This is the format of case study and I want hypothetically patient details according to format and my patient case is tonsillitis This is the format " Name , age ,sex , address, bed no. Ward name , marital status, religion , education, occupation, income, date of admission, diagnosis, name of surgery, date of surgery. * Chief complaint * History of illness - past medical history - past surgical history - present medical history - present surgical history. *Family folder Include:- sr.no, name , age , relation, health status. * Socio-economic history, Income Type of house Water supply Electricity Ventilation * Personal history:- Habit Hobby Dietary habit Sleeping pattern Bladder pattern Bowel pattern * Physical examination:- - genral apperance:- Consciousness Orientation Activity Body build Anthropometry measurement Height Weight * Head :- Hair distribution Colour of hair Scalp Face Symmetry Facial puffiness * Eye :- Eye brow Eye lids Eye balls Conjunctiva Sclera Pupil Eye discharge Blurred vision Glasses * Ears :- Hearing Ear symmetry Discharge Swelling Vertigo Tinnitus Nose Nasal septum Nasal flaring Discharge Epistaxis * Mouth and throat Lips Swelling * Neck :- Lymph nodes Thyroid gland Range of motion * Respiratory system:- Thoracic cage Chest expansion Breathing sound Respiratory pattern Cought Sputum * Cardiovascular system:- Pulse Bp Chest pain Palpitation Tingling sensation Edema Numbness Dizziness Abnormal heart sound * Digestive system Abdominal girth Constipation Nausea Vomiting Distension Pain * Genitourinary system :- Urinatory frequency Amount Urinary pattern Hematuria Urethral discharge Catheter present Integumentry system:- Colour Texture Temperature Allergies * Musculoskeletal system :- Symmetry Posture Coordination Joint pain Swelling Immobility Movement Deformity Paralysis Spinal curvature Neurological system :- Level of consciousness Orientation Headache Confusion Convulsions Paralysis * Inspection * Palpation * Percussion * Auscultation * Vital sign include :- sr no. ,Vital sign , normal value , patient value , remarks * Investigation:- sr.no, name of investigation, pt. Value , normal value , remark * Medication:- sr.no. , medication , dose , route , frequency, action, nurse role . Description of disease:- Introduction Defination Etiology Clinical manifestations Pathophysiology Diagnostic evaluation Management 5 nursing diagnosis using releted to or evidence by And give my the 3 ncp including Assessment (subjective or objective), diagnosis, goal , intervention, implementation , evaluation * Health education * Patient progress * Nurse notes Summary
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HYPOTHETICAL NURSING CASE STUDY: TONSILLITIS
PATIENT DETAILS
| Field | Details |
|---|---|
| Name | Mr. Rohan Sharma |
| Age | 16 years |
| Sex | Male |
| Address | 12, Shanti Nagar, Near Civil Hospital, Nagpur, Maharashtra - 440001 |
| Bed No. | Bed No. 5 |
| Ward Name | ENT Ward |
| Marital Status | Unmarried |
| Religion | Hindu |
| Education | 10th Standard (Secondary School) |
| Occupation | Student |
| Income | Family income - Rs. 15,000/month (father is a daily wage worker) |
| Date of Admission | 10 July 2026 |
| Diagnosis | Acute Bacterial Tonsillitis |
| Name of Surgery | Tonsillectomy (planned) |
| Date of Surgery | 14 July 2026 |
CHIEF COMPLAINTS
- Severe sore throat since 5 days
- Difficulty in swallowing (odynophagia) since 5 days
- High-grade fever since 4 days (recorded 102.4°F at home)
- Referred ear pain (right side) since 2 days
- Muffled voice since 3 days
- Loss of appetite since 4 days
HISTORY OF ILLNESS
Past Medical History
- History of recurrent sore throat - 4-5 episodes per year for the past 2 years
- H/o fever and upper respiratory tract infections - managed with OTC medications
- No known history of hypertension, diabetes mellitus, asthma, or tuberculosis
- No history of rheumatic fever or renal disease
Past Surgical History
- No previous surgeries
- No history of any major procedure or hospitalization
Present Medical History
- Patient presented with acute onset severe sore throat, difficulty in swallowing, high-grade fever, and ear pain for 5 days
- Initially managed at home with paracetamol tablets
- No relief; symptoms worsened - brought to OPD on 10/07/2026
