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TONSILLITIS
I. INTRODUCTION
II. OBJECTIVES
After implementation this case study the student nurse should be able to:
1. Recognize and be appropriate the mainly suitable Nursing Theory to patient, in
assortment to provide relevance for the patient health status.
2. Elucidate and build up the most appropriate nursing management for the
expansion of nursing care plan or NCP.
3. Intricate and develop assessment skills and identification of predictable
conclusion.
4. Discuss the Anatomy and Physiology of Human Respiratory Systems Tonsils.
5. Establish different health teachings that would be advantageous for the
patients recent health provision.
The Body
The Disease
Social sciences
Pathological and
Sciences
therapeutic sciences
aspect of nursing.
The Core
the family
Aspects of nursing
Through the medical care
The Care
The theorist, Lydia E. Hall with her theory which is Core, Care, and Cure was
preferred for this particular case because the student nurses patient who is
suffering hypertension was a could do with a great assessment and the theory of
Lydia E. Hall was needed to expand the patients skill in providing a care for her.
As a student nurse, should first recognized a connection, a relationship with
patient so as to assess the patient for the present problems or disease that the
patient has also this possible disease or risk that the patient might encounter and
plan the suitable things to be done to the patient. This is the enlightenment for
the core of he student nurses patient.
The relevance of the nursing intervention or NANDA will have a massive role
and give support to provide a proper Care to the patient to help the patients
development from a complaint.
Cure is provided when the student nurse apply the knowledge for the
treatment of the patient. As it should be provided administering medication as
prescribed by the doctor or physician, which is also a part of the recovery of the
patient.
I. BIOGRAPHIC DATA
Name:
Ms. K.A.T.
Address:
Antipolo City
Date of Birth:
Age:
Sex:
Female
Civil Status:
Single
Place of Birth:
Baguio City
N/A
Religion:
Roman Catholic
Annual Income:
Chief Complaint:
Provisional Diagnosis:
Attending Physician:
Dra. Ferrer
Admitting Date:
Admitting Doctor:
Dra. Ferrer
DTaP
(diphtheria and tetanus and acellular
pertussis vaccine)
Twinrix
(hepatitis A vaccine with hepatitis B
recombinant vaccine)
Biavax II
(rubella and mumps vaccine)
M-R-Vax II
(measles and rubella virus vaccine)
Orimune
(pollovirus vaccine; trivalent)
Varivax
(against chickenpox)
Dosage
0.2 mL. percutaneously
0.2 mL IM
Three 0.5 mL. IM injections at 2 years
old with 0.5 mL booster at 1 year and 3
months old
0.5 mL SC
Three 0. mL. IM doses; 7-11 months
old
Two 0.5 mg. IM doses; 1 year old 1
year and 11 months old
0.5 mL IM; 1 year and 6 months old
1 mL IM; 1 year old
Followed by booster doses at 2 years
and 6 months old
0.5 mL0 SC
0.5 mL SC
1st dose: 0.5 mL PO at 2 months old, 4
months old and 1 year and 6 months
old
2nd dose: two doses; 2 years old and 2
years and 2 months old
0.5 mL SC; 1 year old
0.5 mL SC; 1 year and 2 months old
Her mother claims that she has experienced a childhood illness which is
Urinary Tract Infection. She had no major operations to date nor serious injuries
or accidents. She has been hospitalized for four times, including present
confinement, for some different reasons. She has been confined due to fever
related to her Tonsillitis.
She was diagnosed of having Urinary Tract Infection and she has it
for 2 years. She has no maintaining medication prescribed by her physician but
she takes up medicine whenever she is confined in the hospital.
She doesnt experience yet any foreign travel, only out-of-town
activities.
Date
26 March,
2007-2nd April,
2007
22nd
December,
2007-12th
January, 2008
24th May, 200825th of June,
2008
th
20 March,
2008 26st
March, 2008
th
Place
Baguio
With whom
With family
Duration
One week
Purpose
Vacation
Bicol
With family
Three weeks
Visited
grandmother
Ilocos Norte
With family
One month
Visited
grandfather
Baguio
With family
6 days
Vacation
DRUG STUDY
Generic
Name
Ampicillin
Specific
Name
Ampicin
Dosage
IV 500 mg - q8h
Albuterol
Ventolin
PO 5ml - q6h
Uses
Actions
Infections of GU,
A broadrespiratory, and
spectrum semiGI tracts and skin
synthetic
and soft tissues;
aminopenicillin,
also gonococcal
is highly
infections,
bactericidal even
bacterial
at low
meningitis, otitis
concentrations,
media, sinusitis,
but is inactivated
and septicemia
by penicillinase
and for
prophylaxis of
bacterial
endocarditis.
Used parenterally
only for
moderately
severe to severe
infections.
