have a fever and to loosen mucus secretions in your throat for a more productive cough. Warm beverages, such as tea with lemon, may help soothe your throat. y Gargle with warm salt water ( tsp. in cup warm water) every few hours. If you have postnasal drip, gargle frequently to prevent throat irritation. y y y Eat and drink cold foods and liquids. Suck on a piece of hard candy or a lozenge with menthol. Avoid smoke, alcohol, and caffeine. Both alcohol and caffeine can increase your likelihood of becoming dehydrated. y Use a cool-mist vaporizer or humidifier in the room where you spend the most time. Steam from a hot shower or a pan of water placed near a heater will also increase the humidity. y Elevate your head with extra pillows at night.

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PREVENTIVE: Here are ways to reduce your chance of getting a TONSILLOPHARYNGITIS: Wash your hands frequently, especially after blowing your nose or after caring for a child with a sore throat.
y

If someone in your home has a sore throat, keep his eating utensils and drinking glasses separate from those of other family members. Wash these objects in hot, soapy water.

If a toddler with a sore throat has been sucking on toys, wash the toys in soap and water.

y y

Immediately get rid of used tissues, and then wash your hands. If you have hay fever or another respiratory allergy, see your doctor. Avoid the substance that causes your allergy.

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DRUG STUDY

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Name of Drug

Frequency

Indication

Contraindication

Side Effects

Mechanism of Action

Paracetamol 125mg/5nl

3ml every 4 hours (BT 37.8) 9ml every 4 hours (BT 38.5)

Fever

Hypersensitivity to drug

Paracetamol 300mg/am p

Nausea, allergic reactions, skin rashes, acute renal tubular necrosis. Potentially Fatal: Very rare, blood dyscrasias

Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heatregulating centre. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

Nursing Responsibiliti es Follow the ten rights of drug administration Monitor the body temperature of the patient

Penicillin Sodium 350,000 units

Every 6 hours after negat ive skin test

Infection

Hypersensitivity severe hepatic impairment;

Neutropenia, agranulocy tosis; GI upsets; rash. Sore mouth or tongue

Keenen Engel B. Pascua

Absorption: Incompletely Follow the ten absorbed from the GI rights of drug tract with peak plasma administration concentrations after 1-2 hr (oral); may be reducedvise mother to in the presence of food. increase fluid Completely absorbed with intake of child peak plasma concentrations after 30 min (IM). Page | 27 Distribution: Pleural and synovial fluids and bone

(therapeutic concentrations), CSF (small amounts except when the meninges are inflamed; crosses the placenta and enters the breast milk. Proteinbinding: 94% Metabolism: Minimal metabolism. Excretion: Via the urine by glomerular filtration and renal tubular secretion (35% of an oral dose); via the bile (Up to 10%). Not removed by dialysis; 0.5-1 hr (elimination half-life).

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DISCHARGE PLANNING
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 her mother for her safety. Exercise should be promoted in a way by stretching all body parts every morning. Patient should be encouraged to keep active on different physical activities at home or at school. It is also

Medication

Exercise

advisable for her to be with her playmates few hours in a day to promote not only physical development but also her social capabilities. FEVER TREATMENT:  Check temperature regularly.  If febrile, a. Perform TSB, b. Remove excess clothing and covering,

Treatment

Treatment of the patient after discharge should be continued for full recovery. The patients significant others play an important role in the promotion and also prevention for the patient not to acquire this kind of illness again. 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 hot, 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. 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. 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.

Health teachings

OPD- check

OPD such as follow-up check-up as ordered by the physician should be greatly encouraged for the patient to determine if she Page | 29

Keenen Engel B. Pascua

up

already fully developed and for them to know if she will continue her medication and treatment which was ordered during her hospitalization. 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 child from infection that can cause fever and if there is a fever, therefore, attacks of seizure may occur.