- On examination: bilateral tonsillar enlargement (Grade III), erythematous tonsils with yellowish-white exudate (follicular tonsillitis), tender jugulodigastric lymphadenopathy
- Admitted for further investigation and management
- Planned for tonsillectomy on 14/07/2026
Present Surgical History
- Advised tonsillectomy (elective) due to recurrent tonsillitis (>4 episodes/year x 2 years)
- Pre-operative workup initiated
- Patient and family counselled regarding procedure
FAMILY FOLDER
| Sr. No. | Name | Age | Relation | Health Status |
|---|---|---|---|---|
| 1 | Mr. Suresh Sharma | 42 years | Father | Healthy, No known illness |
| 2 | Mrs. Anita Sharma | 38 years | Mother | Healthy, mild seasonal allergies |
| 3 | Priya Sharma | 14 years | Sister | Healthy |
| 4 | Master Aakash Sharma | 10 years | Brother | Healthy |
SOCIO-ECONOMIC HISTORY
| Parameter | Details |
|---|---|
| Income | Rs. 15,000/month (below middle class) |
| Type of House | Semi-pucca (brick and cement), 2-room house, 4-5 family members |
| Water Supply | Municipal tap water; available daily 4-6 hours |
| Electricity | Available; no power backup |
| Ventilation | Inadequate - windows small, rooms overcrowded and poorly ventilated |
PERSONAL HISTORY
| Parameter | Details |
|---|---|
| Habits | No smoking, no tobacco, no alcohol; occasionally chews cold ice candies and flavored ice |
| Hobby | Watching cricket, playing mobile games, reading comics |
| Dietary Habit | Mixed diet (vegetarian and non-vegetarian); fond of spicy, cold, and street food; irregular meal timings |
| Sleeping Pattern | 7-8 hours/day; disturbed sleep since last 5 days due to throat pain |
| Bladder Pattern | Normal; 5-6 times/day; no nocturia; no hematuria |
| Bowel Pattern | Regular; once daily in the morning; no constipation or diarrhea |
PHYSICAL EXAMINATION
General Appearance
| Parameter | Finding |
|---|---|
| Consciousness | Conscious and alert |
| Orientation | Oriented to time, place, and person |
| Activity | Slightly restless due to throat pain; reduced activity |
| Body Build | Average/moderate build |
Anthropometry Measurement
| Parameter | Value |
|---|---|
| Height | 162 cm |
| Weight | 52 kg |
| BMI | 19.8 kg/m² (Normal) |
HEAD
| Parameter | Finding |
|---|---|
| Hair Distribution | Uniform and normal distribution |
| Colour of Hair | Black |
| Scalp | Clean; no dandruff; no lesions |
| Face | Symmetrical; mild flushing noted (due to fever) |
| Symmetry | Normal facial symmetry; no asymmetry |
| Facial Puffiness | Absent |
EYES
| Parameter | Finding |
|---|---|
| Eyebrows | Normal distribution; symmetrical |
| Eyelids | No ptosis; no edema |
| Eyeballs | Normal; no exophthalmos |
| Conjunctiva | Pale pink; no pallor; no hyperemia |
| Sclera | White; no icterus |
| Pupils | Equal, round, reactive to light (PERL) bilaterally |
| Eye Discharge | Absent |
| Blurred Vision | Absent |
| Glasses | Not worn |
EARS
| Parameter | Finding |
|---|---|
| Hearing | Adequate on conversational testing |
| Ear Symmetry | Bilateral symmetrical ears |
| Discharge | Absent |
| Swelling | Absent |
| Vertigo | Absent |
| Tinnitus | Absent |
NOSE
| Parameter | Finding |
|---|---|
| Nasal Septum | Midline; no deviation noted |
| Nasal Flaring | Absent |
| Discharge | Mild clear watery discharge (rhinorrhea) |
| Epistaxis | Absent |
MOUTH AND THROAT
| Parameter | Finding |
|---|---|
| Lips | Slightly dry; no cyanosis; no angular stomatitis |
| Oral Cavity | Moist; no ulcers; moderate halitosis present |
| Tonsils | Bilateral Grade III enlargement; erythematous; yellowish-white follicular exudate visible on tonsillar crypts |
| Throat | Posterior pharyngeal wall - hyperemic and injected |
| Swelling | Bilateral tonsillar enlargement; uvula midline |
| Voice | Muffled "hot potato" voice |
NECK
| Parameter | Finding |
|---|---|
| Lymph Nodes | Bilateral jugulodigastric (tonsillar) lymph nodes - enlarged and tender; approximately 1.5 cm size; soft; mobile |
| Thyroid Gland | Not palpable; no enlargement |
| Range of Motion | Full range; no restriction; mild pain on turning neck |
RESPIRATORY SYSTEM
| Parameter | Finding |
|---|---|
| Thoracic Cage | Normal shape and symmetry |
| Chest Expansion | Equal bilaterally |
| Breathing Sound | Vesicular breath sounds bilaterally; no added sounds |
| Respiratory Pattern | Regular; RR = 20 breaths/min |
