Tonsillitis

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I am having trouble getting started. I am doing a patient teaching plan paper about a patient who presents to the emergency room 10 days after being treated with tonsillitis. She states that he throat is so sore she has had difficulty swallowing even liquids. Her assessment findings are: Temperature 102F, acutely swollen and reddened area of the soft palate is noted in her mouth, half occluding the orifice from the mouth into the pharynx. Yellow exudate is present. CBC reveals an elevated WBC of 16,000/mm3. I just don't know how to get started. Any help would be very helpful. They are asking me to have Introduction, assessment, analysis, cultural learning needs, patient outcome, some learning and teaching principals and implementation. I have a nursing diagnoses of ineffective airway clearance and of Impaired nutrition less than body requirements. I am trying to figure how to prioritize patient problems. I put my number one problem is her swollen tonsils with yellow exudate, then her temperature and last her inability to swallow liquids.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome to AN! The largest online nursing community!

We are happy to help but we need to know what you think first. What semester are you? Is this your first care plan? Is this a real patient or a instructor scenario.....what did your assessment reveal to you?

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

  1. Assessment
    (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)

  2. Determination of the patient's problem(s)/nursing diagnosis
    (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  3. Planning
    (write measurable goals/outcomes and nursing interventions)

  4. Implementation
    (initiate the care plan)

  5. Evaluation
    (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What is your assessment? or What other assessment was provided to you?

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I am a first year nursing student. Thank you so much for your help.

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This is just a scenario and this is my first care plan. My assessment data is telling that there is more than tonsillitis going on due to the yellow exudate.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Right...this is all they gave you? This is what makes it so hard for new students. It really gets under my skin....what care plan resource do you have?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
presents to the emergency room 10 days after being treated with tonsillitis. She states that he throat is so sore she has had difficulty swallowing even liquids. Her assessment findings are: Temperature 102F, acutely swollen and reddened area of the soft palate is noted in her mouth, half occluding the orifice from the mouth into the pharynx. Yellow exudate is present. CBC reveals an elevated WBC of 16,000/mm3
You need to develop your data on what you have

So you know that your patient has a fever. An infection. They have a previous diagnosis of tonsillitis. What is tonsillitis? What causes an infection of the throat with exudate? With an acute swollen area on the soft palate means that there is an abcess. What is a peritonsillar abcess?

Peritonsillar Abscess: Diagnosis and Treatment - American Family Physician

Peritonsillar abscess: MedlinePlus Medical Encyclopedia

Peritonsillar Abscess - eMedicine - Medscape (medscape requires registration but it is free...theis is always an excellent reference)

Now if your patient can't swallow liquids odds are she is dehydrated. Would/could this abcess obstruct the airway? What would be the concern of this?

You prioritize according to what wil kill her first.....ABC. Airway breathing circulation.

Maslows hierarchy of needs.....

[h=3]Five Levels of the Hierarchy of Needs[/h] There are five different levels in Maslow’s hierarchy of needs:

  1. Physiological Needs
    These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.

  2. Security Needs
    These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.

  3. Social Needs
    These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.

  4. Esteem Needs
    After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.

  5. Self-actualizing Needs
    This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

This sounds more like a case study.

[TABLE]

[TR]

[TH]Section[/TH]

[TH=width: 75%]Information to Include[/TH]

[/TR]

[TR]

[TD] Introduction (patient and problem)[/TD]

[TD]

  • Explain who the patient is (Age, gender, etc.)
  • Explain what the problem is (What was he/she diagnosed with, or what happened?)
  • Introduce your main argument (What should you as a nurse focus on or do?)

[/TD]

[/TR]

[TR]

[TD] Pathophysiology[/TD]

[TD]

  • Explain the disease (What are the symptoms? What causes it?)

[/TD]

[/TR]

[TR]

[TD] History[/TD]

[TD]

  • Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
  • Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

[/TD]

[/TR]

[TR]

[TD] Nursing Physical Assessment[/TD]

[TD]

  • List all the patient's health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

[/TD]

[/TR]

[TR]

[TD] Related Treatments[/TD]

[TD]

  • Explain what treatments the patient is receiving because of his/her disease

[/TD]

[/TR]

[TR]

[TD]Nursing Care Plan[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]

Nursing Diagnosis & Patient Goal

[/TD]

[TD]

  • Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
  • Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

[/TD]

[/TR]

[TR]

[TD]

Nursing Interventions

[/TD]

[TD]

  • Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

[/TD]

[/TR]

[TR]

[TD]

Evaluation

[/TD]

[TD]

  • Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

[/TD]

[/TR]

[TR]

[TD] Recommendations[/TD]

[TD]

  • Explain what the patient or nurse should do in the future to continue recovery/improvement

[/TD]

[/TR]

[/TABLE]

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After much research and thinking based on the elevated WBC and the yellow exudate I feel that she have a peritonsillar abscess. I don't know how I can put that in the form of an introduction. I think I should introduce the patient, age and say something about the abscess but I am unsure.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Did you look at the post above your response? It tells you what to do.

patient who presents to the emergency room 10 days after being treated with tonsillitis. She states that he throat is so sore she has had difficulty swallowing even liquids. Her assessment findings are: Temperature 102F, acutely swollen and reddened area of the soft palate is noted in her mouth, half occluding the orifice from the mouth into the pharynx. Yellow exudate is present. CBC reveals an elevated WBC of 16,000/mm3. I just don't know how to get started.

Patient x is a ____ year old patient that presented to the emergency department 10 days post diagnosis of Tonsillitis. The patient presented complaining that her throat is so sore she has difficulty swallowing even liquids. Upon assessment it is found that the patient has a temp of 102 F. Inspection of the oral pharnyx reveals....blah blah blah. The lab work reveals Blah blah blah. Based on these finding it is believed that the patient has peritonsllar abcess.

A peritonsillar abcess is....blah blah blah Symptoms are...blah blah blah. Treatment would be blah blah blah. Complications are ...blah blah blah.

Based on the diagnosis of blah. Several nursing diagnosis should be considered. Blah blah blah. Nursing care would include....blah blah blah.

I admit it makes it difficult when you haven't seen a real patient so you are unable to compare and combine evidence.

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