TONSILLITIS

(PEDIA WARD)
Group 3
OUTPUTS TO BE DISCUSSED
ARE:

GUIDE QUESTIONS

NURSING HEALTH HISTORY

NURSING CARE PLAN

RAPP SHEET

DRUG STUDY
What is Tonsillitis?
Tonsillitis is an inflammation of the tonsils, which are
two oval-shaped epithelial pads at the back of the throat,
one on each side.

Most cases of tonsillitis are caused by infection with a

common virus, but bacterial infections also may cause
tonsillitis.
What triggers Tonsillitis?
Tonsillitis is most often caused by common viruses,
but bacterial infections also can be the cause.

The most common bacterium causing tonsillitis is

Streptococcus pyogenes (group A streptococcus), the
bacterium that causes strep throat. Other strains of strep
and other bacteria also may cause tonsillitis.
 How can tonsillitis be avoided?
To reduce your risk of developing tonsillitis, you should:

• Wash your hands often, especially before touching your nose

or mouth.
• Avoid sharing food, drink, or utensils with someone who is
sick.
• Replace your toothbrush regularly.
To help your child prevent the spread of a bacterial or viral
infection to others:
 Keep your child at home when he or she is ill
 Ask your doctor when it's all right for your child to return to
school
 Teach your child to cough or sneeze into a tissue or, when
necessary, into his or her elbow
 Teach your child to wash his or her hands after sneezing or
coughing
 Republic of the Philippines
BICOL UNIVERSITY TABACO CAMPUS
NURSING DEPARTMENT
Tabaco City

STUDENT NURSE: Maria Nyla C. Consuelo LEVEL GROUP NO.: LEVEL 2A, GRP.3
HOSPITAL: LB Cruel Medical Clinic
DATE/ SHIFT: March 26,2022 8:00 am – 4:00 pm
CLINICAL INSTRUCTOR: Ma. Lina P. Castroverde, RN

Client’s Initials: R Gender: Male Age: 5 y/o Marital Status: Child Admission date: March 26, 2022 @7:10 am
Religious Preference: none Occupation: none Ward: PEDIA WARD
Presenting Signs/Symptoms/Chief Complaint(s) (What brought the client to the hospital?): difficulty in swallowing, fever and running nose
 

Admitting/Primary Diagnosis: Tonsillitis

 

History of Present Illness (What led up to his hospitalization?): patient complained of pain on the right ear with on and off fever and sore throat that occurred two days ago.
 

Previous Hospitalization (Date(s) & Reason (s) of this hospitalization): none Previous Surgical Procedure(s) (Name & Date (s): none
 

Health History (Include length of time client has had disease processes; significant family history): none
 
Substance Use (Include use of tobacco, alcohol, street drugs, over-the counter drugs, length of use): analgesic paracetamol was given for fever and pain

Lifestyle (Include personal habits, diet, sleep or rest patterns, activities of daily living, recreation or hobbies): none
 
 STUDENT NURSE: CERNECHEZ, MONALYN C.
HOSPITAL: LB CRUEL MEDICAL CLINIC LEVEL/GROUP NO.: LEVEL 2 – GROUP 3
CLINICAL INSTRUCTOR: MA. LINA P. CASTROVERDE DATE/ SHIFT: MARCH 26-27, 2022 (8:00 AM – 4:00 PM)
NURSING CARE PLAN
       
