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RELIANCE INSTITUTE OF NURSING
DHAMTARI
SUBJECT: MEDICAL SURGICAL
NURSING
TOPIC : TONSILLITIS
OM VERMA
Msc lecturer
Medical surgical nursing
CONTENTCONTENT
• INTRODUCTION
• DEFINITION
• TYPES
• ANATOMY & PHYSIOLOGY
• ETILOGY
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• DIAGNOSTIC EVALUATION
• MEDICAL MANAGEMENT
• SURGICAL MANAGEMENT
• NURSING MANAGEMENT
• DIET MANAGEMENT
• COMPLICATION
INTRODUCTIONINTRODUCTION
THE TONSILS ARE COMPOSED OF LYMPATICTHE TONSILS ARE COMPOSED OF LYMPATIC
TISSUE & ARE SITUATED ON EACH SIDETISSUE & ARE SITUATED ON EACH SIDE
OF THE OROPHARYNX.THEY FREQUENTLYOF THE OROPHARYNX.THEY FREQUENTLY
SERVED AS THE SITE OF ACUTESERVED AS THE SITE OF ACUTE
INFECTION.INFECTION.
GROUP AGROUP A
STREPTOCOCCUS IS THE MOST COMMONSTREPTOCOCCUS IS THE MOST COMMON
ORGANISM ASSOCIATED.ORGANISM ASSOCIATED.
DEFINITION
 TONSILLITIS IS SIMPLY DEFINES AS THE
SWELLING OF THE TONSIL WHICH ARE
LOCATED IN THE THROAT TOWARDS THE
BACK OF THE MOUTH.
 TONSILLITIS THE INFECTION OF
INFLAMMATION OF THE TONSIL.THE
TONSIL ARE THE BALL OF THE LYMPATIC
TISSUES ON BOTH SIDE OF THE
THROAT.THEY ARE THE PART OF IMMUNE
SYSTEM WHICH HELP THE BODY TO FIGHT
AGAINST INFECTION.
CONT….CONT….
 TONSILITIS IS AN INFECTION & SWELLINGTONSILITIS IS AN INFECTION & SWELLING
OF THE TONSIL. THE TONSIL ARE LYMPHOF THE TONSIL. THE TONSIL ARE LYMPH
NODE & OVAL SHAPE MASK OF LYMPHNODE & OVAL SHAPE MASK OF LYMPH
GLAND TISSUES LOCATED ON THE BOTHGLAND TISSUES LOCATED ON THE BOTH
SIDE OF THE THROAT. THAT ARE THE PARTSIDE OF THE THROAT. THAT ARE THE PART
OF THE BODY IMMUNE SYSTEM.OF THE BODY IMMUNE SYSTEM.
TYPESTYPES
• ACUTE TONSILLITIS.
• CHRONIC TONSILLITIS.
ANATOMY AND PHYSIOLOGY
ETIOLOGYETIOLOGY
• PRIMARY INFECTION OF THE TONSIL.
• OCCUR AS A SECONDORY INFECTION OR AS A
RESULT OF INFECTION OF THE URI.
• VIRAL INFECTION OR BACTERIAL INFECTION.
• POOR ORODENTAL HYGIENE MAY CAUSE IN
INFLAMMATION OF THE TONSIL.
• POOR NUTRITIONAL STATUS.
• OTITIS MEDIA
PATHOPHYSILOGYPATHOPHYSILOGY
DUE TO ANY ETIOLOGICAL FACTORSDUE TO ANY ETIOLOGICAL FACTORS
INFECTION CAUSED BY BACTERIAL OR VIRALINFECTION CAUSED BY BACTERIAL OR VIRAL
ORGANISMORGANISM
TONSIL BECOME INFLAMMEDTONSIL BECOME INFLAMMED
HYPEREMIA & EDEMA WITH CONVERSION OFHYPEREMIA & EDEMA WITH CONVERSION OF
LYMPHOID FOLLICLE INTO SMALL ABCESSLYMPHOID FOLLICLE INTO SMALL ABCESS
DISCHARGE INTO CRYPTDISCHARGE INTO CRYPT
AIRWAY OBSTRUCTION DECREASE APPETITE &AIRWAY OBSTRUCTION DECREASE APPETITE &
PAINPAIN
CLINICAL FEATURESCLINICAL FEATURES
 SYMPTOMS:SYMPTOMS:
 FEVER WHICH IS ALWAYS HIGH GRADE.FEVER WHICH IS ALWAYS HIGH GRADE.
