ACUTE

TONSILLO
PHARYNGITIS
EXUDATIVE

CASE STUDY
2013
1. Basis of selection of case

Group A Beta Hemolytic Streptococci (GABHS) is a common cause of sore throat,

usually spread person-to-person. Outbreaks related to infected food have more seldom
been reported. The bacteria may originate from the throat or from wounds on the hands
of persons handling the food. An outbreak in 2003 involving 153 individuals who fell ill
after eating contaminated 'sandwich-layer cakes' was investigated. The average attack
rate was 72%.

A food-borne tonsillopharyngitis outbreak was reported in 2008. The

participants (n = 403) were divided into two groups: the study group (n = 252); those
with any two of the following three complaints; sore throat, fever, and dizziness, and
the control group (n = 151); those without these complaints. This investigation revealed
that 252 people were affected by this outbreak. Group A -hemolytic streptococci were
isolated from the throat cultures of 63 affected individuals (25%) and an employee
working in the patisserie that made desserts served for lunch.

The basis of selection of our study is the alarming number of cases of

tonsillopharyngitis among aged groups especially in children.

2. Clarity of Objectives

GENERAL OBJECTIVES:
After 2 hours of case presentation the students will be able to obtain the
knowledge to enlarge skills and to develop the attitude towards caring of the patient
with cases regarding tonsillopharyngitis.

SPECIFIC OBJECTIVES:
Specifically, this aims to:

KNOWLEDGE
1. Explain the pathophysiology of tonsillopharyngitis.
2. Identify the main cause of the disease.
3. Name the signs and symptoms of the disease manifested of the client.

SKILLS
1. Carry out independent and dependent intervention being done to the client
appropriately and with care.
2. Perform comprehensive nursing interventions base on the client priority needs.
3. Demonstrate proper approach used in clients with tonsillopharyngitis.
ATTITUDES
1. Establish rapport to client and folks.
2. Encourage the folks to cooperate to the intervention being performed.
3. Avoid promising words that might worsen the clients condition.

3. Reflection of Nursing Process

3.1 ASSESSMENT
A. Patients Profile
NAME: J. L.S.
AGE: 6 years old
SEX: Male
DATE OF BIRTH: June 21, 2007
ADDRESS: Pavia, Iloilo
OCCUPATION: None
RELIGION: Roman Catholic
NATIONALITY: Filipino
CHIEF COMPLAINT: Fever and cough
DIAGNOSIS: URTI, ATP-E
PHYSICIAN: Dr. F.A

B. Nursing History
I. Reason for seeking care
Fever and cough

II. Present Health or History of present illness.

PTA the child has noted to have cough and nasal catarrh and 3 days PTA 3
episodes of vomiting noted with fever up to 38C.The effect of pain on the
behavior of the child is that he is irritable and he cannot speak well

III. Past Health

1. Prenatal status
The spacing of the pregnancy was one year and it was planned. The
mothers attitude and the fathers attitude towards pregnancy were glad.
There is a medical supervision and it started at the second month of
pregnancy. The health status of the mother is generally good with no
complication, vomiting noted, gain weight, and edema of the feet. The
medication prescribed to the mother during pregnancy was calcium
supplement and undergone UTZ during her pregnancy.
 2. Labor and Delivery
Gravida 2; Para 2 (G2P2). The duration of the pregnancy is 9 months and
the place of pregnancy was at West Visayas State University Medical
Center and the type of delivery was normal. The birth weight is 7.9 lbs.

3. Postnatal status
She stayed at the hospital for 3 days. The baby was breastfed and the
baby was discharged with the mother.

4. Childhood Illnesses
The child doesnt have experienced any childhood illnesses (mumps,
chickenpox, measles, etc.)

5. Serious Accidents or Injuries

The child doesnt have any record of accidents or injuries.

6. Serious or chronic illnesses

The patient has a pneumonia and asthma last 2 months and the child was
hospitalized.

