3.1. Presenting signs and symptoms; may include some of the following;

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1 1969 Title: Clinical Protocol for the management of Sore throats (patients over 2 years of age). Document Owner: Deirdre Molloy Document Author: Deirdre Molloy Presented to: Care & Clinical Policies Date: August 2015 Ratified by: Care & Clinical Policies Date: August 2015 Review date: August 2017 Links to other policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurses employed by Torbay & Southern Devon Health & Care Trust when providing care to patients over 2 year of age presenting at Minor injury Units with a sore throat. 2. Scope of the Policy: This protocol is for the use by Minor Injury Unit staff employed by Torbay and Southern Devon Health Care Trust who has achieved the agreed Trust clinical competencies to work under this protocol Exclusions/Emergency: Acute Epiglottitis patient may be systemically unwell, with evidence of drooling, have breathing difficulties, stridor and unable to swallow. Do not examine patient as this is an ENT emergency, refer via 999 ambulance to the Emergency department. 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Painful throat, painful swallowing, pyrexia/fever, associated ear pain, coryza, malaise, rash, hoarseness, stiff neck, swollen glands, headache, abdominal pain. 3.2 History: refer to protocol for History taking and Clinical Documentation Specific History; Pat medical history especially rheumatic fever Previous episodes of sore throats and treatment received. Duration of symptoms Current medications; some medications e.g. carbimazole, azathioprine, methotrexate may include blood dycarasias of which a sore throat is one of the presenting symptoms. Self-care measures taken Is the patient immunocompromised? 4. Clinical Examination: Version 1.1 Page 1 of 6

2 4.1. Look : observe patients general appearance for Pallor Sweating/flushed Lethargy/malaise Drooling, difficulty in swallowing saliva Difficulty in swallowing fluid, food. Macular rash 4.2. Look/Inspect specific lips, oral mucosa, gums, tongue, palate, tonsils & pharynx for; Redness Inflammation/swelling (Unilateral/bilateral) Exudate/pus, white spots. Uvula deviation Inspect Cervical, submandibular, tonsilar and auricular glands for; Swelling 4.3. Feel/palpate includes full cervical lymph palpation for: Swelling, nodes. Tenderness Special Tests/additional examinations should include; Ear exam (refer to protocol for the management of patients with ear pain) Chest examination if suspicious of respiratory tract infection. (where competent) 4.5. Clinical Observations 5. Treatment Observations of vital signs to include Temperature 5.1 Probable viral/bacterial Tonsillitis and systemically well Clinical findings: Low grade fever, red, inflamed tonsils ± exudate, ± tender anterior cervical lymphadenopathy. Treatment if Systemically well; Explain sore throat whether bacterial or viral are usually self-limiting illnesses, Reassure patient that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects for example diarrhoea, vomiting and rash. Advise increase in fluid intake; rest until temperature returns to normal. Provide general advice about symptomatic relief, paracetamol for pain relief/antipyretic as per patient Group Direction (PGD), salt water gargles and use of throat lozenges. Over the counter Aspirin gargles may be Version 1.1 Page 2 of 6

3 recommended for those over 16 years of age. Caution patients on potential side effects and interactions associated with aspirin. 5.2 Acute Tonsillitis Clinical indications which require immediate antibiotics and or further investigations/management Are systemically very unwell Have symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital or intracranial complications. Are at a high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely. Are older than 65 years with acute cough and two of or more of the following, or older than 80 years with acute cough and one or more of the following: Hospitalisation in previous year Type 1 or type 2 diabetes History of congestive heart failure Current use of oral glucocorticoids Other Considerations for antibiotic treatment following clinical assessment of severity are: Patients with acute sore throat/acute tonsillitis where there is 3 or more of the following: Presence of tonsillar exudate Tender anterior cervical lymphadenopathy History of a fever Absence of a cough Treatment; Treat with Phenoxymethylpenicillen (Pen V) as per Patient Group Direction PGD. Consider use of syrup if swallowing difficult In patients with penicillin allergy treat with 2nd line antibiotic as per local formulary and correlating PGD, or refer to GP/prescribing practitioner. Provide general advice about symptomatic relief, paracetamol for pain relief/antipyretic as per PGD salt water gargles and use of throat lozenges. Over the counter Aspirin gargles may be recommended for those over 16 years of age. Caution patient on potential side effects and interactions associated with aspirin. Advise rest until temperature returns to normal; increase fluid intake. Ensure all women taking oral contraceptive pill are advised on extra precautions. Patients with recurrent tonsillitis (more than 6 episodes per year) should be followed up by General Practitioner. 5.3 Possible Scarlet Fever more common in children Version 1.1 Page 3 of 6

