Professional Documents
Culture Documents
Enerolisa Paredes
LEHMAN COLLEGE
DEPARTMENT OF NURSING
NUR 405
PROFESSOR MARTINEZ
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Enerolisa Paredes, NUR 405, Nurse Care Plan 04/08/2017
INTRODUCTION- I
can also come to pass in patients who are given antibiotics for simpler infections and
especially types 1, 2, 3, and 5, which are the types that infect small children most
frequently. Other respiratory viruses are less common causes of tonsillitis; the
parainfluenza viruses probably are the most frequently isolated in this group. Herpes
Epstein-Barr virus. The most frequent causes of the common cold, the rhinoviruses and
seven per child per year. It is estimated that children have one streptococcal infection
pharyngitis.
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Age Occurrence. Pharyngitis is infrequent in the first 2 years of life, when all
URIs are most frequent. Most cases of pharyngitis occur in school-age children, when the
incidence of all infections is still high but less than in the first 2 years.
Etiology. Viruses are isolated in about 50% of children less than 2 years old but
Contact. All respiratory agents are spread by close contact or large droplets, with
the exception of influenza, which also is spread by small droplets and the airborne route.
A history of a household, school, or outside contact with another patient who has
the likelihood that the index infection has the same etiology.
OBJECTIVES- II
General Objectives:
Specific Objectives:
2. To know the anatomy and physiology of the body organ involved in Acute
Tonsilopharyngitis.
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Tonsilopharyngitis.
The upper respiratory tract primarily refers to the parts of the respiratory
system lying outside of the thorax or above the sternal angle. Another definition
commonly used in medicine is the airway above the glottis or vocal cords. Some specify
that the glottis (vocal cords) is the defining line between the upper and lower respiratory
tracts; yet even others make the line at the cricoid cartilage.
Upper respiratory tract infections are amongst the most common infections in the
world.
protuberance in vertebrates that houses the nostrils, or nares, which admit and expel air
for respiration in conjunction with the mouth. Behind the nose is the olfactory mucosa
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and the sinuses. Behind the nasal cavity, air next passes through the pharynx, shared with
the digestive system, and then into the rest of the respiratory system. In humans, the nose
is located centrally on the face; on most other mammals, it is on the upper tip of the
snout.
NASAL CAVITY: A large fluid filled space above and behind the nose in the
PHARYNX: The part of the neck and throat situated immediately posterior to
(behind) the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx,
and trachea.
NASOPHARYNX: The uppermost part of the pharynx. It extends from the base
of the skull to the upper surface of the soft palate; it differs from the oral and laryngeal
parts of the pharynx in that its cavity always remains patent (open).
OROPHARYNX: Reaches from the Uvula to the level of the hyoid bone. It
opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall,
LARYNX: Commonly called the voice box, is an organ in the neck of mammals
involved in protecting the trachea and sound production. It manipulates pitch and volume.
The larynx houses the vocal folds, which are an essential component of phonation. The
vocal folds are situated just below where the tract of the pharynx splits into the trachea
DATA COLLECTION
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HEALTH HISTORY
Source and reliability of data: Mother. She was very reliable and
willing to cooperate.
Name: Ms. JM
Age: 10
Sex: Female
Ethnicity: Hispanic
Chief complaint: Sore throat, fever, runny nose, and nasal congestion.
attention. Patient is a problem solver, as per mother said. She has a lot of friends and is very
well adapted.
Allergies: No known history.
Accidents and/or Injuries: No known history.
FAMILY HEALTH HISTORY: Anemia, Colon Cancer, Diabetes, Hypertension and obesity.
Family Genogram:
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Patient/Parents experience of illness: Mom states that she try to control the fever with over the
counter medication, but she felt impotent when the symptoms persist and she decided to go to the
urgent care.
Previous experience with the health care system: She use to go to Montefiores emergency room,
but now she attend to Essen Urgent Care and is very satisfied with the services she and her
not working because she had an accident. Patient spends all weekends with the father that does
not work either. Mom said that both of them are looking for jobs.
Habits of Sleep: Patient use to sleep around 8 to 9 hours every day.
Diet: Mom said that patient has a healthy diet base on fruit, vegetables, rice, chicken and beans.
Play and Recreation: Patient practice softball everyday for more than 2 hours. Sometimes she
dance at home.