7. Operations or Hospitalizations
The child has been hospitalized for 5 days due to pneumonia and asthma
last 2 months ago.

8. Immunizations
The child has a complete immunization.

9. Allergies
The child is allergic to pollens and dust.

10. Medications
When the child has been admitted he was given an antibiotics and PAI.

IV. Developmental History

1. Growth
The height of the patient is 106 cm. and its weight is 19.7 kgs.

2. Milestones
When the child reached 8 months, he learns to pick up toys by himself
within reach and when he reached 1 year old he learns to stand up alone
 and take his first step. The child said his first word dada when he
reached 8 months. He developed bowel and bladder control at the age of
4-5 years old.

3. Current Development

Gross motor skills

He walks alone, skips and climbs at the age of 1 year old.

Fine motor skills

At the age of 2 the child can stack blocks and uses crayons to draw. At the
age of 3 the child can already feed self and at the age of 4 years old the
child can dress and undress on his own, brush teeth and draw simple
shapes.

Language skills
At the age of 3 the child can talk and speak clear and understand some
words.

Toilet training
The child learns to control his bowel/ bladder at the age of 4 years old and
knows the terms used in toileting.

4. Nutritional History
The child has been breastfed by his mother and solid food was introduced
to him at the age of six months.

5. Family History
In their family there is only hypertension in the mother side. His father
consumes 8 packs of cigarette per year.

C. Assessment Findings
Physical Assessment

GENERAL SURVEY
S.J. is a 6 years old male pupil, well developed and appears to be at stated age.
Not well cleaned but wears appropriate clothes. Oriented to time, place, person, and
able to respond to questions and environmental stimuli appropriately. Comprehends
directions. Difficulty or discomfort making laryngeal speech sounds or varying
volume, quality, or pitch of speech.
SKIN
Skin color differences among body areas and between sun-exposed and non-sun-
exposed areas. Presence of scars noted. Darker skin around knees and elbows. Cool to
warm temperature. Turgor resilience. Bilateral symmetry.

HEAD
Hair is black in color, thick and distributed evenly. Head erect and midline. Skull
normocephalic, symmetric and without deformities. Scalp is intact and without lesions
or mass noted. Facial features symmetric. No bruits.

EYES
Eyebrows are smooth, black in color and distributed evenly and in line with each
other. Superior eyelid covering a portion of iris when open. With mote noted. Eyelashes
are black, evenly distributed, present on both lids and turned outward. Conjunctiva
clear and inapparent. Sclerae white and visible above irides only when eyelids are wide
open. Irides are clearly visible and similar in color. Pupil is round, regular and equal in
size, reactive to light and accommodation.

EAR
Auricles in alignment. Moderate cerumen noted on ear canal. Conversational
hearing appropriate. Able to hear whispered voice. Has a good auditory activity and
obeys to verbal commands.

NOSE
Nose in midline and no discharge or polyps, mucosa pink. Conforms to face to
color. Nares oval and symmetrically positioned. No sinus tenderness to palpation.
Correctly identifies odor.

MOUTH AND OROPHARYNX

Lips symmetric vertically and horizontally at rest and moving. Teeth are stained
yellow. Pinkish red, smooth and moist buccal mucosa. Halitosis noted. Gums are light
pink in color and no bleeding. Incomplete teeth noted. Tongue is midline, dull red in
color and moist. Hard palate and soft palate are pinkish in color. Tonsils projecting
beyond limits of tonsillar pillars. Tonsils red, enlarged and covered with exudates.
Grade 2 inflammation of tonsils noted. Posterior wall of pharynx is red bulge adjacent
to tonsil extending beyond midline.

NECK
Neck is straight and symmetrical. Trachea is in midline. No jugular vein
distention or carotid artery prominence. Carotid pulse is palpable. Thyroid is palpable,
firm, smooth and not enlarged. Thyroid and cartilage move with swallowing.
Tenderness noted below the mandible. No bruits noted. Perform limited range of
motion.