| Cough | Occasional dry cough; non-productive |
| Sputum | Absent |
CARDIOVASCULAR SYSTEM
| Parameter | Finding |
|---|---|
| Pulse | 102 beats/min; regular rhythm; normal volume |
| Blood Pressure | 110/70 mmHg |
| Chest Pain | Absent |
| Palpitation | Absent |
| Tingling Sensation | Absent |
| Edema | Absent |
| Numbness | Absent |
| Dizziness | Absent |
| Abnormal Heart Sound | S1, S2 heard normally; no murmur |
DIGESTIVE SYSTEM
| Parameter | Finding |
|---|---|
| Abdominal Girth | Within normal limits (78 cm) |
| Constipation | Absent |
| Nausea | Present (mild; due to high fever and pain) |
| Vomiting | Absent |
| Distension | Absent |
| Pain | Absent; abdomen soft and non-tender |
GENITOURINARY SYSTEM
| Parameter | Finding |
|---|---|
| Urinary Frequency | 5-6 times/day |
| Amount | Adequate; approximately 1200-1500 mL/day |
| Urinary Pattern | Normal; no dysuria |
| Hematuria | Absent |
| Urethral Discharge | Absent |
| Catheter Present | Absent |
INTEGUMENTARY SYSTEM
| Parameter | Finding |
|---|---|
| Colour | Fair; mild flushing over face and neck (febrile flush) |
| Texture | Smooth; slightly dry |
| Temperature | Warm to touch (febrile); skin turgor normal |
| Allergies | No known drug or food allergies |
MUSCULOSKELETAL SYSTEM
| Parameter | Finding |
|---|---|
| Symmetry | Symmetrical |
| Posture | Slightly stooped; prefers to sit upright (reduces throat pain) |
| Coordination | Normal |
| Joint Pain | Absent |
| Swelling | Absent |
| Immobility | Absent |
| Movement | Full range of movement in all joints |
| Deformity | Absent |
| Paralysis | Absent |
| Spinal Curvature | Normal; no kyphosis/scoliosis/lordosis |
NEUROLOGICAL SYSTEM
| Parameter | Finding |
|---|---|
| Level of Consciousness | Fully conscious; GCS 15/15 |
| Orientation | Oriented to time, place, and person |
| Headache | Present; mild; associated with fever |
| Confusion | Absent |
| Convulsions | Absent |
| Paralysis | Absent |
SYSTEMATIC EXAMINATION (LOCAL EXAMINATION - ENT)
Inspection:
Bilateral palatine tonsils - Grade III enlarged (nearly touching midline), erythematous surface, yellowish-white follicular exudate in tonsillar crypts. Uvula is centrally placed. Posterior pharyngeal wall is congested and reddened. Bilateral anterior and posterior tonsillar pillars are inflamed.
Palpation:
Bilateral jugulodigastric lymph nodes palpable, approximately 1.5 cm, tender on touch, soft and mobile. No parapharyngeal or retropharyngeal bulging. No peritonsillar swelling.
Percussion:
Not directly applicable for tonsillar assessment. Chest percussion: resonant bilaterally; no dullness.
Auscultation:
Breath sounds: bilateral vesicular; no crepts or rhonchi. Heart sounds: S1 S2 heard clearly; no added sounds or murmur.
VITAL SIGNS
| Sr. No. | Vital Sign | Normal Value | Patient Value | Remarks |
|---|---|---|---|---|
| 1 | Temperature | 97°F - 99°F (36.1 - 37.2°C) | 102.4°F (39.1°C) | Elevated - Febrile; likely due to active infection |
| 2 | Pulse Rate | 60-100 beats/min | 102 beats/min | Tachycardia - due to fever and infection |
| 3 | Respiratory Rate | 12-20 breaths/min | 20 breaths/min | Within normal limits; upper limit |
| 4 | Blood Pressure | 90/60 - 120/80 mmHg | 110/70 mmHg | Normal |
| 5 | SpO2 (Oxygen Saturation) | 95-100% | 98% | Normal; no airway compromise |
| 6 | Pain Score (NRS) | 0/10 (No pain) | 8/10 | Severe pain; especially on swallowing |
INVESTIGATIONS
| Sr. No. | Name of Investigation | Patient Value | Normal Value | Remark |
|---|---|---|---|---|
| 1 | Hemoglobin (Hb) | 11.8 g/dL | 13.5-17.5 g/dL (Male) | Mildly low; borderline anemia |
| 2 | Total WBC Count | 14,200 cells/mm³ | 4,000-11,000 cells/mm³ | Elevated - indicates bacterial infection |
| 3 | Differential Count - Neutrophils | 78% | 40-75% | Elevated neutrophilia - bacterial infection |
| 4 | Differential Count - Lymphocytes | 16% | 20-45% | Mild decrease |
| 5 | Platelet Count | 2.1 lakh/mm³ | 1.5-4.0 lakh/mm³ | Normal |
| 6 | ESR | 42 mm/1st hour | Male: up to 15 mm/1st hour | Elevated - active inflammation |
| 7 | CRP (C-Reactive Protein) | 18 mg/L | < 5 mg/L | Elevated - acute phase response to infection |
| 8 | Blood Culture | No growth (48 hrs) | No growth | Normal; no bacteremia |
| 9 | Throat Swab Culture | Group A Beta-hemolytic Streptococcus (GABHS) | No pathogenic organism | Confirms bacterial tonsillitis (Streptococcal) |