 GENERELISED MALAISE & BODY ACHE.GENERELISED MALAISE & BODY ACHE.
 ODYNOPHAGIA (PAIN DURINGODYNOPHAGIA (PAIN DURING
SWALLOWING).SWALLOWING).
 DRY MOUTH.DRY MOUTH.
 SORE THROAT.SORE THROAT.
Cont………Cont………
• SIGNS:SIGNS:
• CONGESTED & EDEMATOUS TONSIL.CONGESTED & EDEMATOUS TONSIL.
• TONSILS MAY BE DIFFUSELYTONSILS MAY BE DIFFUSELY
SWOLLEN IN PARENCHYMATOUSSWOLLEN IN PARENCHYMATOUS
TONSILLITIS.TONSILLITIS.
• CRYPTS CAN BE SEEN FILLED WITHCRYPTS CAN BE SEEN FILLED WITH
PUS WITH SWOLLEN FOLLICLES INPUS WITH SWOLLEN FOLLICLES IN
FOLLICULR TONSILITIS.FOLLICULR TONSILITIS.
• EXAMINATION OF THE NECK CANEXAMINATION OF THE NECK CAN
REVEAL ENLARGED AND TENDERREVEAL ENLARGED AND TENDER
JUGULO-DIGASTIC LYMPHNODES.JUGULO-DIGASTIC LYMPHNODES.

COMPLETE BLOOD PICTURE INCLUDING:
* HEMOGLOBIN.
* ESR.
* PLATELET COUNT.
* PERIPHERAL SMEAR.
 CLOTTING & PROTHROMBIN TIME.
 BLOOD GROUPING.
 ASO titer
 THROAT SWAB FOR CULTURE.
 X-RAY CHEST
 ECG MAY BE REQUIRED IN ELDERLY PATIENT.
 NASAL ENDOSCOPY TO RULE OUT THE ADENOID
HYPERTROPHY.
 EVALUATION OF RENAL & CARDIAC FUNCTION IF
RHEUMATIC DISEASE IS SUSPECTED.
MEDICAL MANAGEMENTMEDICAL MANAGEMENT
 IF THE SYMPTOMS ARE SEVERE AND IF MEMBRANE ISIF THE SYMPTOMS ARE SEVERE AND IF MEMBRANE IS
PRESENT, IT IS NECESSARY TO HOSPITALISED THEPRESENT, IT IS NECESSARY TO HOSPITALISED THE
PATIENT.PATIENT.
 PENICILLIN IS THE DRUG OF CHOICE USUALLYPENICILLIN IS THE DRUG OF CHOICE USUALLY
SPECIALLY FOR STREPTOCOCCUS INFECTION.SPECIALLY FOR STREPTOCOCCUS INFECTION.
 ERYTHROMYCIN SHOULD BE PREFFERED IN PATIENTERYTHROMYCIN SHOULD BE PREFFERED IN PATIENT
SENSITIVE TO PENICILLIN GROUP OF ANTIBIOTIC.SENSITIVE TO PENICILLIN GROUP OF ANTIBIOTIC.
 INJECTABLE PENICILLIN LIKE CRYSTALLINE PENICILLININJECTABLE PENICILLIN LIKE CRYSTALLINE PENICILLIN
& CO-AMOXYCLAV SHOULD BE GIVEN IN SEVERE& CO-AMOXYCLAV SHOULD BE GIVEN IN SEVERE
CASES.CASES.
 MOST OF THE PATIENT RESPOND TO THE ANTIBIOTIC.MOST OF THE PATIENT RESPOND TO THE ANTIBIOTIC.
 ANTISEPTIC GARGLES AND THROAT LOZENGES MAY BEANTISEPTIC GARGLES AND THROAT LOZENGES MAY BE
GIVEN.GIVEN.
 PARACETAMOL/NIMESULIDE FOR FEVER.PARACETAMOL/NIMESULIDE FOR FEVER.
 ANTI-INFLAMMATORY FOR PAIN AND INFLAMMATION.ANTI-INFLAMMATORY FOR PAIN AND INFLAMMATION.
