LICEO DE CAGAYAN UNIVERSITY
RODOLFO N. PELAEZ Blvd., KAUSWAGAN CAGAYAN DE OROCITY
COLLEGE OF NURSING
PONR
Submitted to:
Mrs. Arlene B. Celestial, RN, MN
Clinical Instructor
In Partial Fulfillment of the Requirements in Related Learning Exercise in NCM501202
Submitted by:
DeniceI. Galarrita
September 02, 2009
I.INTRODUCTION
- Overview of the Case
Peritonsillar abscess, also called PTA or quinsy, is a recognized complication of tonsillitis and consists of a collection of pus beside the tonsil (peritonsillar space).
PTA usually arises as a complication of an untreated or partially treated episode of acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue and is hence susceptible to formation of abscess. PTA can also occur de novo. Both aerobic and anaerobic bacteria can be causative. Commonly involved species include streptococci, staphylococci and hemophilus.
Unlike tonsillitis, which is more common in the pediatric age group, PTA has a more even age spread — from children to adults. Symptoms start appearing 2–8 days before the formation of abscess. Progressively worsening unilateral sore throat and pain during swallowing usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area, fever, malaise, headache and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and halitosis are also common. Whilst these signs may be present in tonsillitis itself, a PTA should be specifically considered if there is limited ability to open the mouth (trismus).
b. Objective of the Study
The objective of the study is to find a case related to our midterm concept - Fluid and Electrolyte / Acid-Base Imbalance. My client Mr. Milfred H. Tan complained of sore throat and difficulty in swallowing upon admission then later diagnosed with Peritonsillar Abscess L. As a nursing student, I have to do interventions for my patient and render services related to his condition. I aim to have a good patient outcome and prevent complications that could worsen the case of my patient.
As an NCM501202 student, this care study helps us to evaluate our capabilities in rendering services to our clients and evaluate our abilities in implementing the Nursing Care Plan effectively. These study also gives us information in actual handling, caring and dietary management of patient with Peritonsillar Abscess L.
c. Scope and Limitation
Our duty in midterm is in the Pediatric ward at Polymedic GeneralHospitalCagayandeOroCity. Due to limited patient in the ward, our instructor decided to cater the patients in medical ward. Different cases will be observed in the ward like Diabetes Mellitus, URTI, diarrhea, fever and sore throat which is the case of my patient. From Aug 3-4, 2009, I have assessed my patient and did some interventions like monitoring vital signs which are alter when in pain. I instructed the client to increase fluid intake and encourage him to have adequate rest to prevent fatigue. The actual nursing interventions were all carried out with the supervision of our clinical instructor and limited to those who were permitted. The study was completed through research and implementing in actual the care plan.
II. HEALTH HISTORY
a. Profile of Patient
Name:MILFREDO H. TAN
Address: Zone 4 Baculio St. Bulua Cagayan de Oro City
Birth Place: Paranaque., Manila
Birth date: January 20, 1967
Age: 42 years old
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Occupation: Gov’t. Employee @ Bangko Sentral ng Pilipinas
Date of Admission: August 2, 2009
Chief Complaint:Sore throat, difficulty in swallowing
Admitting Diagnosis: Peritonsillar Abscess L
Vital Signs
Temperature: 36.6 C
BP: 110 / 80 mmHg
Pulse Rate:64 bpm
Respiratory Rate:18 cpm
b. Family and Personal Health History
Mr. Milfred H. Tan. 42 years of age, a resident in Zone 4, Baculio St. Bulua Cagayan de Oro City and bank teller in Bangko Sental ng Pilipinas belongs to a middle family. He inherited his hypertension through his father while he got diabetes because he likes sweet foods. He had arthritis when he was just 17 years and took Alaxan as his pain reliever. He was diagnosed with hypertension and diabetes when he was 40 years old and he also has high cholesterol. His medications are Sitagliptin Phospahte, Gliclazide (Glubitor), Arolodipine (Vasalat), Losartan (Lifezar) and Atrovastatin Calcium (Lipitor). He has been taking this medications for two consecutive years spending P8,000.00 a month for his maintenance.
c. History of Illness
Two days prior to admission, patient noted onset of throat discomfort. One day prior to admission, he started to have pain in swallowing then later with fever. He took Clarithromycin in 2 doses because he thought it was just cough. Persistence of signs and symptoms made him prompted admission
III. DEVELOPMENTAL TASKS
ERIK ERICKSON’S PSYCHOSOCIAL THEORY
According to Erickson, mid-adult that ranges from 35 – 65 years old belongs to
Generativity vs. Stagnation. The main task is establishing and guiding the next generation with socially-valued work and discipline.