Date/ Time NURSING PLANNING INTERVENTION
ASSESSMENT DIAGNOSIS EVALUATION

  Independent/  
Goal Desired/ Rationale
Dependent
Expected /
Collaborativ
Outcome (s) e
 March 26, 2022 Subjective Data: Body temperature Short term goal:  After 12 hours of Independent:   At the end of the
“Pinainom ko pa siya above normal After 1 day of nursing interventions, nursing
nin bulong para range related to nursing the patient will have a 1. Establish To create a intervention the
mahali ang saiyang progress of a interventions the temperature below 39.7 rapport therapeutic goal was
kalintura kaso mas disease. patient will degrees Celsius. and relationship as well completely met as
lalo lugod pong demonstrate normal   communic as to create a good evidenced by:
naglangkaw” as body temperature.   ate with communication and - Normal
verbalized by the   By the end of the shift, the comfortability. and
patient’s mother. Long term goal: the patient will have Patient   Stable
  The patient will a normal and stable and vital
Objective Data: remain free from Guardian. Vital signs as a signs.
Temperature: vital signs. baseline data, for
Complications of a early detection of
39.7 degrees 2. Monitor
Celsius disease and fever. and another health
Record problem and to
RR: 22 bpm monitor the
Warm to touch Vital
Signs. response of the
patient to
medications.
       3. Encourage the To improve  
patient to hydration that may
increase fluid alter because of the
intake as well as fever.
inform the  
mother to  
introduce food  
that are water  
content.
  To watch out for the
4. Monitor contraindicated
nntake and foods and drinks.
Output. To monitor the
  fluid and nutrients
  intake.
   
 
 
5. Monitor the To assure that the
Intravenous Fluids flowrate is correct
and the site of IV. and to know the
right time to
introduce another
IVF. For the IV site,
to look for
indications of
infection and to
determine if the
cannula is on the
right place.
           6. Adjust the  The environment  
environmental temperature can
temperature. affect the body
  temperature.
   
7. Provide comfort To promote
and safety (Ensure relaxation and
that the room is comfort.
clean and well  
ventilated.)  
   
8. Offer Tepid Sponge  One way to reduce
Bath or cool moist high temperature and
cloths. promotes comfort.

Dependent:

9. The nurse will It gives or sustain

prepare and water and
administer IVF line. electrolyte that
will help to
improve
imbalances cause
by fever.
10. The nurse will
administer ANST is performed
Prescribe to assess for
medications after medications allergy.
ANST. The prescribe
medications is for
treating the signs
and symptoms
present.
 STUDENT NURSE: COBILLA, KIN JASTIN C.
LEVEL/GROUP NO.: LEVEL 2 – GROUP 3
HOSPITAL: LB CRUEL MEDICAL CLINIC
DATE/ SHIFT: MARCH 26-27, 2022 (8:00 AM – 4:00 PM)
CLINICAL INSTRUCTOR: MA. LINA P. CASTROVERDE

           
Date/ Time ASSESSTMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS     Dependent/  
Goal Desired/ Expected Independent/ Rationale
Outcome (s) Collaborative
 March 26, 2022  Subjective Data: Risk for aspiration Short Term After 36 hours of Prevent Goals are met as
related to Goal: nursing Place the child in a Aspiration evidenced by:
“Pagmakaon po siya impaired After 1 day of interventions, partially prone  
kan saeyang pagkaon, position with head    Prevention of
minakulugon po daa swallowing. nursing interventions, The patient will now
turned to one side   aspiration.
ang saeyang halunan” the patient’s pain on properly eat his foods
until the child is    Relief from
as verbalized by the swallowing will without pain in his  
patient’s mother. decrease. throat. completely awake;   pain, especially
    encourage the child   while
Objective Data: Long Term to expectorate all   swallowing.
Goal: secretions;    Improvement of
Tonsils   fluid intake.
The patient will be discourage the
Enlargement    Increase of
more comfortable child from
  knowledge and
 Both eardrums looked with less pain. coughing; and keep
  understanding of
reddish the head slightly  
lower than the postdischarge
 
chest to help care and
facilitate drainage possible
of secretions. complication s.
 
 
          Apply an ice collar  Relieve Pain
postoperatively;  
administer pain  
medication as  
ordered; encourage  
the caregiver to  
remain at the  
bedside to provide  
soothing  
reassurance; crying  
irritates the raw  
throat and increases
the child’s
discomfort; thus, it
should be avoided
if possible.
 
 
Providing
Instruct the caregiver Family
to keep the child Teaching
relatively quiet for a
few days after
discharge;
recommend giving
soft foods and
nonirritating liquids
for the first few days;
teach family
members to note any
signs of hemorrhage
and notify the
healthcare provider;
          and provide written  
instructions and  
telephone numbers  
 
before discharge.  
 