SURGICAL MANAGEMENTSURGICAL MANAGEMENT
 TONSILLECTOMYTONSILLECTOMY
 METHOD OF SURGERY:METHOD OF SURGERY:
* DISSECTION* DISSECTION
* GUILLOTINE* GUILLOTINE
* ELECTRO CAUTERY* ELECTRO CAUTERY
* CRYO SURGERY* CRYO SURGERY
* LASER* LASER
PRE MEDICATION:PRE MEDICATION:
* ANTIBIOTIC* ANTIBIOTIC
* ATROPINE* ATROPINE
* ANTI EMETIC* ANTI EMETIC
* SEDATIVE* SEDATIVE
COMPLICATION OF SURGERYCOMPLICATION OF SURGERY
 HAEMORRHAGEHAEMORRHAGE
 REACTION TO ANAESTHESIAREACTION TO ANAESTHESIA
 OTITIS MEDIAOTITIS MEDIA
 BACTERIMIABACTERIMIA
NURSING
MANAGEMENT
• ASSSESSMENT
* History taking
* Physical examination
* Nutritional status
* Skin condition
* Personal hygiene
* Anxiety level
* Knowledge level
 NURSING DIAGNOSIS:NURSING DIAGNOSIS:
 RISK FOR DEFICIENT FLUID VOLUMERISK FOR DEFICIENT FLUID VOLUME
RELATED TO REDUCED INTAKE POST-RELATED TO REDUCED INTAKE POST-
OPERATIVELY & BLOOD LOSSOPERATIVELY & BLOOD LOSS
 INEFFECTIVE AIRWAY CLEARENCEINEFFECTIVE AIRWAY CLEARENCE
RELATED TO PAIN & EFFECTS OFRELATED TO PAIN & EFFECTS OF
ANAESTHESIAANAESTHESIA
 ANXIETY OF THE PATIENT RELATED TOANXIETY OF THE PATIENT RELATED TO
CONCEPT OF SURGERYCONCEPT OF SURGERY
 FEAR RELATED TO PAINFULL PROCEDUREFEAR RELATED TO PAINFULL PROCEDURE
& UNFAMILIAR ENVIRONMENT.& UNFAMILIAR ENVIRONMENT.
DIET MANAGEMENTDIET MANAGEMENT
►A liquid or soft diet is give during acuteA liquid or soft diet is give during acute
stage of disease.stage of disease.
►Diet is give depending on the patientsDiet is give depending on the patients
swallowing condition.swallowing condition.
►In severe condition fluid may be administerIn severe condition fluid may be administer
intravenously.intravenously.
►The patient also encourage to drink asThe patient also encourage to drink as
much as possible(2-3L/day)much as possible(2-3L/day)
► Milk & milk product should be provided.Milk & milk product should be provided.
►Avoid spicy food & food with high roughageAvoid spicy food & food with high roughage
►Gelatinous food are acceptable.Gelatinous food are acceptable.
CONT…..
• DAILY REQUIREMENT OF TONSILITIS PATIENTS:
Total calories : 2700-2800 Kcal
Protein : 35 gm
Carbohydrate : 485-500 gm
Fat : 25-30 gm
VITAMIN A: 3000 IU
COMPLICATION
 PULMONORY HTN
 RESPIRATORY FAILURE
 PERI TONSILLAR ABSCESS
 DYSPHAGIA
HEALTH EDUCATION
 INSTRUCT THE PATIENT TO TAKE REST.
 EDUCATE ABOUT WARM SALINE ANTISEPTIC GARGLING
 INSRUCT THE PATIENT TO TAKE DRUG THERAPY & ITS
IMPORTANCE.
 INSTRUCT THE PATIENT TO TAKE BED REST WITH
INCREASED FLUID INTAKE DURING FEVER.
 EDUCATE THE PATIENT TO MINIMIZE EXPOSURE TO
POLLUTANTS BY WEARING FACE MASK
 INSTRUCT THE PATIENT TO AVOID THE USE OF
ALCOHOL , TOBACCO, & THE SECOND HAND SMOKE.
 AVOID COUGHING AND HAWKING.
 VOICE REST.
 INSTRUCT THE PATIENT TO MAINTAIN PROPER ORAL
HYGEINE.
 PROVIDE SEMISOLID OR LIQUID DIET TO THE PATIENT.