4 Clinical Findings: Sore throat and fever are the typical first symptoms A bright red (scarlet) rash then soon develops. The rash starts as small red spots, usually in the neck and upper chest. It may feel like sandpaper. It soon spreads too many other parts of the body. The face becomes quite flushed. The rash blanches if pressed. The area of skin around the eyes, lips and nose are usually spared from this rash, The tongue may become pale but coated with red spots (strawberry tongue) after a few days the whole tongue may look red. Other symptoms may include headaches, vomiting, being off food and feeling generally unwell. Treatment: Treat with Phenoxymethylpenicillen (Pen V) as per Patient Group Direction PGD. Consider use of syrup if swallowing difficult In patients with penicillin allergy treat with 2nd line antibiotic as per local formulary and correlating PGD, or refer to GP/prescribing practitioner. Provide general advice about symptomatic relief, paracetamol for pain relief/antipyretic as per PGD salt water gargles and use of throat lozenges. Over the counter Aspirin gargles may be recommended for those over 16 years of age. Caution patient on potential side effects and interactions associated with aspirin. Advise rest until temperature returns to normal; increase fluid intake. Ensure all women taking oral contraceptive pill are advised on extra precautions. Follow up with General practitioner. GP to ensure notification of the disease to public health, 5.4 Possible Epiglottis Refer to ED as 999 emergency Do not examine mouth Monitor patient s vital signs until transfer. Administer oxygen where required as per PGD 5.5 Possible Quinsy Clinical indications: If large unilateral tonsil swelling associated with pus refer a possible Quinsy. If airway compromised or there is serious systemic illness arrange transfer to Emergency department by calling 999 ambulance otherwise discuss with ENT doctor. 5.6 Possible Glandular fever History of a sore throat, prolonged lymphadenopathy with malaise Refer to General practitioner. Advise on pain relieve, rest and fluid intake. Advise patient that glandular fever can be spread though saliva e.g. kissing, exposure to coughs and sneezes, sharing eating and drinking utensils such as cups, glasses and unwashed forks and spoons. 5.7 Immunocompromised patients: Discuss with Emergency department or ENT for referral. Version 1.1 Page 4 of 6

5 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and Southern Devon Health & Care Trust History Taking and Clinical Documentation protocol and the Nursing & Midwifery Council guidelines of records and record management (2009) A summary letter of the MIU attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure clinical records are completed in a timely manner on shared symphony IT system. A summary will be sent to the General practitioner in the normal manner For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A copy will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they Have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L Acute Medical Emergencies, a nursing guide. Harrison R, Daly L Version 1.1 Page 5 of 6

6 British National Formulary 2015 British National Formulary for Children 2015 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Clinical knowledge summaries (NICE) Sore throat. Revised July 2015 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S NHS Devon Protocol for Sore throats NICE Respiratory tract Infections June 2012 Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition Distribution Torbay Care Trust Protocol for limb simple fractures and soft tissue injuries South & West Devon Joint Formulary Amendment History Issue Status Date Reason for Change Authorised V 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for Sore throats V 1.1 Reviewed August 2015 Review no clinical changes Documentation amended to reflect new Symphony IT system. Updated references D Molloy D Molloy Version 1.1 Page 6 of 6