Diet

UPDATES

UPDATES
(By agrimonia) Feb 24, 2011 In that uses most often galazolin,sanorin,but causes a spasms peryphery vessels,mint oil with drops not too use,but effectivity is lemon drops,juice lemon drip for baby incline head. Professor ozarovski is advices in bronchitis,cold,ache throat use balsam,like camhorae 0.3 gr,ol.terebinthinae 10 gr,ol.sojae 10 gr,ol.lavandula 1 r,ol.jumiperus 0.5 gr,ol.calami 0.5 gr,ol.thymi 0.3 gr,aethylli acetici 0.5 gr,sol.jodi spirit .5 percent gutt.nr 5.M.F.balsaminum ,to 6 y.old childrens rub 12 drops balsam for age depends in breast cell,and in complicated ,causes bronchitis same in between shoulder bladde sides,close blanket a baby,2 times/day repeat for 5 days. or methyli salycili 10 gr,camphor 3 gr,ol.eucaliptus gr,ol.lavandulae 3 gr,ol.thyme 3 gr,M.F.balsamum. same use. tbl.sp.cammomile in l.hot water or mixing herbs sage,herb thyme,flowers cammomile,leafs melissa,flowers lavender for inhalations,closed towel a baby face,incline under pan with herbs and breath in 10 min,and care take off a sweat,or use bath with straw oats . 100 gr herb for night add in cold water,warm,add in bath,use warm 10 min.
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17

gr,ol.pini

sylv.5

keep at home twigs pine,fir for microbes fight. A leafs nasturcia eating is fight microbes 1/2 leaf ,like salad in kind of,half leaf for baby shreded in sour milk mixing,or 1/2 tea.sp.nettle leafs juice in flue fight,or in cough cold leafs coltsfoot press juice,3 big onions cut,press juice,mix with 0.25 l.red wine,mix all,col,shake,use 3 times/day tbl.sp.in 5 tbl.sp.boiled water,warm,in strong cough mix leafs coltsfoot,leafs plantain lancet,roots shreded licorice,herb viola fragrant. tbl.sp.herbs in glass hot water,close,warm use 1/2 glass /day,adding lemon juice,thermos in keep. in dry cough. glass shrede onion,1/4 glass shreded garlic,add 1/2 glass honey,add in jar,close,warm infuse 3 hours,juice received tea.sp.for children give every 3 hours. in cucumber brine garlic cooked is use 1/2 tea.sp.every 4 hours after meal. juice leaf plantain in honey tea.sp.a few times/day. or washed 4 leafs plantain,press,add water,0.5 kg honey,steam to evaporate,thick mass in jar add,cold,use tea.sp.3 times/day to meal,cold keeping. in weak babies. in glass cold water add juice lemon half,tbl.sp.honey,lead to boil,add tbl.sp.herbs ,like 1/2 tbl.sp.plantain,with 1/2 tbl.sp.thyme,close,infuse,drink gulps for min,hot,if not help,cook 3 times/day and drink to help. in strong whooping cough handful fresh viola leafs fragrant in glass hot water,close,infuse,10 min after use 2 tbl.sp. in throat aches that for rinse throat. boiled potato knead,apply in gauze on throat compresses. althaea,mallow forest is antispasm,expectorate ,like 2 tbl.sp.cut in adding 2 glasses cold water,infuse 8 hours,mixing,filter,warm,use glass for a day,rinse throat. angine,aches throat,ears,breast aches mallow forest in cow herb flowers use for inhalations,steam baths in cold,bronchitis,or in any throat aches from leafs sage,herb horse tail. tea.sp.10 perc.propolis solution in 1/2 glass boiled water,2 tea.sp.lemon juice in 1/3 glass boiled water,powder clay 1/2 tea.sp.in 1/2 glass water,warm liquid rinse throat.

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BIBLIOGRAPGY
BOOKS:

Burke, S.RHuman Anatomy and Physiology in Health and Disease. 1992.

Deglin, J. H. (2004). Davis Drug guide for Nurses.

Doenges , M. E. Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span 7th edition

Marieb, E. N. (2006). Essentials of Human Anatomy and Physiology.

Pillitteri, Adele.Materbal Child Nursing.Care of the Childbearing and Childbearing Family.Volume II. Smeltzer, Suzanne C. And Brenda G. Bare.Brunner & Suddarth sTextbook of Medical-Surgical Nursing.Volume 2.10th Edition.

Spratto, George R and Adrienne L woods.PDR Nurse s Drug Handbook.2007 Edition.

INTERNET:

Microsoft Encarta 2009. 1993-2008 Microsoft Corporation. All rights reserved. http://www.nlm.nih.gov/medlineplus/ www.slideshare.net/.../lungs-anatomy-and-physiology www.enotes.com

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