My client belongs to Generativity wherein he maintains healthy life patterns despite his hypertension and diabetes. He takes his medications on time and avoids foods that may harm him. He wanted to create a comfortable home for his family and help his children to grow responsible. He uses leisure time creatively by browsing to internet as pass time. He also said that he can relate to the saying that “life starts at 40” because when he reached 40 he was diagnosed with hypertension, diabetes and started to wear his eyeglasses. Despite of the conditions that he has, according to him havebeen able to adjust with his new lifestyle.
IV. MEDICAL MANAGEMENT
- Medical Orders and Rationale
DOCTOR’S ORDER / RATIONALE
August 3, 2009
> Vital signs every 4 hours
> Soft and liquid diet
> Medications:
Gliclazide ( Glubitor) 30 mg OD
Sitagliptin Phosphate (Januvia) 100mg OD
Amlodipine (Vasalat) 50 mg OD
Lozartan (Lifezar) 50 mg OD
Atorvastatin Calcium (Lipitor) 40 mg OD / > to check for any changes to prevent complications
> to prevent pain in swallowing
> for diabetes uncontrolled by diet and exercise
> to improve glycemic control
> for hypertension
>treatment of hypertension
> treatment of elevated cholesterol
DOCTOR’S ORDER / RATIONALE
August 4, 2009
> Vital signs every 4 hours
> Soft and liquid diet
> Medications:
Gliclazide ( Glubitor) 30 mg OD
Sitagliptin Phosphate (Januvia) 100mg OD
Amlodipine (Vasalat) 50 mg OD
Lozartan (Lifezar) 50 mg OD
Atorvastatin Calcium (Lipitor) 40 mg OD / > to check for any changes to prevent complications
> to prevent pain in swallowing
> for diabetes uncontrolled by diet and exercise
> to improve glycemic control
> for hypertension
>treatment of hypertension
> treatment of elevated cholesterol
Laboratory Results
Hematology
Complete Blood Count
August 2, 2009
Result Expected values Impression
White Cell count 3,000 5,000 – 10,000decreased due
to infection
Differential Count
Neutrophils40.4 43.4 – 76.2%indication of infection
Lymphocytes16.3 17.4 - 46.4%Indication of infection
Monocytes 2 4.5 - 10.5 decreased due to infection
Eosinophils1.5 2 - 3% decreased due to infection
V. PATHOPHYSIOLOGY WITH ANATOMY & PHYSIOLOGY
ANATOMY & PHYSIOLOGY
The basic parts of the mouth are :
The upper jaw, that is part of the skull
The lower jaw, connected with the upper jaw and with ability to move up-down and from side to side
The teeth and gums
The muscles which form the cheeks
The tongue
The salivary glands that pour the saliva into the mouth
USE OF THE HUMAN MOUTH AND TEETH
The human mouth and teeth are used not only for eating, but also for formatting the sounds while speaking and for the expression of our feelings and emotions. All the parts of the mouth contribute to performing these actions.
The absence of one or more teeth can cause problems to digesting your food, right speech and good appearance, affecting your physical and mental health.
Reduced flow of saliva creates problems with chewing, swallowing and digesting food.
Peritonsillar abscess is a complication of tonsillitis. It is most often caused by a type of bacteria called group A beta-hemolytic streptococcus.
Peritonsillar abscess is generally a disease of older children, adolescents, and young adults. It has become relatively uncommon since the use of antibiotics to treat tonsillitis.