 
 
 
 
 
 
ANATOMY PATHOPHYSIOLOGY
ETIOLOGY
1. GROUP A STREPTOCOCCAL BACTERIA
2. RHINO VIRUS, INFLUENZA VIRUS
3. ADENOVIRUS
 
DUE TO CAUSE
 
 
 
 

INVATION OF BACTERIA INTO TONSILS

 
 
 
 

ANTIGEN ANTIBODY REACTION LEADING TO HISTAMINE PROSTAGLANDINS RELEASE

 
 
 
 

INCREASE BLOOD SUPLY EDEMATUS TONSIL

 
 
 
 

PERITONSILAR ABSESS (PUSS FORMATION)

 
 
 DRUG STUDY
EFFECTS
FREQ./ROUTE
THERAPEUTIC
GENERIC OF NURSING
DATE BRAND NAME MECHANISM OF
NAME ADMINISTRAT Adverse Effect(s) Side Effect(s) CONSIDERATION
ACTION
ION
03/26/2022 Sodium Chloride Sodium Chloride 1/2 L @ 40 Replaces and maintains  Pulmonary •Allergic  Monitor patient’s
(NaCL) (NaCL) ugtts/min IV sodium and chloride levels Edema Reactions electrolyte levels
which are essential ions  Edema  
necessary in normal  Vomiting  Assess patient’s fluid
cellular metabolism. Diarrhea status

 Hypernatremia  
Sodium is a major cation in
 Hyperactivity  Assess Patient’s and
extracellular fluid and
 Tachycardia Family’s knowledge on
helps maintain water
distribution, fluid and convulsion drug therapy
electrolyte balance, acid-  Numbness  
base equilibrium, and  Confusion  Instruct Patient to
osmotic pressure  Back pain report occurrence of
 Muscle drug induced adverse
Chloride is the major Twitching reactions
amino in extracellular fluid
and is involved in
maintaining acid-base
balance.
 DRUG STUDY
EFFECTS
FREQ./ROUTE
THERAPEUTIC
GENERIC OF NURSING
DATE BRAND NAME MECHANISM OF
NAME ADMINISTRAT Adverse Effect(s) Side Effect(s) CONSIDERATION
ACTION
ION
03/26/2022 Ceftin Cefuroxime 500 mg IV every Cefuroxime binds to one ● CNS: Seizures ● Injection site ● Assess patient for signs
8 hours ANST or more of the penicillin- reactions and symptoms of infection
binding proteins (PBPs) ● GI: Pseudomem (inflammatio prior to and throughout
which inhibits the final branous Colitis, n, blood therapy.
transpeptidation step of diarrhea, nausea, clot) ● Before initiating therapy,
peptidoglycan synthesis in vomiting, ● Diarrhea obtain a history to
bacterial cell wall, thus cramps.  ● Watery or determine previous use of
inhibiting biosynthesis and ● Derm: rashes, bloody and reactions to penicillins
arresting cell wall assembly urticaria, diaper stools or cephalosporins. Persons
resulting in bacterial cell dermatitis.  ● Stomach or with a negative history of
death. abdominal penicillin sensitivity may
● Hematologic: bl pain still have an allergic
eeding, ● Fever response.
eosinophilia, ● Cough ● Observe patient for signs
hemolytic ● Stuffy nose and symptoms of
anemia, ● Headache anaphylaxis (rash,
leukopenia.  ● Drowsiness pruritus, laryngeal edema,
● Restlessness wheezing). Discontinue
● Local: pain at ● Muscle pain the drug and notify
IM site, phlebitis ● Swelling physician or other health
at IV site.  care professional
immediately if these
● Misc: Allergic symptoms occur. Keep
reactions , norepinephrine, an antihistamine,
including and resuscitation equipment
Anaphylaxis, close by in the event of an
and serum anaphylactic reaction.
sickness,
superinfection. ● Instruct patient to report
signs of hypersensitivity.
 DRUG STUDY
             