THORAX AND CHEST

Elliptical in shape and move symmetrically when breathing. No chest retraction
noted. Tachypnea noted with a respiration of 29 bpm. The areola and nipples are brown
in color and no discharges noted. Apical pulse auscultated. Crackles noted on anterior
lungs.

BACK
Spinal column in proper alignment. Slightly cold back was observed. Crackles
are heard upon auscultation.

ABDOMEN
Flat, rounded and symmetrical. Uniform in color, no pigmentation and rashes
noted. No abdominal scars and masses. Active bowel sounds audible in all four
quadrants. Abdomen is soft.

UPPER EXTREMITIES
Arms are fair in color and symmetrical. Scars noted. No tenderness upon
palpation of the muscles and joints. The patient can perform passive range of motion.
Radial and brachial pulses are palpable. With D5IMB 500 cc x 66 cc/h infusing at right
basilic vein. Good capillary refill noted. Full range of motion.

LOWER EXTREMITIES
Legs are fair in color. Muscles are firm and skin is slightly dry. Palms are not
pale. Full range of motion. The popliteal and dorsalis pedis pulses can be felt upon
palpation. The client has good capillary refill.

GENITO-ANAL AND GENITO-URINARY

Pubic hairs are not present. There is no skin lesions, penile discharges and
swelling noted. No hemorrhoids and bleeding. Urinated a minimal amount of yellowish
color urine. Defecated to a yellowish brown watery stool.
 DIAGNOSTIC TEST
LABORATORY TESTS RESULT NORMAL VALUE SIGNIFICANCE
Urinalysis
Color Pale straw
Transparency Slightly hazy
Reaction Neutral
Specific gravity 1.020 1.0 10-1.025 NORMAL
Pus cells 0-2 hpf
Red blood cell 0-2 hpf
amorphous Few
phosphate
squamous Occasional
epithelial cells
bacteria Occasional
mucus threads Occasional
Hematology
hemoglobin 99 gms/L Male: 130-180 g/L Anemia
hematocrit 0.29 vol. fr Male: 0.40 0.54 Anemia
vol. fr
red blood cell count 3.43 x 1012 /L Male: 4.6 6.2 x 1012 Anemia, nutritional
/L deficiency
white blood cell 3.65 x 103 /L 4.5 11 x 103 /L Infection
count
neutrophil 23 % 55-70% Lower protection to
bacteria
segmenter 18 % 50-70%
stab 5% 2-5% NORMAL
lymphocyte 73 % 20-40% Acute infection
monocyte 4% 3-9% NORMAL
platelet count 328 x 109 /L 150-450 x 109/L NORMAL
MCV 85.2 fl Male: 60 100 fl NORMAL
MCH 98.8 pg 25.4 34.6 pg Macrocytic anemia
due to low vitamin
B12 or folic acid
MCHC 33.8 g/dl Male: 31 37 g/dl
RDW 11.52 11.5-14.5
Throat Culture Positive Causative agent
GABHS detected
D. Drug Therapy

Generic name: Cetirizine

Classification: Antihistamine
Dosages: (Adults and Children 6 yr and older)
= 10 mg/day PO or 5 mg PO bid
Therapeutic actions:
Potent specific histamine (H1) receptor antagonist; inhibits histamine release and
eosinophil chemo taxis during inflammation, leading to reduced swelling and
decreased inflammatory response.
Indications:
Management of seasonal and perennial allergic rhinitis, allergies, hay fever
Treatment of chronic, idiopathic uticuria
Unlabeled uses: To decrease wheal response and pruritus of mosquito bites;
possible use in allergic asthma.
Contraindications and cautions:
Contraindicated with allergy to any anti histamines, hydroxyzine.
Not recommended for children < 2 y.o.
Lactation
Adverse Effects:
CNS: Somnolence, sedation
CV: Palpitation, edema, dizziness
GI: Nausea, diarrhea, abdominal pain
Respiratory: Bronchospasm
Other: Fever, rash, fatigue
Nursing Considerations:
Give w/out regard on meals
Provide oral solution form or chewable tablets for pediatric use if needed.
Evaluate therapeutic response
Patient teaching:
Take this drug w/out regards to meals
Report difficulty of breathing, hallucinations, tremors, loss of coordination,
irregular heartbeat.