Smoking: No history
Alcohol: No history.
Client Profile: MJ is a 10 years old girl who loves to play softball and dance. She is one of the
best at school, as per mother said. She is good at everything, said the mother. When she started
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something never stop until is done. She enjoys playing with the grandmother and loves to eat at
everything she needs because the father is not working at this moment.
REVIEW OF SYSTEMS
Patient reports, fever, runny nose shivering, sore throat and nasal congestion.
SKIN: No birth marks, color changes, dryness, moles, moisture, pruritus (itching),
NEUROLOGICAL
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responsibilities
paresis or paralysis
discharge or cataracts.
brushes her teeth after each meal. Reports sore throat 4 to 5 times a year.
Tonsillectomy: No history.
or stiffness.
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dyspnea. Patien does not have any activity limitations an is able to keep up with
peers.
BM (once a day).
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VITAL SIGNS
RR: 16/min
Temp: 98.5 C
Height: 56 inches
Pulse Oximeter: 96
GENERAL SURVEY
Patient looks alert, oriented on time, space and person. Appears stated age, looks
Hair long length hair, quantity is normal, evenly distributed, black color
Eyes the conjunctive is pinkish, eye lashes are black, eyebrows are also
black and it is evenly distributed, pupil size is 3mm and corneas are clear
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Enerolisa Paredes, NUR 405, Nurse Care Plan 04/08/2017
Ears - there is presence of ear wax in the ear canal, its upper portion is in
line with the outer part of the eye and he has a good hearing acuity.
Nose the mucosa is pinkish in color and the nasal septum is at the
midline.
Mouth lips are symmetrical, pale, dry and without lesions. Oral mucosa
Neck
Its color is similar to other body parts. No lumps or goiter noted upon
Heart
Abdomen
inspection.
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Enerolisa Paredes, NUR 405, Nurse Care Plan 04/08/2017
Back
Symmetrical to the head, straight and there are no lesions but sores are
noted upon inspection. He has a skin color similar to other body parts.
They are symmetrical to their opposites. Finger nail are non-cyanotic and
parts.
Skin
Color of the skin is light brown, its moisture is dry, warm to touch and she
LABORATORY DATA:
MEDICATIONS
Short-acting beta2-agonists are bronchodilators. They relax the muscles lining the
airways that carry air to the lungs; treatment of choice for acute exacerbation of asthma.
Corticosteroids reduce inflammation in the airways that carry air to the lungs and reduce
the mucus made by the bronchial tubes. Inhaled steroids should be given after beta-2-
adrenergic agonist.
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Derivative of ampicillin and has similar antibacterial spectrum (certain gram-positive and
superior bioavailability and stability to gastric acid and has broader spectrum of activity
penicillin-resistant strains also resistant to amoxicillin, but higher doses may be effective;
penicillin.
DISCHARGE INSTRUCTIONS:
Your child is urinating less than usual or has fewer diapers than usual.
Your child has pain on one side of his throat that is much worse than the other
side.
Your child has throat pain, trouble swallowing, fever, or other symptoms that are
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Your child has a rash on his body. He may also have reddish cheeks and a red,
swollen tongue.
Your child has new ear pain, headaches, or pain around his eyes.
Write down your questions so you remember to ask them during your visits.
Give your child plenty of liquids so he does not get dehydrated. Give him
liquids that are easy to swallow and will soothe his throat.
Soothe your child's throat. If your child can gargle, give him of a teaspoon of
salt mixed with 1 cup of warm water to gargle. If your child is 12 years or older,
Use a cool mist humidifier to increase air moisture in your home. This may
make it easier for your child to breathe and help decrease his cough.
Wash your hands and your child's hands often. Keep your child away from other people
while he is still contagious. Ask your child's healthcare provider how long your child is
contagious. Do not let your child share food or drinks. Do not let your child share toys or
Your child may return to daycare or school when his symptoms go away.
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REFERENCES
Herdman, H. T., & Kamitsuru, S. (2014). Nursing diagnoses 2015-2017 definitions and
classification. Oxford: Wiley.
Hockenberry, M. J. & Wilson, D. (2011). Wongs Nursing Care of Infants and Children
(9th ed.). Philadelphia, PA: FA Davis Company.
Jarvis, C. (2012). Physical examination and health assessment (6th ed). Saunders.