Acute Ton Silo Pharyngitis

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Acute Tonsilopharyngitis

Transcript of Acute Ton Silo Pharyngitis

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Acute Tonsilopharyngitis

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INTRODUCTION Pharyngitis is the swelling and inflammation of the

pharynx. The pharynx is the back of the throat, including the back of the tongue. Tonsillopharyngitis is the swelling of the pharynx and the tonsils. Both pharyngitis and tonsillopharyngitis are commonly called a sore throat.

It ranks within the top 20 most-common primary diagnosis groups.Acute pharyngitis accounts for approximately 12 million annual ambulatory care visits in the United States. It ranks within the top 20 most-common primary diagnosis groups

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I. NURSING ASSESSMENTPersonal Information Name: Kathrina Halili Age: 14 years old Sex: Female Civil Status: Single Position in the family;Youngest Address: Bauang La Union Date of Birth: Place of Birth: Bauang La Union Religion: Roman Catholic Date of admission: June 25 2011 Admitting Diagnosis: Acute TonsiliPharyngitis

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MEDICAL HISTORY History of Present Illness.

4 days prior to admission, the patient developed fever which was an associated symptom. He took paracetamol to attend temporary relief. 1 day prior to admission, the patient complained of sore throat and then was give care at emergency room. He was sent home with medical prescription of paracetamol and Amoxiclav. On the day of admission, patient consulted an attending physician due to the persistency of symptoms, he was complaining about weakness difficulty of eating, vomiting and difficulty of breathing and so he was admitted.

With chief complaint of Vomiting and sore throat

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Past Medical History

According to the Mother our client has experienced colds, cough, and fever before. She has incomplete vaccinations and cannot recall the specific vaccines she had. She had no any allergies and has not experienced any injury or accident. It was her first time to be hospitalized

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Family Medical History

The patient’s family background use to have asthma on the paternal side but doesn’t have any diseases or complications on the maternal side.

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FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION & HEALTH MANAGEMENT PATTERN

The patient looks weak in appearance and have disturbed mental status due to her illness. She kept complaining of pain on hid neck and while eating.She seldom got colds in the past, and seeks no medical advice everytime she get sick. She and her family was aware the cause of her disease was due to infection.

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ELIMINATION PATTERN Prior to hospitalization she is used to defecate once

per day with semi formed and Golden brown stool and urinate 3 times per day with amber yellow color and aromatic odor

NUTRITIONAL HEALTH PATTERN Prior to hospitalization her typical food intake consists

of meat, fried fish such as galunggong and vegetables like kamote tops, squash and his favorite dish is “pinakbet” But during his hospitalization he have difficulty of swallowing because of his swolen tonsils.

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ACTIVITY/EXERCISE PATTERN Prior her hospitalization she used to go to school by

walking and after that she helps her mother in house chores and sometimes chatting with her friends during his hospitalization she appears to be weak.

SLEEP REST PATTERN Prior her hospitalization she sleeps about 6 to 8 hours

at night. And no complaint of having sleep problems after school she just lay down and take some rest before doing her homework and helping her mother.during her hospitalization she sleep 3 to 4 hours and feels weak all the time

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COGNITIVE PERCEPTUAL PATTERN According to the Patient she doesnt experience any

visual problems and hearing difficulties, and feels comfortable during this conversation.

SELF-PERCEPTION/SELF-CONCEPT PATTERN Prior to her hospitalization she feels that she is always

ing good mood and good shapetyhat she doesnt feel any problems because her family is always with her, but during her hspitalization she thinks that she is a big burden ti her family beacause she got sick

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SEXUALITY REPRODUCTIVE PATTERN According to the patient she is 12 years old

when she started to have menstrual period and she stated that she feel scary when it started but afterwards she understanf that this is a part of getting older or puberty.

ROLE RELATIONSHIP PATTERN She is the youngest of all the 3 Children of

there family and she is closer to her mother because she is the only girl and she wants to be like her mother who is very caring and loving

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COPING STRESS TOLERANCE The client is tensed most of the time

especially when she thinks about her condition she wants her mother to be with her all the time. She usually shares problems with her family and friends and it seems to be effective for her. When they have big problems, she and her family talk about it and find ways to solve it and most of the time they are able to solve it.

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VALUES BELIEF PATTERN She want to finish her studies to help her

mother and she believe that if she study hard she can finish her studies but right now, the most important thing for her is to be cured. Religion is important to her and believes that it helps when difficulties arise. She also asks God for her and her family’s good health.

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Developmental Task

Developmental Task Sigmund FreudGenital StageMy Client Mentioned some of her crush and

what are the things that she admire from them like being gentleman and cute but she emphasizes that they are just her crush for now because her mother is very strict and she want to finish her studies first she said that “Study first before others”

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Erick Erickson Identity VS. Role ConfusionMy client stated that as she grow up she want

to become successful Teacher to help, educate other students and a effective mother to her future family someday however she feels little bit scared when that time comes because she know how hard to became a mother that’s why she is a fan of her mother she want to follow the footstep of his mother who is loving and caring

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Laboratory Result Normal Value Interpretation

COMPLETE BLOOD COUNT

HemoglobinHematocritErythrocytesPlateletsTotal WBC

149 g/L0.45 g/L528 10^12/L

299 10^9/L

18.010^9/L

145 – 160 g/L0.40-0.484.5-5.0 for male150-4405.0-10.0

NormalNormalHighNormalHigh (Presence of Infection)

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Diagnostic Laborator

y Procedure

s

Dates

Indications or Purpose

ResultsNormal Values

Analysis and

interpretation of the

resultsOrderedResult

in

Arterial Blood Gas

8/22/09

8/23/09 To assess ventilation and acid base balance

Compensated Metabolic Acidosis with uncorrected oxygenation

1st

pH 7.39 7.35-7.45

pCO2 31.6 35-45

pO2 72.6 80-100

HCO3 18.7 22-26mEq/L

O2sat 93.8% 9%

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Anatomy And Physiology The tonsils (palatine tonsils) are a pair of soft tissue

masses located at the rear of the throat (pharynx). Each tonsil is composed of tissue similar to lymph nodes, covered by pink mucosa (like on the adjacent mouth lining). Running through the mucosa of each tonsil are pits, called crypts.

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. Tonsils vary widely in size and swell in response to infection.

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Pathophysiology

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