Generic name: Paracetamol

Classification: Analgesic and Anti pyretic
Dosages: 250 mg/tab q 4 hr for fever
Route: Oral
Therapeutic actions:
It inhibits prostaglandin synthesis
 Is effective at reducing pain and fever
Indications:
Treatment of mild to moderate pain
Temporary reduction of fever
Temporary relief of minor aches
Contraindications and cautions:
Contraindicated in patients w/ hypersensitivity to paracetamol
Contraindicated in patients w/ kidney and liver diseases
Adverse Effects:
CNS: Headache
CV: Chest pain, dyspnea
GI: Acute renal failure
Nursing considerations:
Do not exceed the recommended dosage
Reduce dosage w/ hepatic impairment
Discontinue drug if hypersensitivity reactions occur
Patient teaching:
Take the drug only for complaints indicated; it is not an anti-inflammatory agent
Report for rash, unusual bleeding or bruising, yellowing of skin or eyes, changes
in voiding pattern.

Generic name: Paracetamol

Brand name: Acetaminophen
Classification: Antipyretic
Dosages: 12.5 mg/kg q 4 hr
Route: IV/Parenteral
Therapeutic actions:
Inhibits the synthesis of prostaglandin that may serve as mediators of pain and
fever, primarily in the CNS.
Has no significant anti-inflammatory properties/GI toxicity.
Indications:
Treatment of mild pain
Treatment of moderate to severe pain
Contraindications and cautions:
Contraindicated in previous hypersensitivity
Products containing alcohol should be avoided in patients who have
hypersensitivity/intolerance to these compounds.
Adverse Effects:
Skin eruption
Hematological toxicity(thrombocytopenia)leading to cyanosis
 Renal damage
Nursing considerations:
Assess overall health status
Assess type, location, and intensity of pain prior to 30-60 minutes following
administration.
Assess fever, note presence of associated sign.
Patient teaching:
Advise patient to consult physician if discomfort or fever is not relieved by
routine doses.
Report for rash, unusual bleeding or bruising, yellowing of skin or eyes, changes
in voiding pattern.

Generic name: Zinc

Classification: Vitamins and Mineral
Dosages: 5 ml OD
Route: Oral
Therapeutic actions:
Serve as cofactor for many enzymatic reactions. Required for normal growth and
tissue repair, wound healing, and sense of taste and smell.
Indications:
Replacement and supplement therapy in patients who are at risk of zinc
deficiency.
Contraindication and cautions:
Hypersensitivity / allergy to any components in the formulation.
Use cautiously in renal failure.
Adverse effects:
Acute toxicity may cause diarrhea, vomiting & lethargy
Nursing Considerations:
Monitor progression of zinc deficiency symptoms during therapy.
Emphasize the importance of follow up exams.
Patient teaching:
Inform the patient to notify any health care team if he/she feels nausea, vomiting,
abdominal pain, tarry stools occur.