 PATIENT WITH SURGERY SHOULD BE PROVIDED ICE
CREAMS & COLD DRINKS.
Tonslitis
Tonslitis

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Tonslitis

  • 1. RELIANCE INSTITUTE OF NURSING DHAMTARI SUBJECT: MEDICAL SURGICAL NURSING TOPIC : TONSILLITIS OM VERMA Msc lecturer Medical surgical nursing
  • 2. CONTENTCONTENT • INTRODUCTION • DEFINITION • TYPES • ANATOMY & PHYSIOLOGY • ETILOGY • PATHOPHYSIOLOGY • CLINICAL FEATURES • DIAGNOSTIC EVALUATION • MEDICAL MANAGEMENT • SURGICAL MANAGEMENT • NURSING MANAGEMENT • DIET MANAGEMENT • COMPLICATION
  • 3. INTRODUCTIONINTRODUCTION THE TONSILS ARE COMPOSED OF LYMPATICTHE TONSILS ARE COMPOSED OF LYMPATIC TISSUE & ARE SITUATED ON EACH SIDETISSUE & ARE SITUATED ON EACH SIDE OF THE OROPHARYNX.THEY FREQUENTLYOF THE OROPHARYNX.THEY FREQUENTLY SERVED AS THE SITE OF ACUTESERVED AS THE SITE OF ACUTE INFECTION.INFECTION. GROUP AGROUP A STREPTOCOCCUS IS THE MOST COMMONSTREPTOCOCCUS IS THE MOST COMMON ORGANISM ASSOCIATED.ORGANISM ASSOCIATED.
  • 4. DEFINITION  TONSILLITIS IS SIMPLY DEFINES AS THE SWELLING OF THE TONSIL WHICH ARE LOCATED IN THE THROAT TOWARDS THE BACK OF THE MOUTH.  TONSILLITIS THE INFECTION OF INFLAMMATION OF THE TONSIL.THE TONSIL ARE THE BALL OF THE LYMPATIC TISSUES ON BOTH SIDE OF THE THROAT.THEY ARE THE PART OF IMMUNE SYSTEM WHICH HELP THE BODY TO FIGHT AGAINST INFECTION.
  • 5. CONT….CONT….  TONSILITIS IS AN INFECTION & SWELLINGTONSILITIS IS AN INFECTION & SWELLING OF THE TONSIL. THE TONSIL ARE LYMPHOF THE TONSIL. THE TONSIL ARE LYMPH NODE & OVAL SHAPE MASK OF LYMPHNODE & OVAL SHAPE MASK OF LYMPH GLAND TISSUES LOCATED ON THE BOTHGLAND TISSUES LOCATED ON THE BOTH SIDE OF THE THROAT. THAT ARE THE PARTSIDE OF THE THROAT. THAT ARE THE PART OF THE BODY IMMUNE SYSTEM.OF THE BODY IMMUNE SYSTEM.
  • 8. ETIOLOGYETIOLOGY • PRIMARY INFECTION OF THE TONSIL. • OCCUR AS A SECONDORY INFECTION OR AS A RESULT OF INFECTION OF THE URI. • VIRAL INFECTION OR BACTERIAL INFECTION. • POOR ORODENTAL HYGIENE MAY CAUSE IN INFLAMMATION OF THE TONSIL. • POOR NUTRITIONAL STATUS. • OTITIS MEDIA
  • 9. PATHOPHYSILOGYPATHOPHYSILOGY DUE TO ANY ETIOLOGICAL FACTORSDUE TO ANY ETIOLOGICAL FACTORS INFECTION CAUSED BY BACTERIAL OR VIRALINFECTION CAUSED BY BACTERIAL OR VIRAL ORGANISMORGANISM TONSIL BECOME INFLAMMEDTONSIL BECOME INFLAMMED HYPEREMIA & EDEMA WITH CONVERSION OFHYPEREMIA & EDEMA WITH CONVERSION OF LYMPHOID FOLLICLE INTO SMALL ABCESSLYMPHOID FOLLICLE INTO SMALL ABCESS DISCHARGE INTO CRYPTDISCHARGE INTO CRYPT AIRWAY OBSTRUCTION DECREASE APPETITE &AIRWAY OBSTRUCTION DECREASE APPETITE & PAINPAIN
  • 10. CLINICAL FEATURESCLINICAL FEATURES  SYMPTOMS:SYMPTOMS:  FEVER WHICH IS ALWAYS HIGH GRADE.FEVER WHICH IS ALWAYS HIGH GRADE.  GENERELISED MALAISE & BODY ACHE.GENERELISED MALAISE & BODY ACHE.  ODYNOPHAGIA (PAIN DURINGODYNOPHAGIA (PAIN DURING SWALLOWING).SWALLOWING).  DRY MOUTH.DRY MOUTH.  SORE THROAT.SORE THROAT.