Symptoms
One or both tonsils become infected. The infection may spread over the roof of the mouth (palate), and to the neck and chest, including the lungs. Swollen tissues may block the airway, which is a life-threatening medical emergency.
The abscess can break open (rupture) into the throat, infecting or further blocking the airway.
Symptoms of peritonsillar abscess include:
- Chills
- Difficulty and pain with opening the mouth
- Drooling
- Facial swelling
- Fever
- Headache
- Hoarseness (occasionally)
- Sore throat (may be severe)
- Tender glands of the jaw and throat
PATHOPHYSIOLOGY OF PERITONSILLAR ABSCESS
Definition: A peritonsillar abscess (PTA) is a localized accumulation of pus in the peritonsillar tissues that forms as a result of suppurative tonsillitis. An alternative explanation is that PTA is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands. The nidus of accumulation is located between the capsule of the palatine tonsils and the constrictor muscles of the pharynx. The anterior and posterior pillars, torus tubarius (superior), and pyriform sinus (inferior) form the boundaries of this potential peritonsillar space. Because it is composed of loose connective tissue, severe infection of this area may rapidly lead to formation of purulent material. Progressive inflammation and suppuration may extend to directly involve the soft palate, the lateral wall of the pharynx, and, occasionally, the base of the tongue.
Pathophysiology
The pathophysiology of PTA is unknown. The most widely accepted theory is the progression of an episode of exudative tonsillitis first into peritonsillitis and then into frank abscess formation. Extension of the inflammatory process may occur in both treated and untreated populations. PTA also has been documented to arise de novo without any prior history of recurrent or chronic tonsillitis. A PTA also can be the presentation of an Epstein-Barr virus (ie, mononucleosis) infection.
Another theory proposes the origin of PTA in Weber glands. These minor salivary glands are found in the peritonsillar space and are thought to help in clearing debris from the tonsils. Should obstruction as a result of scarring from infection occur, tissue necrosis and abscess formation result, leading to PTA.
HEALTH TEACHINGS
MEDICATIONS / Advised the patient to keep on taking his maintenance medications – Glicalzide (Glubitor), Sitagliptin Phosphate, Lozartan Potassium (Lifezar) Amlodipine Bensylate (Vasalat) and Atorvastatin Calcium (Lipitor).EXERCISE / Encourage the patient to have a regular exercise like walking and emphasize the i9mportance of bed rest.
TREATMENT / Instruct the client to always drink plenty of water after eating to wash the food particle left in the throat that may cause irritation.
OUT – PATIENT
(CHECK – UP) / Encourage the patient to have a check-up 1 week or 2 weeks after discharge to check if the inflammation is still present and to check also the sugar level and blood pressure.
DIET / Instruct patient to have a proper diet and nutrition. Limit intake of sweet foods and avoid seafood’s like crabs and shrimps to avoid triggering allergies.
IX. PROGNOSIS
Most experts agree that immediate tonsillectomy is not required for treatment of peritonsillar abscess. Tonsillectomy should be performed three to six months after the abscess in patients who have recurrent tonsillitis or peritonsillar abscess. If the family physician is inexperienced in treating peritonsillar abscess, an otolaryngologist should be consulted at the time of the diagnosis to determine the appropriate surgical treatment.
In the case of my patient, he was treated with antibiotics in Polymedic General Hopspital and considered as good prognosis as evidenced by a change in his appetite. He eats well without any signs of pain and tonsillectomy would no longer be necessary
X. EVALUATION
During the assessment and observations, and with the understanding of his disease process, I can say that hes not able to maintain homeostasis and not able to function well in which expected for him top perform. Because of disease process, he was not able to do his usual activities.
It is said to know how this disease affects my clietn’s function strength and comprehensions. However, with palnning and management of care-rehabilitation program which improving mobility by promoting regular ROM exercise, achieving a form of communication, restore famil;y factors and prevent complications, my client will be able to achieve wellness. There is always a big chance that he will be able to recover and put things back together through strict compliance of therapeutic regimen.
Reference
- WEBSITE
- BOOKS
- Medical Surgical Nursing by Smeltzer
- Nursing Pocket Guide by Sheesy Gail