Sunday, October 20, 2013

Nursing Care Plan for Acute Tonsillitis

Tonsillitis is an inflammation of the tonsils. according to the stage, tonsillitis is divided into three stages, namely:

  1. Acute tonsillitis
  2. Membranous tonsillitis
  3. Chronic tonsillitis

Acute Tonsillitis
Acute definition is an inflammation of the tonsils and sudden in onset.

Etiology
  1. Group A Beta-Hemolytic Streptococcal.
  2. Pneumococcus.
  3. Staphylococcus.
  4. Haemophilus influenzae.

Pathophysiology
  1. Inflammation of the tonsils caused by a virus.
  2. Resulted in the formation of exudate.
  3. Cellulitis tonsils and surrounding areas.
  4. Peritonsilar abscess formation.
  5. Tissue necrosis.

Symptoms
  1. Sore throat and dysphagia.
  2. Patients do not want to eat or drink.
  3. Malaise.
  4. Fever.
  5. Breath odor.
  6. Otitis media is one of the originators.

Management
  1. Bed rest.
  2. Provision of adequate fluids and light diet.
  3. Giving medications (analgesics and antibiotics).
  4. If there is no progress then the alternative actions that can be done is surgery.

Preparation operations may be undertaken
  1. Laboratory tests (hemoglobin, leukocytes, bleeding time).
  2. Give an explanation to the client, treatment and care after surgery.
  3. Fasting 6-8 hours before surgery.
  4. Give antibiotics as prophylaxis.
  5. Give premedication ½ hours before surgery.


Assessment

1. Medical history factors associated with the occurrence of tonsillitis supporters , as well as bio - psycho - socio - spiritual.

2. Circulatory
Palpitations, headache during position changes, decreased blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination ( urinary incontinence ), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia , tiredness, difficulty in recuperating from muscle cramps or spasms and pain. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea and vomiting due to increased ICP ( intracranial pressure ), impaired swallowing, and loss of sensation on the tongue.

6. Nervous system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the area of ​​the face and extremities. Comatose mental status, weakness in the extremities, muscle paralise face, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychological
Denial, disbelief, anguish, fear, anxiety.

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