| 10 | ASO Titer (Anti-Streptolysin O) | 320 IU/mL | < 200 IU/mL (Adults/teens) | Elevated - confirms recent Streptococcal infection |
| 11 | Blood Urea | 18 mg/dL | 7-20 mg/dL | Normal |
| 12 | Serum Creatinine | 0.8 mg/dL | 0.7-1.2 mg/dL | Normal - rules out renal complication |
| 13 | Random Blood Sugar | 92 mg/dL | 70-140 mg/dL | Normal |
| 14 | Urine Routine/Microscopy | Normal; no RBC/casts | No RBC, no casts, protein negative | Normal - no glomerulonephritis |
| 15 | ECG | Normal sinus rhythm | Normal sinus rhythm | Normal - rules out cardiac sequelae |
| 16 | Chest X-ray (PA view) | Normal lung fields | Normal | Normal - no pulmonary involvement |
MEDICATIONS
| Sr. No. | Medication | Dose | Route | Frequency | Action | Nurse Role |
|---|---|---|---|---|---|---|
| 1 | Inj. Benzyl Penicillin (Penicillin G) | 10 lakh units (1 MU) | IV | 6 hourly (QID) | Bactericidal - kills Group A Streptococcus by inhibiting bacterial cell wall synthesis | Check allergy before administration; reconstitute properly; administer slowly; monitor for anaphylaxis; maintain IV site |
| 2 | Tab. Paracetamol (Crocin) | 500 mg | Oral | 8 hourly (TDS) | Antipyretic and analgesic - reduces fever and relieves pain via prostaglandin inhibition in CNS | Administer with water; monitor temperature before and after; avoid overdosage; record response |
| 3 | Tab. Ibuprofen | 400 mg | Oral | BD (after meals) | NSAID - anti-inflammatory and analgesic; reduces tonsillar edema and throat pain | Administer strictly after food; monitor for gastric discomfort; assess pain score before and after; avoid in asthmatics |
| 4 | Inj. Dexamethasone | 8 mg | IV | Once daily (OD) | Corticosteroid - reduces tonsillar inflammation and edema; expedites resolution of pain and swelling | Administer slowly IV; monitor blood sugar; monitor for signs of adrenal suppression; taper dose as directed |
| 5 | Betadine / Normal Saline Gargles (0.9% NaCl) | 10 mL warm solution | Gargle (topical) | 6 hourly | Antiseptic/soothing - reduces local bacterial load; relieves throat discomfort and halitosis | Demonstrate gargling technique; ensure warm (not hot) solution; encourage at least 4x daily; supervise in adolescent patients |
| 6 | Syrup Cetirizine (Zyrtec) | 10 mg | Oral | OD at night | Antihistamine - reduces post-nasal drip and throat irritation; mild anti-inflammatory effect | Administer at bedtime; warn about drowsiness; monitor for urinary retention |
| 7 | IV Fluids - Ringer's Lactate | 1000 mL | IV | 8 hourly | Fluid replacement - maintains hydration when oral intake is reduced due to odynophagia | Monitor IV site for infiltration; maintain I&O chart hourly; check for fluid overload; change IV set every 72 hours |
| 8 | Multivitamin + Zinc Tablet | 1 tab | Oral | OD after breakfast | Supports immune response; promotes healing of inflamed mucosa | Ensure intake after food; counsel on importance of nutrition during recovery |
DESCRIPTION OF DISEASE
Introduction
Tonsils are lymphoid organs strategically placed at the entrance of the aerodigestive tract, forming part of Waldeyer's ring. They serve as the first line of immunological defense against inhaled and ingested pathogens. Tonsillitis is one of the most common ENT conditions encountered in clinical practice, particularly in children and adolescents.
Definition
Tonsillitis is defined as the inflammation of the palatine tonsils, usually caused by viral or bacterial infection, characterized by sore throat, fever, odynophagia (pain on swallowing), and tonsillar enlargement. It may be acute, recurrent, or chronic in nature.
Etiology
Bacterial Causes (approximately 50% of cases):
- Group A Beta-hemolytic Streptococcus (GABHS) - most common bacterial cause
- Staphylococcus aureus
- Haemophilus influenzae
- Moraxella catarrhalis
- Streptococcus pneumoniae
- Anaerobes (in chronic cases)
Viral Causes (approximately 50% of cases):
- Adenovirus (most common viral cause)
- Epstein-Barr Virus (EBV) - causes infectious mononucleosis/glandular fever
- Influenza virus
- Rhinovirus
- Enteroviruses (Coxsackievirus)
- Parainfluenza virus
Predisposing Factors:
- Young age (5-15 years)
- Overcrowded living conditions
- Poor ventilation
- Immunocompromised states
- Previous episodes of tonsillitis
