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Nursing Care Plan (NCP) Tonsillitis

Tonsillitis is an inflammation of the tonsils at the back of the throat caused by infection by a virus or bacterium. The tonsils themselves are two areas of lymphoid tissue; they are part of the lymphatic system and act as part of the immune system. Tonsillitis may be caused by either viruses (about 75 percent of cases) or bacteria (the remaining 25 percent).

Recurrent tonsillitis is defined as seven episodes of tonsillitis in one year; five episodes in two successive years; or three infections per year for three straight years.

The tonsils are part of the immune system protecting the body against infections of the throat and upper respiratory tract. These areas of tissue normally function to neutralize disease organisms before they reach the lower throat; however, they can be overwhelmed by a virus or bacterium. At that point the tonsils become red and swollen, and may develop abscesses, which are pus-filled pockets.

Whether caused by viruses or bacteria, all forms of tonsillitis are contagious. Tonsillitis usually spreads from person to person by contact with discharges from the nose or throat of an infected child or adult. It is often spread by carriers—children or adults who carry a disease agent but do not have any of the symptoms of the disease.

Tonsillitis is a common illness among children in the United States; nearly all have at least one episode of tonsillitis by the time they reach the teen years, although tonsillitis is rare in children younger than two. Recurrent tonsillitis is less common, occurring in 11–13 percent of children.

Tonsillitis caused by bacteria is most common in children between the ages of five and fifteen, while children younger than five are more likely to have viral tonsillitis. As far as is known, tonsillitis affects boys and girls equally, and is equally common in all races and ethnic groups in
the United States. Children at increased risk of tonsillitis include those with malnutrition or weakened immune systems as well as those who attend schools or day care centers with other children who may be carriers.

Nursing Care Plan Signs and Symptoms

About three-quarters of all cases of tonsillitis are caused by viruses, with the remaining quarter caused by bacteria. The most common virus that causes tonsillitis is the Epstein-Barr virus (EBV), often as part of infectious mononucleosis. Viral tonsillitis can also be caused by the measles virus, herpes virus (the virus that causes cold sores), or adenoviruses (viruses that also cause stomach flu). The most common organisms responsible for bacterial tonsillitis are group A streptococci, the bacteria that cause strep throat and scarlet fever.

The symptoms of tonsillitis may include:
• Sore throat
• Pain in the ears
• Fever and chills
• Red, swollen tonsils
• White or yellow patches on the tonsils
• Pain or difficulty in swallowing
• Bad breath
• Swollen lymph nodes in the neck
• Tiredness and overall sick feeling
• Difficulty breathing or disturbed sleep, if the tonsils are extremely swollen

Nursing Care Plan Diagnosis

The diagnosis of tonsillitis is made in the doctor’s office by a physical examination of the patient’s mouth and throat followed by a rapid strep test or culture to identify the disease organism that is causing the infection. During the physical examination, the doctor will feel the lymph nodes in the patient’s neck as well as taking the temperature and looking into the throat with the help of a tongue depressor. Redness and swelling of the tonsils, along with pus or other discharges, will be visible to the doctor without the need for special equipment.

To see whether the infection is caused by strep throat bacteria, the doctor will take a throat swab and send the sample of the patient’s throat secretions to a laboratory for culture. The doctormay also perform a rapid strep test in the office. This test is faster than a throat culture but is slightly less accurate. The doctor may also order a blood test to check for signs of a viral infection. An unusually high number of certain white blood cells called atypical lymphocytes in the sample may indicate that the tonsillitis is caused by the mononucleosis (Epstein-Barr) virus.

Nursing Care Plan Treatment

It is important for the doctor to know whether the tonsillitis is caused by strep throat bacteria or viruses because the treatments are different. If the child has viral tonsillitis, treatment consists largely of self-care at home: drinking plenty of warm fluids, taking nonaspirin pain relievers (Tylenol or Advil) to bring down the fever, and gargling with salt water to relieve the sore throat. It may take a week or so for the child to feel better. Antibiotics do not help in treating viral infections.

If the doctor determines that the tonsillitis is caused by a bacterium (almost always the group A streptococcus), he or she will prescribe a course of antibiotics, usually for ten days. If the child has trouble swallowing, the antibiotic may be given by injection, or the doctor may also
prescribe a steroid medication to bring down the throat swelling. The child should not return to school or day care for twenty-four to forty eight hours after beginning antibiotic treatment, to prevent spreading the infection to others. In addition, it is important for the child to take the full course of antibiotics even though he or she may feel better in a day or two.

The doctor may recommend tonsillectomy (surgical removal of the tonsils) for patients with recurrent tonsillitis. Tonsillectomies are not performed nearly as often as they were in the 1950s and 1960s; the number of tonsillectomies performed each year in the United States has dropped from several million in the 1970s to approximately 600,000 in the late 1990s. Tonsillectomies are still recommended, however, to treat severe cases of recurrent tonsillitis accompanied by airway obstruction, and to reduce the risk of ear infections and other potential complications of tonsillitis.

Prognosis
Most children and teenagers with tonsillitis recover without any longterm problems. In a few cases, however, the infection can spread from the tonsils to the deeper tissues of the neck or chest. If the tonsillitis is caused by streptococci, it can lead to such complications as inflammation of the kidney or rheumatic fever. For this reason, children with a sore throat and other symptoms of tonsillitis should see the doctor at once. Tonsillectomy is the second most common operation performed on school-age children and is an extremely safe procedure. It is often done as an outpatient procedure; however, the child may need to recover at home for a week or two afterward.

Nursing Care Plan Prevention

People can lower their risk of tonsillitis by washing their hands frequently, avoiding sharing drinking glasses and food utensils, covering the nose and mouth when coughing or sneezing, and avoiding close contact with others who have upper respiratory infections.

Nursing Care Plan The Future
A major concern among doctors is the overuse of antibiotics in treating tonsillitis and other throat infections. Across the United States, 70 percent of children with sore throats who are seen by a doctor are treated with antibiotics even though 30 percent at most have bacterial infections. It can be difficult to distinguish between bacterial and viral infections of the throat even when a throat culture is performed because some people may be carriers of group A streptococci and have the bacteria in their throat at the same time that they have tonsillitis caused by a virus. The chief danger from the overuse of antibiotics is the creation and spread of drug-resistant disease organisms.
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