Date BRAND NAME GENERIC NAME FREQ./ROUTE OF THERAPEUTIC EFFECTS NURSING
ADMINISTRATION MECHANISM OF CONSIDERATION
ACTION Adverse Effect(s) Side Effect(s)

March 26, 2022 Naprex Paracetamol 2OOmg IV q4 Paracetamol     Assess patient for
exhibits analgesic Thrombocytopenia Nausea history of liver
action by peripheral disease.
Leukopenia Vomiting
blockage of pain
Check that the
impulse generation. Neutropenia Headache
patient is not taking
It produces Constipation
Tachycardia any other medication
antipyresis by Pruritus
containing
inhibiting the
Hypotension paracetamol.
hypothalamic heat Flushing
regulating centre. Hepatotoxicity Evaluate therapeutic
Erythema
Its weak anti response
Stevens
inflammatory
activity is related to Assess for any
Johnson Syndrome
inhibition of hypersensitivity
prostaglandin reactions.
synthesis in the
CNS.
 DRUG STUDY
EFFECTS
FREQ./ROUTE
THERAPEUTIC
GENERIC OF NURSING
DATE BRAND NAME MECHANISM OF
NAME ADMINISTRAT Adverse Effect(s) Side Effect(s) CONSIDERATION
ACTION
ION
03/26/2022 ● Ceclobid Cefaclor 250mg/5ml, Bactericidal: inhibits ● CNS: ● Diarrhea, ● Monitor signs of
● Ceclor/ 5ml TID synthesis of bacterial cell- headache, stomach diarrhea, abdominal
Ceclor-DS wall, causing cell death dizziness, upset pain, fever, and other
● Ephron   lethargy, ● Difficulty severe or prolonged GI
  paresthesias of problems.
● GI: nausea, breathing ● Monitor signs of
vomiting, ● Unusual allergic reactions and
diarrhea, tiredness anaphylaxis, including
anorexia, or fatigue pulmonary symptoms
abdominal ● Derm: & skin reactions.
pain, rashes, ● Assess muscle aches
flatulence, urticaria. and joint pain that may
pseudomemb be caused by serum
 
ranous colitis, sickness.
hepatotoxicit ● Monitor signs of blood
y dyscrasias, including
fatigue, weakness,
 
bruising, nose bleeds,
bleeding gums, other
bleeding problems,
hemolytic anemia, sore
throat, signs of
infection, bruising.
● Report these signs to
the physician.
 
 DRUG STUDY
             
  FREQ./ THERAPEUTI EFFECTS NURSING CONSIDERATION
Date BRAND GENERIC ROUTE OF C MECHANISM
NAME NAME ADMINISTR OF ACTION
ATION
Adverse Side Effect(s)
Effect(s)

03-26- Bactidol Hexetidine 10 ml Synthetic oral   irritation, tingling or Note for the drugs, dosage, time,
22 For gargle antiseptic with GI: Taste numbness of the route, client.
BID (twice a broad-spectrum disturbances, tongue or inside the  
day) bactericidal and transient anaesthesia, mouth, taste
fungicidal activity irritation, disturbance or loss Note the side effects of the drugs.
upon topical sensitization. of taste, dry mouth.
application. Do not swallow
Hexetidine has both If prompt relief is not obtained, or if
antibacterial and soreness persists, worsens or spreads,
antifungal properties discontinue use and consult a doctor.
in vivo and possesses
a broad spectrum of Fever, headache, nausea, and/or
activity against both vomiting usually indicate sever
gram-positive and infection requiring advice from a
gram-negative doctor.
organisms that cause
mouth and throat Supervise children ages 6 to 12 years
infections. when using Bactidol. Do not administer
Hexetidine has been to children under six years of age unless
proven to exhibit an directed by a doctor.
analgesic property.
It possesses an
anti-infective
        (preventive and      
curative) property. It
has been shown to have
a cicatrizing action. It
also exhibits a mild
hemostatic action.
Thank you!