  • 11. Cont………Cont……… • SIGNS:SIGNS: • CONGESTED & EDEMATOUS TONSIL.CONGESTED & EDEMATOUS TONSIL. • TONSILS MAY BE DIFFUSELYTONSILS MAY BE DIFFUSELY SWOLLEN IN PARENCHYMATOUSSWOLLEN IN PARENCHYMATOUS TONSILLITIS.TONSILLITIS. • CRYPTS CAN BE SEEN FILLED WITHCRYPTS CAN BE SEEN FILLED WITH PUS WITH SWOLLEN FOLLICLES INPUS WITH SWOLLEN FOLLICLES IN FOLLICULR TONSILITIS.FOLLICULR TONSILITIS. • EXAMINATION OF THE NECK CANEXAMINATION OF THE NECK CAN REVEAL ENLARGED AND TENDERREVEAL ENLARGED AND TENDER JUGULO-DIGASTIC LYMPHNODES.JUGULO-DIGASTIC LYMPHNODES.
  • 12.  COMPLETE BLOOD PICTURE INCLUDING: * HEMOGLOBIN. * ESR. * PLATELET COUNT. * PERIPHERAL SMEAR.  CLOTTING & PROTHROMBIN TIME.  BLOOD GROUPING.  ASO titer  THROAT SWAB FOR CULTURE.  X-RAY CHEST  ECG MAY BE REQUIRED IN ELDERLY PATIENT.  NASAL ENDOSCOPY TO RULE OUT THE ADENOID HYPERTROPHY.  EVALUATION OF RENAL & CARDIAC FUNCTION IF RHEUMATIC DISEASE IS SUSPECTED.
  • 13.
  • 14. MEDICAL MANAGEMENTMEDICAL MANAGEMENT  IF THE SYMPTOMS ARE SEVERE AND IF MEMBRANE ISIF THE SYMPTOMS ARE SEVERE AND IF MEMBRANE IS PRESENT, IT IS NECESSARY TO HOSPITALISED THEPRESENT, IT IS NECESSARY TO HOSPITALISED THE PATIENT.PATIENT.  PENICILLIN IS THE DRUG OF CHOICE USUALLYPENICILLIN IS THE DRUG OF CHOICE USUALLY SPECIALLY FOR STREPTOCOCCUS INFECTION.SPECIALLY FOR STREPTOCOCCUS INFECTION.  ERYTHROMYCIN SHOULD BE PREFFERED IN PATIENTERYTHROMYCIN SHOULD BE PREFFERED IN PATIENT SENSITIVE TO PENICILLIN GROUP OF ANTIBIOTIC.SENSITIVE TO PENICILLIN GROUP OF ANTIBIOTIC.  INJECTABLE PENICILLIN LIKE CRYSTALLINE PENICILLININJECTABLE PENICILLIN LIKE CRYSTALLINE PENICILLIN & CO-AMOXYCLAV SHOULD BE GIVEN IN SEVERE& CO-AMOXYCLAV SHOULD BE GIVEN IN SEVERE CASES.CASES.  MOST OF THE PATIENT RESPOND TO THE ANTIBIOTIC.MOST OF THE PATIENT RESPOND TO THE ANTIBIOTIC.  ANTISEPTIC GARGLES AND THROAT LOZENGES MAY BEANTISEPTIC GARGLES AND THROAT LOZENGES MAY BE GIVEN.GIVEN.  PARACETAMOL/NIMESULIDE FOR FEVER.PARACETAMOL/NIMESULIDE FOR FEVER.  ANTI-INFLAMMATORY FOR PAIN AND INFLAMMATION.ANTI-INFLAMMATORY FOR PAIN AND INFLAMMATION.