- Close contact with infected individuals (school, dormitories)
- Consumption of cold foods/drinks
Clinical Manifestations
- Sore throat - sudden onset, severe, worsens on swallowing
- Odynophagia - painful swallowing; may refuse food/liquids
- Fever - high-grade (101-104°F); chills and rigors may be present
- Referred otalgia - ear pain via the glossopharyngeal nerve (Jacobson's nerve)
- Muffled/hot potato voice - due to tonsillar edema
- Halitosis - foul breath due to tonsillar exudate
- Cervical lymphadenopathy - bilateral jugulodigastric (tonsillar) lymph node enlargement, tender
- Trismus - if peritonsillar abscess develops
- Malaise and fatigue - general systemic symptoms
- Headache - associated with fever
- Nausea and reduced appetite
On examination:
- Bilateral tonsillar erythema and enlargement (Grade I-IV)
- Yellowish-white follicular exudate or membrane on tonsillar crypts ("follicular tonsillitis")
- Congested and injected posterior pharyngeal wall
Pathophysiology
Exposure to pathogen (GABHS/Virus) via droplet/contact
↓
Colonization on tonsillar epithelium
↓
Pathogen invasion of tonsillar tissue
↓
Activation of innate immune response
(mast cells, macrophages, complement)
↓
Release of inflammatory mediators
(IL-1, IL-6, TNF-α, Prostaglandins)
↓
Vasodilation + increased vascular permeability
↓
Recruitment of neutrophils and lymphocytes
↓
INFLAMMATION OF TONSILS
(Erythema, Edema, Exudate formation)
↓
Tonsillar swelling → Odynophagia + Airway narrowing
↓
Prostaglandin E2 action on hypothalamus → FEVER
↓
Lymphatic spread → Cervical lymphadenopathy
↓
If untreated / inadequately treated:
Peritonsillar abscess / Rheumatic fever / Glomerulonephritis
Diagnostic Evaluation
- Clinical Assessment - history, symptoms, throat examination (tonsil grading)
- Centor/McIsaac Scoring Criteria - to differentiate bacterial from viral (exudate, tender anterior nodes, absence of cough, fever >38°C)
- Throat Swab Culture and Sensitivity - gold standard for confirming GABHS
- Rapid Antigen Detection Test (RADT) - for Strep A
- Complete Blood Count (CBC) - leukocytosis with neutrophilia suggests bacterial; lymphocytosis suggests viral
- ESR and CRP - elevated in acute bacterial infection
- ASO Titer - confirms recent Streptococcal infection; rules out rheumatic sequelae
- Monospot test / EBV serology - to rule out infectious mononucleosis
- Urine routine/microscopy and serum creatinine - to rule out post-streptococcal glomerulonephritis
- Neck X-ray / Ultrasound - if peritonsillar abscess suspected
Management
Medical Management:
- Antibiotic therapy: Penicillin (drug of choice for GABHS) for 10 days; erythromycin/azithromycin if penicillin-allergic
- Analgesics: Paracetamol and/or Ibuprofen for pain and fever
- Corticosteroids: Dexamethasone - reduces edema and expedites symptom resolution
- Adequate hydration - IV fluids if oral intake poor
- Warm saline gargles and throat lozenges
- Bed rest
Surgical Management:
- Tonsillectomy - indicated when:
- Recurrent tonsillitis (Paradise criteria: ≥7 episodes/year, or ≥5/year x 2 years, or ≥3/year x 3 years)
- Obstructive sleep apnea due to tonsillar hypertrophy
- Peritonsillar abscess (quinsy)
- Suspected tonsillar malignancy
- Unilateral tonsillar enlargement
NURSING DIAGNOSES (5)
-
Acute Pain related to inflammation and edema of tonsillar tissue as evidenced by patient's verbal complaint of severe sore throat (NRS 8/10), facial grimacing on swallowing, and guarding behavior.
-
Hyperthermia related to infectious process (Group A Streptococcal infection) as evidenced by elevated body temperature of 102.4°F, flushed skin, tachycardia (HR 102 bpm), and diaphoresis.
-
Imbalanced Nutrition: Less Than Body Requirements related to pain on swallowing (odynophagia) as evidenced by reduced oral intake, refusal of solid foods, decreased appetite, and mild pallor.
-
Risk for Ineffective Airway Clearance related to tonsillar enlargement (Grade III bilateral) and excessive secretions in oropharynx as evidenced by muffled voice, mild throat congestion, and Grade III tonsillar hypertrophy on examination.
-
Deficient Knowledge related to lack of information about disease process, treatment plan, and post-operative care (planned tonsillectomy) as evidenced by patient and family asking repeated questions about diagnosis, surgery, and home care.
