ACUTE TONSILLOPHARYNGITIS

+ Tonsillopharyngitis is the acute inflammation of the pharynx, tonsils, or both which is caused by gram-positive bacteria
known as Streptococcus pyogenes
+ Spreads through person-to-person contact, usually through saliva or nasal secretions from an infected person
+ It is usually a self-limiting condition, i.e. it gets better without treatment, and generally there are no complications.
+ Humans are the primary reservoir of group A streptococcus.
+ The disease is easily transmitted in the following places:
+ Schools
+ Day care centers
+ Military training facilities

Anatomy and Physiology

+ The tonsils are a pair of soft tissue masses located at the pharynx. Each tonsil is composed of tissue similar to lymph
nodes, covered by pink mucosa. Running through the mucosa of each tonsil are pits, called crypts.
+ These immunocompetent tissues are the immune system's first line of defense against ingested or inhaled foreign
pathogens, and as such frequently engorge with blood to assist in immune responses to common illnesses such as the
common cold.
+ Tonsils have on their surface specialized antigen capture cells called M cells that allow for the uptake of antigens
produced by pathogens. M cells then alert → B cells and T cells in the tonsil that a pathogen is present and an immune
response is stimulated. B cells are activated and proliferate in areas called germinal centres in the tonsil.
 Germinal centres → places where B memory cells are created and IgA is produced.
+ The tonsils are part of the lymphatic system, which helps to fight infections. However, removal of the tonsils does not
seem to increase susceptibility to infection.
Pathophysiology
1. Invasion of mucosa 5. M-protein bacteria & sarcolemma antigens of
2. Local inflammation myocardium
3. Mucosa irritation 6. Immune complex deposition in glomeruli
4. Release of toxins and proteases

+ Signs and Symptoms

+ The incubation period is approximately 2-7 days + Risk Factors
+ Pain with swallowing is the hallmark sign of this disease. + Commonly infects children aged 5-15 years old &
rare in <3 years old
+ Most Classic Symptoms: + Parents of school-aged children and other adults
 Tonsillar swelling/exudates who are in close contact with the infected individual
 Anterior cervical lymphadenopathy + Crowded places like day care centers, schools and
 Absence of cough military barracks
 Fever >38°C

+ Diagnosis
+ Clinical evaluation
+ Rapid antigen test, culture, or both
+ Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea and cough usually indicate a
viral cause. A dirty gray, thick, tough membrane that bleeds if peeled away indicates diphtheria (rare in the US).
 Possible Nursing Diagnoses
1. Acute pain 3. Hyperthermia
2. Imbalanced Nutrition Less Than Body 4. Disturbed Sleep Pattern
Requirements 5. Anxiety

+ Medical Management
+ Symptomatic treatment + Antibiotics
 Pain Management(NSAIDS)  Penicillin remains the drug of choice;
 Corticosteroids cephalosporins or macrolides are alternatives
 Hydration for patients allergic to penicillin.
 Rest + Tonsillectomy

+ Nursing Management
+ Prevent aspiration. Keep the head slightly lower than the chest to help facilitate drainage of secretions.
+ Relieve pain. Administer pain medication as ordered.
+ Encourage fluid intake. Record intake and output until adequate oral intake is established.
+ Provide family teaching. Recommend giving soft foods and non-irritating liquids for the first few days; teach
family members to note any signs of hemorrhage and notify the healthcare provider.

CASE PRESENTATION
+ Patient’s Demographic Data
+ Cajes, Juliet Auxillo + Also had a breast tissue biopsy 9 days PTA.
+ 21 y.o. ; Female Filipino Catholic, Single + The recent assessment data are shown below:
+ From Santo Nino, Talibon, Bohol + T – 36.7 °C
+ Admitted by Dr. Laarni A. Corado-Yucot on + P – 84 bpm
December 1, 2018 at 8:20 P.M. due to + R – 22 cpm
persistent symptoms of high-grade fever + BP – 100/90 mmHg
associated with dysphagia and vomiting 3 days
PTA.

