Pain Nursing Diagnosis

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Wednesday, February 5, 2014

Acute Pain - Nursing Care Plan for Tonsillitis

Acute tonsillitis is an acute inflammation caused by Beta-Hemolytic

Streptococcal, Viridans streptococci andStreptococcus pyogenes, can also be
caused by a virus.
Etiology of Tonsillitis
1. Beta-Hemolytic Streptococcal
Beta-Hemolytic Streptococcal is a gram-positive bacterium that can multiply in
a healthy throat and can cause acute respiratory tract infections.
2. Streptococcus pyogenes
Streptococcus pyogenes is a gram-positive bacterium that grows in a circular
form long chains and lead group A streptococcal infection
Streptococcus pyogenes is the cause of many important human diseases ranging
from infection typically begins in the throat and skin.
3. Viridans streptococci

Viridans streptococci has the unique ability dextran synthesis of glucose

which allows them adhere to fibrin-platelet aggregates in damaged heart
valves.
4. Influenza virus
The influenza virus is an RNA virus of the family Orthomyxo Viridae(influenza
virus). The virus is transmitted by the medium of air, by sneezing in humans,
common symptoms that occur are fever, sore throat, headache, nasal congestion.
In a bad case of influenza can also cause pneumonia.
Classification of Tonsillitis
1. Acute tonsillitis
Acute tonsillitis caused by streptococcus on hemoliticus, viridians
streptococcus, and Streptococcus pyogene, can also be caused by a virus.
2. Follicular tonsillitis
Tonsils swollen and hyperemic, covered its surface covered with patches of
white exudate filling detritus called tonsil crypt. This detritus contained
leukocytes, epithelial apart due to inflammation and the remnants of food
stuck.
3. Lacunar Tonsillitis
Adjacent patches together and fill Lacuna (curves) surface of the tonsils.
4. Membranous Tonsillitis (Septic Sore Throat)
Tonsillar exudate covering the surface of the swollen membrane resembles.
These membranes are usually easily removed or discarded and yellowish white.
5. Chronic Tonsillitis
Recurrent tonsillitis, predisposing factors: chronic stimulation (cigarettes,
food) the effects of weather, the treatment of acute inflammation of
inadequate and poor oral hygiene.
Nursing Diagnosis for Tonsillitis : Acute Pain Acute pain related to swelling
of the tonsils
Goal : Pain ilang or reduced
Outcomes:

Getting to know the causes.

Recognize the onset of pain.

Analgesic non -aid measures.

Recognizing the symptoms of pain.

Indicate the position / relaxed facial expression.

Intervention and Rational :
1. Assess complaints of pain, note the location, intensity (scale of 1-10),
frequency and time. Marking non-verbal, eg restlessness, tachycardia,

grimacing.
R:/ Indicate the need for intervention and also the signs of progression /
resolution of complications.
2. Encourage expression of feelings.
R:/ Can reduce the anxiety and fear, thereby reducing the perception of the
intensity of fear.
3. Provide entertainment activities, eg reading, watching TV, playing mobile
phone.
R:/ Improve ability to cope with the attention back.
4. Perform palliative measures, eg changing positions, massage.
R:/ Increase relaxation / tension decreases.
5. Instruct patients to use visualization / guided imagery, progressive
relaxation, deep breathing techniques.
R:/ Increase relaxation and feeling healthier.
6. Give analgesic / antipyretic. Use patient -controlled analgesia, to provide
24- hour analgesic doses.
R:/ R :/ Providing a decrease in pain or discomfort : reduce fever. Controlled
drugs by patients or 24 hours of analgesia maintain blood levels remain
stable. Prevent deficiency or excess drugs.
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Acute Pain - Nursing Care Plan for Tonsillitis

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