NURSING CARE PLANS (NCPs)
NCP 1 - Acute Pain
| Component | Details |
|---|---|
| Assessment (Subjective) | Patient states: "Bahut dard ho raha hai gale mein, kuch nahi nigal sakta" ("My throat is very painful; I cannot swallow anything"). Complains of ear pain on the right side. |
| Assessment (Objective) | NRS pain score: 8/10; Facial grimacing on swallowing; Holding neck and avoiding head movements; HR: 102 bpm (pain and fever); Temp: 102.4°F; Bilateral Grade III tonsillar enlargement with exudate; Tender jugulodigastric lymph nodes; Patient avoiding oral intake |
| Nursing Diagnosis | Acute Pain related to inflammation and edema of tonsillar tissue as evidenced by verbal report of NRS 8/10, odynophagia, facial grimacing, and guarding behavior |
| Goal | Patient will report a reduction in pain score to NRS ≤ 3/10 within 48 hours; patient will be able to swallow oral fluids comfortably within 24-48 hours |
| Intervention | 1. Assess pain using NRS scale every 4 hours and document. 2. Administer prescribed analgesics (Tab. Paracetamol 500 mg TDS, Tab. Ibuprofen 400 mg BD after meals) on time. 3. Administer prescribed IV Dexamethasone 8 mg OD to reduce tonsillar edema. 4. Provide warm saline gargles 4-6 times daily (demonstrate technique). 5. Apply cool sponging for fever (which aggravates perception of pain). 6. Offer cold soothing fluids (ice cream, cold water, cold fruit juice) as tolerated - cold reduces local edema and provides analgesia. 7. Position patient in semi-Fowler's (30-45°) or sitting upright to reduce throat congestion. 8. Provide a quiet, restful environment. 9. Teach non-pharmacological pain relief: deep breathing, distraction techniques. 10. Educate patient to avoid spicy, hard, and rough-textured foods. |
| Implementation | Assessed pain score (8/10) at 0800 hours. Administered Tab. Paracetamol 500 mg with water. Prepared warm saline gargle solution and demonstrated technique to patient. Positioned patient in high Fowler's. IV Dexamethasone 8 mg administered slowly IV as per prescription. Offered cold water 150 mL - patient tolerated. Educated patient to inform nurse immediately if pain worsens. |
| Evaluation | After 8 hours: Patient reports pain score reduced to 5/10. Patient able to sip cold liquids. After 48 hours: Pain score 3/10; patient tolerating soft diet. Goal partially met at 8 hours; fully met at 48 hours. |
NCP 2 - Hyperthermia
| Component | Details |
|---|---|
| Assessment (Subjective) | Patient states: "Kal raat se bahut tez bukhar hai" ("I have had high fever since last night"). Mother reports temperature was 103°F at home. Complains of headache and feeling very warm. |
| Assessment (Objective) | Temperature: 102.4°F (39.1°C) at admission; Skin warm and flushed; HR: 102 bpm (tachycardia); Slight diaphoresis; Eyes appear mildly sunken; Dry lips; Elevated WBC 14,200/mm³; Throat swab: GABHS positive |
| Nursing Diagnosis | Hyperthermia related to infectious process (Group A Beta-hemolytic Streptococcal tonsillitis) as evidenced by temperature 102.4°F, tachycardia (HR 102 bpm), flushed warm skin, and elevated WBC count |
| Goal | Patient's temperature will return to normal range (97-99°F / 36.1-37.2°C) within 24-48 hours; patient will remain adequately hydrated throughout febrile period |
| Intervention | 1. Monitor temperature every 4 hours (or every 2 hours if temp >103°F); record on TPR chart. 2. Administer Tab. Paracetamol 500 mg (antipyretic) as prescribed; note time and response. 3. Apply tepid sponging with lukewarm water (not cold) to forehead, axilla, and groin for 15-20 minutes during fever spikes. 4. Ensure IV Ringer's Lactate 1000 mL/8 hourly to maintain hydration (fever increases insensible fluid loss). 5. Encourage oral fluid intake: minimum 2-2.5 L/day (water, ORS, juices, soups). 6. Maintain strict Intake and Output (I&O) chart. 7. Provide light cotton clothing; remove excess blankets to facilitate heat dissipation. 8. Ensure adequate ventilation in room; use fan if necessary. 9. Administer IV Benzyl Penicillin as prescribed to treat the underlying infection. 10. Monitor for febrile convulsions (especially relevant in adolescents with high-grade fever); keep emergency tray ready. |
| Implementation | Temp recorded 102.4°F at 0800h. Tab. Paracetamol 500 mg administered orally. Tepid sponging done for 15 minutes using lukewarm water on forehead and axilla. IV RL started at prescribed rate. Light cotton clothing provided. Room fan positioned. Encouraged patient to drink cold water. I&O chart initiated. Temp rechecked at 1000h: 101.2°F (improving). |
| Evaluation | After 6 hours: Temperature 100.4°F (improving trend). After 24 hours: Temperature 99°F (near normal). After 48 hours: Temperature 98.2°F (afebrile). Adequate urine output maintained (1400 mL/day). Goal fully met at 48 hours. |
NCP 3 - Imbalanced Nutrition: Less Than Body Requirements
| Component | Details |
|---|---|
| Assessment (Subjective) | Patient states: "Kuch bhi nahi kha sakta, bahut dard hota hai nighalne mein" ("I cannot eat anything; swallowing is very painful"). Mother reports patient has not eaten solid food for 3 days; drinking very little water. |