Generic name: Ampicillin Sulbactam

Classification: Antibiotic
Dosages: 750 ml IVTT q 6 hr
Route: IV/Parenteral
Therapeutic actions:
Bactericidal action against sensitive organism; inhibits synthesis of bacterial cell
wall, causing cell death.
Indications:
Treatment of infections caused by susceptible strains of Shigella, Salmonella, E
Coli, gram positive organism
Meningitis
Contraindications and cautions:
Contraindicated w/ allergies to penicillin, cephalosporin, or other allergens.
Use cautiously with renal disorder.
Adverse effects:
CNS: Lethargy, hallucinations, seizures
CV: Heart Failure
GI: Nausea, vomiting, abdominal pain, bloody diarrhea
GU: Nephritis
Hematologic: Anemia, prolonged bleeding time
Hypersensitivity: Rash, fever, wheezing
Local: Pain
Nursing considerations:
Check IV site carefully for signs of thrombosis or drug reaction
Do not give IM injections in the same site; atrophy can occur
Patient teaching:
Inform patient that they may experience these side effects: Nausea, vomiting, GI
upset (eat small frequent meals), diarrhea
Tell patient to report pain or discomfort at sites unusual bleeding or bruising,
mouth sores, rash, hives, fever, itching, diarrhea, difficulty of breathing

Generic name: Salbutamol

Brand name: Albuterol
Classification: Anti-asthmatic, Bronchodilators
Dosages: 2-12 yrs old: for child 10-15 kg use 1.25 mg BID or TID by nebulization; for
child more than 15 kg, use 2.5 mg BID or TID by nebulization
Route: Inhalation
Therapeutic actions:
In low doses, acts relatively selectively at beta2 adrenergic receptor to cause
bronchodilation and vasodilatation; at higher doses beta2 selectivity is lost, and
the drug acts at beta2 receptors to cause typical symphatomimetic cardiac effects.
Indications:
Relief and prevention of bronchospasm in patients w/ reversible obstructive
airway disease or COPD
 Inhalation: Treatment of acute attacks of bronchospasm
Prevention of exercise-induced-bronchospasm
Contraindicated with hypersensitivity to albuterol, tachyarrhythmia,
tachycardia.
Patients w/ diabetes mellitus
Adverse effects:
CNS: Restlessness, anxiety, fear, CNS stimulation
CV: Cardiac arrhythmias, tachycardia, palpitations, anginal pain
Dermatologic: Sweating, pallor, flushing
Respiratory: Coughing, respiratory difficulties
Nursing Consideration:
Do not exceed recommended dosage
Maintain a beta-adrenergic blocker on standby in case of emergency
Patient Teaching:
Inform patient that they may experience these side effects: Dizziness, drowsiness,
fatigue, headache, nausea, vomiting, change in taste, anxiety, sweating, flushing,
insomnia.
Tell patient to report chest pain, dizziness, weakness, tremors, or irregular
heartbeat, difficulty of breathing, productive cough.

E. PATHOPHYSIOLOGY:

Anatomy of Upper Respiratory Tract

OVERVIEW:

Respiration provides the body with a means of gas exchange. It is the process whereby
oxygen from the air is transferred to the blood and carbon dioxide is eliminated from
the body. The nervous system controls the movement of the respiratory muscles and
adjusts the rate of breathing so that it matches the needs of the body during various
levels of activity.

The respiratory center consists of two dense, bilateral aggregates of respiratory neurons
involved in initiating inspiration (the drawing of air into the lungs.) and expiration
(expelling air from the lungs) and incorporating afferent impulses into motor responses
of the respiratory muscles. The first, or dorsal, group of neurons in the respiratory
center is concerned primarily with inspiration. These neurons control the activity of the
phrenic nerves that innervate the diaphragm and drive the second, or ventral, group of
respiratory neurons. They are thought to integrate sensory input from the lungs and
airways into the ventilator response. The second group of neurons, which contains
inspiratory and expiratory neurons, controls the spinal motor neurons of the
intercostals and abdominal muscles.
The respiratory system consists of the air passages and the lungs. Structurally, the
respiratory system is divided into two: the upper respiratory tract and the lower
respiratory tract.

The upper respiratory tract includes nose or nostrils, the sinuses, nasal cavity,
pharynx, and larynx. These structures direct the air we breathe from the outside to the
trachea and eventually to the lungs for respiration to take place.