  • 15. SURGICAL MANAGEMENTSURGICAL MANAGEMENT  TONSILLECTOMYTONSILLECTOMY  METHOD OF SURGERY:METHOD OF SURGERY: * DISSECTION* DISSECTION * GUILLOTINE* GUILLOTINE * ELECTRO CAUTERY* ELECTRO CAUTERY * CRYO SURGERY* CRYO SURGERY * LASER* LASER PRE MEDICATION:PRE MEDICATION: * ANTIBIOTIC* ANTIBIOTIC * ATROPINE* ATROPINE * ANTI EMETIC* ANTI EMETIC * SEDATIVE* SEDATIVE
  • 16. COMPLICATION OF SURGERYCOMPLICATION OF SURGERY  HAEMORRHAGEHAEMORRHAGE  REACTION TO ANAESTHESIAREACTION TO ANAESTHESIA  OTITIS MEDIAOTITIS MEDIA  BACTERIMIABACTERIMIA
  • 17. NURSING MANAGEMENT • ASSSESSMENT * History taking * Physical examination * Nutritional status * Skin condition * Personal hygiene * Anxiety level * Knowledge level
  • 18.  NURSING DIAGNOSIS:NURSING DIAGNOSIS:  RISK FOR DEFICIENT FLUID VOLUMERISK FOR DEFICIENT FLUID VOLUME RELATED TO REDUCED INTAKE POST-RELATED TO REDUCED INTAKE POST- OPERATIVELY & BLOOD LOSSOPERATIVELY & BLOOD LOSS  INEFFECTIVE AIRWAY CLEARENCEINEFFECTIVE AIRWAY CLEARENCE RELATED TO PAIN & EFFECTS OFRELATED TO PAIN & EFFECTS OF ANAESTHESIAANAESTHESIA  ANXIETY OF THE PATIENT RELATED TOANXIETY OF THE PATIENT RELATED TO CONCEPT OF SURGERYCONCEPT OF SURGERY  FEAR RELATED TO PAINFULL PROCEDUREFEAR RELATED TO PAINFULL PROCEDURE & UNFAMILIAR ENVIRONMENT.& UNFAMILIAR ENVIRONMENT.
  • 19. DIET MANAGEMENTDIET MANAGEMENT ►A liquid or soft diet is give during acuteA liquid or soft diet is give during acute stage of disease.stage of disease. ►Diet is give depending on the patientsDiet is give depending on the patients swallowing condition.swallowing condition. ►In severe condition fluid may be administerIn severe condition fluid may be administer intravenously.intravenously. ►The patient also encourage to drink asThe patient also encourage to drink as much as possible(2-3L/day)much as possible(2-3L/day) ► Milk & milk product should be provided.Milk & milk product should be provided. ►Avoid spicy food & food with high roughageAvoid spicy food & food with high roughage ►Gelatinous food are acceptable.Gelatinous food are acceptable.
  • 20. CONT….. • DAILY REQUIREMENT OF TONSILITIS PATIENTS: Total calories : 2700-2800 Kcal Protein : 35 gm Carbohydrate : 485-500 gm Fat : 25-30 gm VITAMIN A: 3000 IU
  • 21. COMPLICATION  PULMONORY HTN  RESPIRATORY FAILURE  PERI TONSILLAR ABSCESS  DYSPHAGIA
  • 22. HEALTH EDUCATION  INSTRUCT THE PATIENT TO TAKE REST.  EDUCATE ABOUT WARM SALINE ANTISEPTIC GARGLING  INSRUCT THE PATIENT TO TAKE DRUG THERAPY & ITS IMPORTANCE.  INSTRUCT THE PATIENT TO TAKE BED REST WITH INCREASED FLUID INTAKE DURING FEVER.  EDUCATE THE PATIENT TO MINIMIZE EXPOSURE TO POLLUTANTS BY WEARING FACE MASK  INSTRUCT THE PATIENT TO AVOID THE USE OF ALCOHOL , TOBACCO, & THE SECOND HAND SMOKE.  AVOID COUGHING AND HAWKING.  VOICE REST.  INSTRUCT THE PATIENT TO MAINTAIN PROPER ORAL HYGEINE.  PROVIDE SEMISOLID OR LIQUID DIET TO THE PATIENT.  PATIENT WITH SURGERY SHOULD BE PROVIDED ICE CREAMS & COLD DRINKS.