+ History of Present Illness

+ 9 days PTA, pt had sought consultation to surgery due to a mass at the right breast. Biopsy was done and pt was
scheduled for surgery.
+ 3 days is seen with intermittent high – grade fever associated with dysphagia and vomiting.
+ Physical assessment revealed inflammation of tonsils (+3)
+ Patient was also initially hooked with D5 ) 0.3 NaCl 1L at 30 gtts/min
+ Past Medical History
+ 1. Immunizations --According to the S.O., the pt. had a complete record of all childhood immunizations.
+ 2. Allergies --The S.O. states that the patient has not experienced or had allergic reactions as of the moment.
+ 3. Accidents --According to the S.O. that so far, she hasn‘t experienced any accident prior to this admission.
+ 4. Hospitalization - According to the S.O., the patient had hospitalizations as a kid. As she grew up, she only had
clinic visits with regards body problems.
+ 5. Medicines – The S.O. notes that the patient has been taking OTC drugs.
+ 6. Operation --According to the S.O., the patient hasn't undergone any prior operations.
 + 7. Diet – The S.O. stated that the patient's diet comprises mostly of roughage and protein in balanced amounts.
Pt. does take 9-11 glasses of water a day as much as possible. Moreover, the patient does eat sweets and other
luxury foods if available and in moderation.
+ 8. Lifestyle – The S.O. states that she does exercises sometimes if vacant but manages to do it after work (since
she is a teacher).
+ 9. Existing Diseases – According to S.O., the patient has no existing history of hypertension, diabetes, and
bronchial asthma. Although she does have a mass on her right breast which prompted her to seek medical
attention.
+ Family History
+ The patient cannot recall any family member that has any history of HPN, DM, or asthma.
+ Socio-Economic History
+ The S.O. considers themselves as living in a middle-class family. As of his admission, the patients
relatives are doing their best to improve the patients condition and abides by the doctor’s orders.

NURSING CARE PLAN

+ Nursing Care Plan: Acute Pain
+ Subjective data: “Sakit kaayo itulon sa akong tilaok, hilabi nag mukaon ug muinom ko...” as verbalized by patient.
COLDSPA: Sharp pain in the throat that persisted 3 days PTA, happens upon swallowing; 7 on pain scale.
+ Objective data: Pt. seen at bed awake and hooked with D5 0.3 NaCl 1L at 30 gtts/min; oral mucosa is inflammed;
throat is warm to touch; with the ff. V/S and laboratory results (latest):
+ T – 36.3 °C P – 96 bpm R – 21 cpm BP – 100/60
+ Leukocyte Count: 13.9 x 10 9/L [above normal (5-10)]
+ Nursing Diagnosis: Acute pain related to heightened inflammatory process as evidenced by inflammed oral mucosa,
dysphagia, and verbal reports of discomfort.
+ Scientific Analysis
+ In tonsillitis, the tonsils are enlarged, red, and often coated (either partly or entirely) by a substance that
is yellow, gray, or white. Tonsillitis usually occurs as part of pharyngitis (throat infection). The immune
system responds to the infection by activating the inflammatory response mediated by the immune cells
of the body. Tonsillitis usually begins with sudden sore throat and painful swallowing. This may bring
intense pain and discomfort to the individual afflicted by the disease.
+ Plan of Care
+ After 8 hours of nursing intervention, the patient will exhibit signs of decreased pain sensation as
evidenced by a pain scale of 6 or lower and verbal reports of comfort.
 Nursing Interventions
+ Establish rapport with pt. & S.O. (to facilitate patient and S.O. Participation and trust)
+ Provide morning care (to provide comfort and promote hygiene)
+ Take, monitor, and record V/S and I&O (to provide baseline data during treatment)
+ Regulate IVF (to maintain fluid balance in the vascular system)
+ Increase fluid intake as tolerated (to provide oral protection and prevent dehydration)
+ Advise avoidance of sweets intake and cold beverages (to avoid bacterial proliferation in sweet environment)
+ Provide tepid sponge bath if necessary (to decrease body temp thru condution)
+ Administer medications as indicated by the physician (to provide pharmacologic care; specifically to help bacterial
load in the body)
+ Provide opportunity for rest (to aid in cellular regeneration of the body)
+ Nursing Care Plan: Risk for Imbalanced Nutrition: Less than body requirements
+ Subjective data: “Wala may lami ikaon ani sitwasyona; gamay rako ug makaon tungod sa aning gibati nako...” as
verbalized by patient.
+ Objective data: Pt. seen at bed awake and hooked with D5 0.3 NaCl 1L at 30 gtts/min; verbal report of
uncomfortable eating, weakness noted; with the ff. V/S and laboratory results (latest):
+ T – 36.3 °C P – 96 bpm R – 21 cpm BP – 100/60
+ Nursing Diagnosis: Risk for Imbalanced Nutrition related to inadequate nutritional intake as evidenced by
decreased appetite, verbal reports of uncomfortable eating, and weakness.
+ Scientific Analysis
+ Adequate nutrition is necessary to meet the body’s demand for energy. Nutritional status can be
affected by disease or injury state. In the case of the patient, imbalanced nutrition is due to the
experienced discomfort upon intake of nutritive elements brought about by the disease process. In this
state of medical condition, food preparations are altered to be appropriate for the patient as discreet as
possible.
Plan of Care
+ After 8 hours of nursing intervention, the patient will exhibit signs of increased nutrition as evidenced
verbal reports of willingness to eat and increased food and fluid intake.
 Nursing Interventions
+ Increase fluid intake as tolerated (to provide oral protection and prevent dehydration, and promote appetite)
+ Encourage patient to eat food that seems appealing (to whet appetite and to involve patient in nutrition
awareness)
+ Advise patient to avoid foods that may exacerbate disease such as sweets and cold items (to avoid irritating the
oral mucosa and to lessen pain upon food intake)