The lower respiratory tract begins with the trachea which enters the thoracic
cavity and subsequently divides into two main bronchi, one supplying each lung. The
bronchi then divide repeatedly forming airways of ever decreasing diameter (see
below). The smallest bronchi are called terminal bronchioles; these are the last of the
purely conducting portion of the lungs.

The upper respiratory tract warms, humidifies, and filters the air; in this process
it is exposed to the wide variety of pathogens that may lodge and grow in various areas
depending on the susceptibility of the host. Pathogens may lodge in the nose, pharynx
(particularly the tonsils), larynx, or trachea, and may proliferate, if the defenses of the
host are depressed. The spread of the infection depends on the resistance mounted by
the host and on the virulence of the organism.

An upper respiratory tract infection, or upper respiratory infection, is an

infectious process of any of the components of the upper airway. It is one of the most
frequent causes of physician visits with varying symptoms ranging from runny
nose, sore throat, cough, to breathing difficulty, and lethargy

Acute tonsillopharyngitis is the swelling of the pharynx and the tonsils. Pharyngitis
is an acute inflammation of the pharynx, which is the back of the throat, including the
back of the tongue, is one of the most commonly identified clinical problems. Although
it is usually viral in origin, pharyngitis may also be caused by bacterial infection. Group
A beta-hemolytic Streptococcus (GABHS) (strep throat) is the most common cause of
bacterial pharyngitis. Tonsillitis is an acute inflammation of the palatine tonsils.
Although it is sometimes viral in origin, tonsillitis is usually due to streptococcal
infection.

Clinical Manifestations:

Pharyngitis
A bacterial pharyngitis may occur by itself or as a complication of the common cold or
flu. The bacteria most commonly responsible is the Group A beta-hemolytic
Streptococcus. Less frequently the infection is caused by pneumococcus, staphylococcus
pyogenes or hemophilus influenzae. As an acute bacterial pharyngitis develops, the
child complains of a sore throat which may become severe very rapidly, making it
difficult to swallow (dysphagia). The child may develop chills, and at times his/her
temperature may reach 104F to 105F. He may complain of earache. This is usually a
result of pain in the throat being referred to the ears; however, an acute ear infection can
complicate pharyngitis. Since a baby or young child cannot complain of a sore throat,
irritability, and fever are the first manifestations of pharyngitis. The child is flushed and
looks ill. Hemolytic Streptococcal pharyngitis can be associated with a skin rash. The
throat appears bright red and there may be small yellow pustules and stringy mucus on
the pharyngeal wall.

Tonsillitis
A child who develops acute tonsillitis due to hemolytic streptococci complains of an
excruciatingly sore throat and has difficulty in swallowing (dysphagia). The child
appears flushed and on occasion develops a rash. He may have chills, and his
temperature usually rises to 103F or higher. Frequently the child complains of earache
to pain being referred from the throat to the ears. The tonsils are usually larger than
normal and are visible during inspection. They are bright red. In acute tonsillitis
enlarged lymph nodes frequently appear as tender lumps in the upper neck, just below
the angle of the jaw.

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 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.
Avoid drinking alcohol.

Complications of Streptococcal Tonsillopharyngitis

Non Suppurative Complications:

Acute rheumatic fever
Scarlet fever
Streptococcal toxic shock syndrome
Acute glomerulonephritis
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.
 Ingestion of food with microorganism

Airborne Droplets

Group A Beta hemolytic streptococcus

Tonsil/Pharynx

Lymphocytes IgM

Inflammatory Process

5 Cardinal signs:
Warmth
Redness
Neutrophils/ Swelling Histamine/Kinins Secretions
Pyrogen Secretions
Macrophages (causes vascular permeability &
Pain
Stimulates fever production Decreased vasodilator)
Reset Hypothalamus Regulator
Fever Loss of Appetite Dysphagia
Malaise
Function
The tonsils and pharynx as part of the upper respiratory tract helps in warming,
humidifying, and filtering the air; in this process it is exposed to the wide variety of
pathogens that may lodge and grow in various areas depending on the susceptibility of
the host. Pathogens may lodge in the nose, pharynx (particularly the tonsils), larynx, or
trachea, and may proliferate, if the defenses of the host are depressed. The spread of the
infection depends on the resistance mounted by the host and on the virulence of the
organism.