To relieve
Synthetic
bronchospasm
sympathomimetic
associated with
amine and
acute or chronic
moderately
asthma,
selective beta2bronchitis, or
adrenergic
other reversible
agonist with
obstructive airway
comparatively
diseases. Also
long action. Acts
used to prevent
more prominently
exercise- induced
on beta2
bronchospasm.
receptors
(particularly
smooth muscles
of bronchi,
uterus, and
vascular supply
to skeletal
muscles ) than
on beta1 (heart)
receptors.
Minimal or no
effect on alphaadrenergic
Paraceta
mol
Tempra
Fever reduction.
Temporary relief
of mild to
moderate pain.
Generally as
substitute for
aspirin when the
latter is not
tolerated or is
contraindicated.
receptors.
Inhibits histamine
release by mast
cells.
Produces
analgesia by
unknown
mechanism,
perhaps by
action on
peripheral
nervous system.
Reduces fever by
direct action on
hypothalamus
heat-regulating
center with
consequent
peripheral
vasodilatation,
sweating, and
dissipation of
heat. Unlike
aspirin,
acetaminophen
has little effect on
platelet
aggregation,
does not affect
bleeding time,
and generally
produces no
gastric bleeding.
During the interview, the client already is in her fourth day of confinement at
Antipolo Medical Center for having a provisional diagnosis of intermittent high-fever
related to her Tonsillitis. The client admitted that for the present year, this already was his
second time to be brought to a hospital for the same diagnosis. For the past history of
the client, she received all the childhood vaccines. She still presently has Urinary Tract
Infection. Now, she is not taking any medications but during her stay in the hospital she
took up Ampicin(Ampicillin), Paracetamol(Tempra) and Albuterol(Ventolin). Health
according to her mom, para sa akin, para maconsider na healthy ang isang tao,
Each person defines health in terms of his or her own values and beliefs. The
family, community, and society in which one lives also influence ones personal
perception of health. Health, as defined by each person, integrates all the human
dimensions-the physical, emotional, socio-cultural, spiritual, and environmental aspects
as a whole person. (Fundamentals of Nursing: Concepts, Process, and Practice, 7 th
Edition by Kozier, p.60)
Behavior-specific knowledge, beiefs, and relationships are considered to be
major motivators for engaging in health-promoting behaviors. (Fundamentals of Nursing:
Concepts, Process, and Practice, 7th Edition by Kozier, p.65)
Nutritional-Metabolic Pattern
The clients usual meal consists of 1 cup of rice and any viand which is prepared
by her mom. She 3 to 5 glasses of water a day and sometimes drinks C2 in the morning.
She doesnt have any food preferences. She eats whatever she likes. Her mom also
claimed she had a huge appetite until he experienced signs and symptoms of headache
and fever because of her tonsillitis, since then, her appetite decreased and hasnt eaten
normally as before. She then cannot consume rice for the mean time. The client also has
no diet restrictions. She also takes Poten-Cee for her vitamins. The client has no
difficulty regarding swallowing or chewing of food. Her mom is the one who prepare
meals for them. The client has no spiritual or cultural belief regarding food. Her mom is
the one who manages the buying and preparing of food.
Time of
Eating
Break fast
8:15 A.M8:30 A.M
Lunch
12:0012:30 pm
Snack
4:30 pm
Dinner
( 9:309:45 pm)
Type of food
-Bread
-milk
Quantity
-3 pcs. Regular
size
-1 glass-250 ml
-2 pcs of bread
1 slice of tomato
2 teaspoon of
mayo with
shredded meat
and onion.
-1 bottle-250 ml
-Baked
-Cold milk
water
1 glass-250 ml
Cold drinks
-Chopsuey
-Rice
-Water
-banana
-1 small saucer as
big as a cup
- 1 glass-250 ml
-1 banana
-Stir fry
-steame rice
-cold drinks
-ripe banana
-Jollibee
burger
-C2
Method of Cooking
The daily needed servings for every food in the Food Pyramid
Her fluid intake is 3-5 glasses of water a day but most of the time she
drinks C2 as for her refreshment beverage.
Interpretation:
The alteration in nutrient requirements that results from illness and trauma varies
with the intensity and duration of the stress. For instance, fever increases the need for
calories and water. Unlike fevers related to septicemia, however, fever caused by a mild
case of flu requires few dietary adjustments.
(Source: Fundamental of Nursing, Taylor, page 1251)
Analysis:
Pain, illness, anxiety and medications can contribute to anorexia and poor intake
when in healthcare facility or home. To the hospitalized patient, food and eating may
take on much greater meaning. Loss of control over food choice, the way food is
prepared, when and how food is served and eating alone may do little to encourage
normal eating.
(Source: Fundamentals of Nursing, Taylor, page 1260)
Elimination Pattern
sensation or anything while urinating. She can control her urine. He eliminates 12 times a day. Normally his excreta are brown in color. He doesnt feel any
discomfort while eliminating. The clients usual bowel pattern is every other day,
or sometimes when she just feels the urge to eliminate her bowel. It is brown in
color, soft formed, semi-solid, cylindrical and moist. She doesnt experience yet
to have diarrhea or history of bleeding.