| Assessment (Objective) | Weight: 52 kg; Hb: 11.8 g/dL (borderline anemia); Dry lips; Grade III tonsillar enlargement causing odynophagia; Patient refusing meals on tray; Inadequate oral intake documented on I&O chart; Mild nausea present; NRS pain score 8/10 on swallowing |
| Nursing Diagnosis | Imbalanced Nutrition: Less Than Body Requirements related to painful swallowing (odynophagia) secondary to tonsillar inflammation as evidenced by refusal of oral intake, weight of 52 kg (lower end for age/height), Hb 11.8 g/dL, and patient's verbalization of inability to swallow |
| Goal | Patient will maintain adequate nutritional intake (minimum 1500-1800 kcal/day); patient will consume at least 50% of each meal served within 48 hours; patient will not lose additional weight during hospital stay |
| Intervention | 1. Assess daily caloric and fluid intake; document on I&O chart. 2. Administer analgesics 30 minutes before meals to reduce pain during eating. 3. Provide soft/semi-liquid diet: warm dal/khichdi, porridge, curd, ice cream, milkshakes, soups, mashed potato; avoid spicy, hard, or rough-textured food. 4. Offer small frequent meals (6 small meals > 3 large meals) to reduce the burden of swallowing. 5. Offer cold or room-temperature foods - cold reduces throat inflammation and numbs pain. 6. Maintain IV fluid therapy to supplement hydration. 7. Administer prescribed multivitamin + zinc supplement for immune support and tissue repair. 8. Involve mother in meal planning - familiar home foods (if suitable texture) improve intake. 9. Encourage patient to drink nutritional supplements (Complan, Horlicks, protein milkshakes). 10. Monitor weight daily; report any significant weight loss (>1 kg/day) to treating physician. |
| Implementation | Assessed dietary intake at 0800h - patient consumed only 100 mL water overnight. Administered Tab. Ibuprofen 400 mg after first small feed (porridge 150 mL). Cold milk 200 mL offered and consumed. Small frequent feeding schedule created (6 times/day at 2-hour intervals). Mother counselled about soft diet preparation. Dietitian referral requested. Multivitamin tablet given after second feed. Intake documented: 850 mL fluids + 200 kcal solids by 1400h. |
| Evaluation | Day 1: Patient consumed approximately 40% of prescribed diet; 1200 mL fluids. Day 2: Patient consuming 60% of soft diet; pain score reduced to 4/10 on swallowing. Day 3: Patient tolerating full soft diet; intake ~1600 kcal/day. Goal partially met by Day 2; fully met by Day 3. |
HEALTH EDUCATION
Pre-operative Health Education (Before Tonsillectomy on 14/07/2026)
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About the Disease: Explained to patient and family that tonsillitis is an infection of the tonsil glands at the back of the throat. The recurring nature of his infections makes surgery (tonsillectomy) necessary to prevent future complications like rheumatic fever or kidney problems.
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About the Surgical Procedure: Explained that tonsillectomy is a safe, short surgery done under general anesthesia. The surgeon removes the tonsils through the mouth - no external incision. Duration: 20-30 minutes. Patient stays 1-2 days post-operation.
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Pre-operative Instructions:
- Keep the patient nil by mouth (NPO) for 6-8 hours before surgery
- Ensure all investigations and consent forms are completed
- Remove any metal objects, nail paint, or jewelry on day of surgery
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Post-operative Care:
- Throat pain is expected and will be managed with pain medications
- Cold fluids (ice water, ice cream, cold milk) are beneficial and reduce bleeding risk and pain
- Avoid hot, spicy, hard, or crunchy foods for 2-3 weeks post-surgery
- Watch for signs of bleeding: spitting blood, blood in saliva, frequent swallowing - report immediately
- Adequate rest at home for 10-14 days; avoid school/strenuous activity
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Medications at Home:
- Complete the full prescribed antibiotic course (10 days) even if feeling better
- Do not self-medicate with aspirin (risk of bleeding post-tonsillectomy)
- Use paracetamol only as directed
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Hygiene and Prevention:
- Hand washing before meals and after using the toilet
- Avoid sharing utensils, glasses, or towels with others
- Cover mouth while coughing or sneezing
- Wear a mask in crowded places during recovery
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Diet Instructions:
- Post-op: soft, smooth, cold foods for 2 weeks (ice cream, yogurt, pudding, milkshakes)
- Avoid chips, toast, biscuits, and raw vegetables until full healing
- Ensure adequate fluid intake (minimum 2 liters/day)
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Follow-up: Attend follow-up OPD visit 7 days post-discharge; return immediately if fever recurs, significant throat bleeding, or difficulty breathing develops.