Predisposing factors are classified as Non Modifiable and Modifiable.

Non Modifiable factors include:

Age
Gender
Heredity

Modifiable factors include:

Environment
a. Exposure to different smoke, pollutants or irritants
Lifestyle
Past Medical History
 Group A Beta-Hemolytic Streptoccocus as the causative agent can be acquired
through ingestion of foods with the microorganism or by airborne droplet as the means
of transmission.

In the case of the patient, the causative agent GABHS lodged in the tonsils and
the pharynx. As a normal response of the body, lymphocytes, the smallest of the white
blood cells, will be stimulated by the bacteria to divide and form cells that produce
proteins called antibodies. Antibodies can attach to bacteria and activate mechanisms
that result to the destruction of the bacteria. Antibodies are also called Immunoglobulin
(Ig) because they are globulin proteins involved in immunity. Immunoglobulin M is
often the first antibody produced in response to a foreign antigen (components of
bacteria, viruses, and other microorganisms that cause disease).

The actions of the lymphocytes and the IgM will signal the start of an
inflammatory process.

Stage I:

Injured tissues and the leukocytes in this area secrete histamine, serotonin and
kinins that constrict the small veins and dilate the arterioles in the area of injury. These
blood vessels changes cause redness, and warmth of the tissues. This increased blood
flow increases delivery of nutrients to injured tissue. Blood flow to the area increases
(hyperemia) an edema (swelling) forms at the site of the injury or invasion. Capillary
leak also occurs, allowing blood plasma to leak into the tissues. This response causes
swelling and pain.

Stage II:

In this stage, neutrophilia occurs. Exudates in the form of pus occur, contain with
dead WBCs, nephrotic tissue, and fluids that escape from the damage cells. The
neutrophil attack and destroy organisms and remove dead tissue through phagocytosis.
When an infection stimulating inflammation lasts longer than few days, the bone
marrow cannot produce and release enough mature neutrophils into the blood to keep
pace with the growth of organisms. In this situation, the bone marrow begins to release
immature neutrophils, reducing the number of circulating mature neutrophils. This
reduction of mature neutrophils limits the helpful effects of inflammation and increases
the risk for sepsis.

Pyrogen Secretions are then excreted by the microorganisms, neutrophils,

monocytes and other cells that stimulate fever production by acting the hypothalamus.

Increasing levels of prostaglandin E2 in the brain induce an area called the

hypothalamus to turn up the body's thermostat a notch. Suddenly, the same external
temperature feels colder, and various means are employed to restore the subjective
impression of warmth. These include involuntary processes such as shivering, which
generates heat by movement, and voluntary behavior such as putting on more clothes,
finding a warm radiator to sit next to, and so on.

Like pain and swelling, fever plays a vital part in defending the body against
infection. Many bacteria reproduce most effectively at normal body temperature. So by
raising body temperature the rate at which the bacteria can divide is slowed down.
Fever has the opposite effect on most immune cells, causing them to divide more
quickly. So fever both slows down the spread of the infection and accelerates the
counterattack by the immune system.

All injuries and infections, as stated above cause a fever. This might only
manifest itself in a localized heat, and does not always produce an overall increase of
the body temperature.