She doesnt have excessive perspiration. It was also mentioned that her
practice to achieve normal elimination is to drink a lot of water.
Interpretation:
The client seems no difficulty in urinating, and urinates in normal amount. She
also defecates normal amount per day.
Analysis:
The frequency of micturation depends on the amount of urine being produced.
The more urine produced, the more often voiding is necessary, except when fluid intake
is very large. Most people have individual patterns of bowel elimination involving
frequency, timing considerations, position and place. For example many people defecate
after breakfast, when the gastrocolic and duoodenocolic reflexes cause mass propulsive
movements in the large intestine. (Reference: Fundamentals of Nursing 5th edition by
Taylor pg. 1292 and 1341)
Activity-Exercise Pattern
The patient prior to hospitalization spends pretty much of his time at home
playing and watching television all the time. She seldom walks and usually found at her
room. Also as part of his activity and exercise, her mom and the client is strolling to
some places whenever there is free time. She lives with her mom and uncle; she doesnt
help in household chores since shes too young to do so. Aside from the mentioned
routine of activity and exercise, her mom did not mention any other form of exercising.
From the time that he was confined to the hospital because of having fever for 3 days,
she was kept lying in bed.
ACTIVITIES OF DAILY LIVING
Activities of Daily
Living
Before
Hospitalization
During
Hospitalization
Interpretation and
Analysis
1. Nutrition
2. Elimination
3. Exercise
4. Hygiene
He likes to keep
himself clean. He
bathes for 2-3 times
a day and brushes
his teeth for 2-3
times a day. He
trims his nails and
wears clean clothing
and footwear.
5. Substance Use
He is an active
smoker for already
10 years and
consumes about a
pack of cigarettes in
a day. He drinks 3-4
bottles of beer 1-2
times a week.
He usually sleeps
for 7-8 hours a day.
He describes the
sleep as continuous
and satisfying
enough to promote
relaxation.
7. Sexual Activity
He usually engages
in sexual intercourse
for about once or
twice a week. He
reports not using
He has no sexual
activity or
intercourse.
persons ability to
perform hygienic
measures. In the
clients case, the
intravenous fusion
reduces the ability
to perform usual
hygiene practices.
(p.1009, Taylor, 5th
ed)
Substance abuse is
significantly related
to risk-taking
behavior. The
absence of such
behavior may
indicate that there is
no abuse of
alcoholic beverages.
(p.410-411, Taylor,
5th ed).
Middle-aged adults
generally maintain
the sleeping pattern
they have
established at a
younger age. They
usually sleep 6-8
hours per night, with
the number of
arousals per sleep
increasing. Any
disease or
discomfort can
affect the quantity
and quality of sleep.
(Fundamentals of
Kozier, p.1116)
Sexual activity is
common as one
establishes lifestyle
and values.
Although they often
any contraceptive
devices.
require information
about measures to
prevent pregnancy
(i.e., abstinence,
contraceptive
devices). Regular
communication is
required to
understand
partners sexual
needs and to work
through problems
and stresses.
(Fundamentals of
Nursing by Kozier)
Interpretation:
The patient does not exhibit a healthy form of activity and exercise since she
doesnt exert any effort to do so. She just plays around and watches television all the
time.
Analysis:
A number of changes take place during the middle ages. At 40, most adults can
function as effectively as they did in their 20s. Many middle- aged adults remain healthy
however; the risk of developing health problems is greater than that of the young adult.
Exercise involves the active contraction and relaxation of muscles. Exercises can be
classified according to the type of muscle contraction whether isotonic, isometric or
isokinetic and according to the source of energy such as aerobic or anaerobic. Walking
and playing golf is included in the isotonic exercises in which the muscle shortens to
produce muscle contraction and active movement. Isotonic exercises increase muscle
tone, mass and strength and maintain joint flexibility and circulation. During isotonic
exercises, both heart rate and cardiac output quicken to increase blood flow to all parts
of the body. Little or no change in blood pressure occurs. Aerobic exercise is the activity
during which the amount of oxygen taken in the body is greater than that used to
perform the activity. This uses large muscle groups, is performed continuously and is
rhythmic in nature and an example of this is walking. (Reference: Fundamentals of
Nursing by Kozier pg.1065)
J.T.
20 y/o
A and W
M.T.
44 y/o
A and W
J.T.
24 y/o
A and W
J.T.
17 y/o
A and W
F.T.
51 y/o
A and W
M.T
22 y/o
A and W
M.T.
24 y/o
A and W
K.A.T
3 y.o
A and W
Legend:
- Female
-Client
A and
W- alive and well
-male
M.T
30 y/o
A and W
E.T.
50 y/o
A and W
M.T.
20 y/o
A and W
M.T
19 y/o
A and W
M.T
16 y/o
A and W