PATIENT PROGRESS
| Date | Progress Notes |
|---|---|
| 10/07/2026 (Day 1 - Admission) | Patient admitted via ENT OPD. Bilateral Grade III tonsillitis with follicular exudate. Temp: 102.4°F. Pain: 8/10. IV access established (right forearm). IV Benzyl Penicillin and IV RL started. Throat swab sent. All baseline investigations done. Patient and family counselled. |
| 11/07/2026 (Day 2) | Fever: 100.8°F (decreasing). Pain: 6/10 (improved). Patient sipped cold milk and rice porridge. IV antibiotics continued. Dexamethasone administered. Throat swab report: GABHS sensitive to Penicillin. ASO titer elevated (320 IU/mL). Patient and family counselled about upcoming surgery. |
| 12/07/2026 (Day 3) | Fever: 99.2°F (near normal). Pain: 4/10. Tolerating soft diet (60% of meals). Voice improving. Tonsils still enlarged but reduced erythema and exudate. Pre-operative consent obtained. Anaesthesia review done. Patient is NPO after midnight for surgery on 14/07/2026. |
| 13/07/2026 (Day 4 - Pre-op day) | Afebrile (98.4°F). Pain: 3/10. WBC repeat: 9,800/mm³ (improved). Pre-operative checklist completed. IV line patent. Patient anxious about surgery - reassured by nursing staff and doctor. Parents counselled on post-operative care. NPO continued from midnight. |
| 14/07/2026 (Day 5 - Surgery day) | Tonsillectomy performed under general anesthesia at 0900h. Procedure uneventful. Duration: 25 minutes. Shifted to recovery room at 0930h. SpO2: 99% on room air. Patient conscious post-op. Cold water given in small sips 2 hours post-operatively. No active bleeding from tonsillar fossa. Vital signs stable. |
NURSE NOTES (NURSING DOCUMENTATION)
Date: 10/07/2026 | Time: 1400h
Patient Master Rohan Sharma, 16 years, male, admitted to Bed 5, ENT ward with c/o severe sore throat x 5 days, fever x 4 days, difficulty swallowing x 5 days. Patient conscious, oriented, appears distressed due to throat pain. Temp: 102.4°F, PR: 102/min, RR: 20/min, BP: 110/70 mmHg, SpO2: 98%. Throat examination: bilateral Grade III tonsillar enlargement with follicular exudate. Bilateral jugulodigastric lymphadenopathy noted. Pain score: 8/10. IV access established on right forearm (20G cannula). IV RL 1000 mL/8hrly started. IV Benzyl Penicillin 10 lakh units 6 hourly commenced as per prescription. Throat swab sent to microbiology lab. All investigation samples collected and sent. Patient kept on soft diet and cold fluids. Warm saline gargle demonstrated to patient. Patient and mother counselled about diagnosis and treatment plan. I&O chart initiated. Nurse: Staff Nurse Priya Gaikwad
Date: 11/07/2026 | Time: 0800h
Patients' condition slightly improved. Temp: 100.8°F (decrease from yesterday). PR: 96/min. Pain score: 6/10. Patient slept for 5-6 hours (disturbed sleep). Consumed 400 mL cold milk and 200 mL porridge overnight. IV medications given as per schedule without complications. Throat swab report received: Group A Beta-hemolytic Streptococcus - sensitive to Penicillin (continue current antibiotic). Dexamethasone 8 mg IV administered at 0800h. Tepid sponging done at 0700h for temp 100.8°F. I&O: Input 1800 mL, Output 1200 mL urine (adequate). Patient informed about surgery scheduled for 14/07/2026. Family education regarding post-operative care initiated. Nurse: Staff Nurse Priya Gaikwad
Date: 13/07/2026 | Time: 2000h (Pre-operative night)
Patient afebrile (98.4°F). Pain: 3/10. Pre-operative checklist completed. Consent form signed by guardian (father - Mr. Suresh Sharma). NPO since 2000h. IV line patent - right forearm, 20G cannula. Pre-op medications given as per anaesthetist's order. Patient's anxiety addressed - reassured about procedure, post-op care, and pain management. Patient expressed understanding of the procedure. Vital signs stable: Temp 98.4°F, PR 82/min, RR 18/min, BP 112/70 mmHg. Jewellery removed and kept with guardian. Patient changed into operation theatre gown. Nurse: Staff Nurse Kavita Deshmukh
SUMMARY
Master Rohan Sharma, a 16-year-old male student from Nagpur, was admitted to the ENT Ward (Bed No. 5) on 10 July 2026 with a 5-day history of severe sore throat, odynophagia, high-grade fever (102.4°F), referred otalgia, and muffled voice. This presentation was consistent with acute bacterial tonsillitis. He had a background of recurrent tonsillitis with 4-5 episodes/year over the preceding 2 years.
On clinical examination, bilateral Grade III palatine tonsillar enlargement with yellowish-white follicular exudate and bilateral tender jugulodigastric lymphadenopathy were the predominant findings. Investigations confirmed a significant leukocytosis (WBC 14,200/mm³), elevated ESR and CRP, and throat swab culture yielded Group A Beta-hemolytic Streptococcus (GABHS), sensitive to Penicillin. ASO titer was elevated at 320 IU/mL.
The patient was managed with IV Benzyl Penicillin, IV corticosteroids (Dexamethasone), oral analgesics (Paracetamol and Ibuprofen), IV fluid therapy, warm saline gargles, and multivitamins. Over 4 days, fever resolved, pain improved from 8/10 to 3/10, and nutritional intake improved significantly. He underwent an uneventful tonsillectomy under general anesthesia on 14 July 2026.
Nursing management focused on pain control, fever management, maintaining nutritional status, monitoring for airway compromise, and providing thorough health education to the patient and family. The patient responded well to treatment and was discharged on Day 7 post-admission, with instructions for soft diet, antibiotic course completion, and ENT follow-up at 7 days.
Prognosis is excellent following tonsillectomy. The patient and family were adequately counselled on post-operative care, warning signs requiring emergency re-presentation, and preventive measures to avoid future upper respiratory infections.
Case study prepared for academic/nursing educational purposes. All patient details are hypothetical.
Clinical information sourced from: Bailey and Love's Short Practice of Surgery (28th Edition), Scott-Brown's Otorhinolaryngology Head & Neck Surgery (Vol. 2), StatPearls - Tonsillitis (NIH/NCBI), and Nurseslabs Tonsillitis NCPs.
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