DRUG STUDY
+ As the physician made his notes, he ordered the following medications (drugs were not given all at once):
+ Ceftriaxone 2 g IV drip OD ANST (-) + Ketorolac 30mg IVTT stat
+ Paracetamol 500 mg 1tab q4 PRN for T > 38 C + Clindamycin 300mL IVTT q6 ANST (-)
+ Ranitidine 50 mg IVTT q8 + Celecoxib 200 mg 1 tab BID
+ Metoclopramide 10 mg IVTT q8 PRN for
vomiting

Ceftriaxone 2 g IV drip OD ANST (-); Drug Class: 3rd  Report signs such as petechiae, ecchymotic
generation cephalosporin areas, epistaxis or other forms of unexplained
+ Works by inhibiting the mucopeptide synthesis bleeding.
in the bacterial cell wall. By binding to these
enzymes, Ceftriaxone results in the formation of
of defective cell walls and cell death.
Nursing Considerations
 Assess patient’s previous sensitivityreaction to
penicillin or other cephalosphorins.
 Assess patient for signs and symptoms of
infection before andduring the treatment
 Obtain C&S before beginning drug therapy
toidentify if correcttreatment has beeninitiated.
 Paracetamol 500 mg 1tab q4 PRN for T > 38 C; Drug
Class: Antipyretic
+ Works by blocking pain impulses by inhibiting
synthesis of prostaglandin. It relieves fever by
central action in the hypothalamic heat-
regulating center.
Nursing Considerations
+ Tell patient that tablets may be crushed or
swallowed whole
+ Teach patient signs of hepatoxicity; such as
bleeding, easy bruising and malaise
+ Should not be used for self medication of
marked fever (39.5 C (103.1 F))
+ This drug should not be used for medicating
fever persisting for 3 days
Ranitidine 50 mg IVTT q8; Drug Class: Anti-ulcer
+ Works by inhibiting the action of histamine at
the H2 receptor site located primarily in gastric
parietal cells, resulting in inhibition of gastric
acid secretion; has some antibacterial action
against H. Pylori
Nursing Considerations
+ Allow 1 hour between any other antacid and
ranitidine
+ Avoid excessive alcohol
+ Assess patient for epigastric or abdominal pain
and frank or occult blood in the stool, emesis,
or gastric aspirate
+ Nurse should know that it may cause false-
positive results for urine protein; test with
sulfosalicylic acid
Metoclopramide 10 mg IVTT q8 PRN for vomiting; Drug
Class: gastrointestinal stimulant
+ Works by increasing sensitivity to
acetylcholine; results increase motility of the
upper GI tract and relaxation of pyloric
sphincter and duodenal bulb.
Nursing Considerations
+ Instruct to take as directed may dilute syrup in
water, juice or carbonated drink
+ Advise that drug increases movements or
contractions
+ Instruct to avoid alcohol and CNS depressants
Ketorolac 30mg IVTT stat; Drug Class: NSAID
+ Works as anti-inflammatory and analgesic activity;
inhibits prostaglandins and leukotriene synthesis
Nursing Considerations
+ Be aware that patient may be at risk for CV
events, GI bleeding, renal toxicity, monitor
accordingly.
+ Keep emergency equipment readily available at
time of initial dose, in case of severe
hypersensitivity reaction.
+ Protect drug vials from light.
Clindamycin 300mL IVTT q6 ANST (-); Drug Class:
Antibiotic
+ Works by inhibiting bacterial protein synthesis by
binding to 50S subunit of ribosome.
Nursing Considerations
+ assess patients infection before and regularly
throughout therapy
+ before giving first dose, obtain specimen for
culture and sensitivity test, begin therapy
pending results.
+ monitor renal, hepatic, and hematopoetic
functions during prolonged therapy.
+ be alert for adverse reactions and drug
interactions
+ if adverse GI reactions occurs, monitor patients
hydration.
Celecoxib 200 mg 1 tab BID; Drug Class: COX-2
Inhibitor NSAID
+ Works by exhibiting anti-inflammatory, analgesic,
and antipyretic action due to inhibition of the
enzyme COX-2
Nursing Considerations
+ Assess pt’s history of allergic reaction to the
drug
+ Teach patient to avoid aspirin and other NSAIDs
(such as ibuprofen and naproxen) during
therapy.
+ Advise patient to immediately report bloody
stools, blood, or symptoms of liver damage
+ Instruct patient to take drug with food or milk.