Due to fever the patient has loss his appetite which is also a result of dysphagia or
difficulty to swallowing that pleads to body malaise.
 Nursing Outcome Interventions Rationale Evaluation Discharge Plann
Diagnosis Criteria
Medication:
Altered Independent: Goals Met: >Medications should be
breathing After 30 Monitor vital To obtain regularly as prescribed,
pattern minutes of signs baseline data. After 30 dosage, time, & frequency, m
wa related to nursing minutes of sure that the purpose of me
t acute intervention, Assess for any Early nursing is fully disclosed by the
n tonsillophar the patient will signs and recognition of intervention, care provider. It should
As yngitis as be able to symptoms of untoward the patient with the assistance of th
by evidenced maintain altered signs and was able to safety.
. by presence airway patency breathing symptoms. maintain
of exudates. and clear pattern and airway Environment:
secretions. refer for any patency and > Should have an easy a
untoward clear necessities, should be w
ns: signs and secretions ventilated. Provide quie
symptoms. readily. peaceful environment fo
m and relaxation of patien
m Evaluate To determine
clients ability to Treatment:
cough/gag protect own >Encourage the patient
reflex and airway. complete the full days o
 swallowing medication therapy
ability Home care:
of To promote Get plenty of rest
Elevate head physiological Drink warm liqu
of bed and/or and liquids.
ess have client sit psychological Encourage patien
up on chair. ease of gargle with warm
maximal water.
inspiration. If febrile, perform
give antipyretic
medication.

Observe for To identify

signs and infectious
symptoms of process and Health Teaching:
infection promote >Teach patient of freque
timely proper hand washing (t
intervention. spreading of infection to
Encourage/
provide Helps to >PROMOTE PROPER
opportunities prevent/reduc HYGIENE/PREVENTIO
for rest; limit e fatigue. INFECTION.
activities to Since the immune system
level of compromised, every eff
respiratory be maintained to preven
tolerance infection. Frequent hand
is the best way to contro
Advice to infection. Wash hands th
increase fluid To prevent with warm, soapy water
intake drying of especially before eating
secretions preparing food and afte
the toilet. Carry an alcoh
Collaborative: hand sanitizer during ti
Administer water is not available.
medications To relax
(antibiotics, smooth >ADHERE TO TREATM
bronchodilator respiratory REGIMEN
s) as ordered musculature Adherence to the treatm
 and mobilize regimen is essential in o
Assist with secretions. prevent relapse. Most co
use of cause of relapse is loss t
respiratory Various compliance. Medication
devices and therapies/mod be administered at prop
treatments. alities may be and proper dosage.
required to
acquire and >Avoid irritants, such as
maintain pollutants and cigarette
adequate
airways, > Advice patients folks
improve food for diet thoroughly
respiratory
function and Out Patient:
gas exchange. >OPD such as follow-up
Perform chest as ordered by the physic
physiotherapy To get rid of should be greatly encou
after PAI. airway the patient to determine
secretion and patients development a
to help patient physician to know if the
breathe more medication and treatme
freely. will be continued or not

Diet:
>Advice patients folks t
healthy nutritious food.
foods that can cause alle
reactions to patient.

>High Protein- Protein i

tissue repair since patien
some tissue damage, giv
protein diet aids in heal

>High in Vitamins- Vita

protects the patient from
infection.
 >MEETING NUTRITIO
AND FLUID NEEDS
Bear in mind the food p
of the child when plann
menus. Presenting the fo
attractive manner increa
interest of the patient. In
intake of protein-rich fo
further healing and food
fiber and Vitamin C. En
patient to increase fluid

Support system:
> Encourage family to en
patients treatment.

> Have the family attend

spiritual, physical and e
needs of the patient at h

F. Prioritizing Nursing Diagnosis

1. Altered breathing pattern related to acute tonsillopharyngitis as evidenced by
presence of exudates.
2. Acute pain related to inflammation of tonsillopharyngeal as evidenced by
difficulty of swallowing.
3. Imbalance nutrition less than body requirements related to difficulty of
swallowing.
4. Hyperthermia related to acute infection by microorganisms.
5. Knowledge deficit related to not familiar with the sources of infection.
6.