Tonsillitis refers to inflammation and infection of the tonsils, which consist of pairs of lymph tissue in the nasal and oropharyngeal passages. Bacterial or viral pharyngitis usually leads to the infection of the tonsils. Inflammation and edema of the tonsillar tissue makes swallowing and talking difficult, and forces the child to breathe through the mouth. Advanced infection can result in cellulitis to adjacent tissue or abscess formation which may require drainage.
Management of bacterial tonsillitis is through the use of supportive measures such as adequate hydration, rest, antipyretics, analgesic, and complete course of an antibiotic such as penicillin. A client with chronic tonsillitis is advised to undergo tonsillectomy which is the removal of the palatine tonsils located in the oropharynx. The adenoids are tonsils located in the nasopharynx and also sometimes removed by adenoidectomy.
Nursing Care Plans
Nursing care plan goals for a child experiencing tonsillitis include maintaining a patent airway, preventing aspiration, relieving pain, especially while swallowing, encouraging fluid intake, and understanding of post-discharge care and possible complications.
Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for tonsillitis:
- Ineffective Airway Clearance
- Acute Pain
- Deficient Knowledge (Postoperative Home Care)
- Risk for Deficient Fluid Volume
Ineffective Airway Clearance
Nursing Diagnosis
May be related to
- Bleeding from surgery
- Side effects of anesthesia
- Swelling/edema
Possibly evidenced by
- Difficulty swallowing
- Child breathe via mouth only
Desired Outcomes
- Child will maintain a patent airway as demonstrated by normal respiratory
rate and rhythm and clear breath sounds.
Nursing Interventions | Rationale |
---|---|
Assess for signs and symptoms of inadequate oxygenation. | Early signs of hypoxia include confusion, irritability, headaches, pallor, tachycardia, and tachypnea. |
Place the child prone or side-lying position. | Promotes drainage of blood and unswallowed saliva from the mouth that can potentially be aspirated. |
Discourage the intake of milk, ice cream, and pudding. | These dairy products may coat the throat causing the child to cough out and clear the throat. |
Encourage the child to drink fluids adequately. | Hydration loosens thick secretions or maintains the secretions moist to facilitate easy removal. |
Have a suction equipment available at the bedside. | Suctioning removes clots at the surgical site and is done only during an airway obstruction due to risk of bleeding in the operative site. |
Teach and demonstrate breathing exercises. | Promotes lung expansion, enhanced air exchange and prevents the risk of pneumonia. |
Administer medications as prescribed: | |
| Prevent an infection caused by bacteria. |
| Reduce pharyngeal edema. |
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Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for pediatric conditions and diseases:
- Acute Glomerulonephritis | 4 Care Plans
- Acute Rheumatic Fever | 4 Care Plans
- Apnea | 4 Care Plans
- Brain Tumor | 3 Care Plans
- Bronchiolitis | 5 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cerebral Palsy | 7 Care Plans
- Child Abuse | 4 Care Plans
- Cleft Lip and Cleft Palate | 6 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Congenital Hip Dysplasia | 4 Care Plans
- Croup Syndrome | 5 Care Plans
- Cryptorchidism (Undescended Testes) | 3 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Dying Child | 4 Care Plans
- Epiglottitis | 5 Care Plans
- Febrile Seizure | 4 Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Hospitalized Child | 5 Care Plans
- Hydrocephalus | 5 Care Plans
- Hypospadias and Epispadias | 4 Care Plans
- Intussusception | 3 Care Plans
- Juvenile Rheumatoid Arthritis | 4 Care Plans
- Kawasaki Disease | 6 Care Plans
- Meningitis | 7 Care Plans
- Nephrotic Syndrome | 5 Care Plans
- Osteogenic Sarcoma (Osteosarcoma) | 4 Care Plans
- Otitis Media | 4 Care Plans
- Scoliosis | 4 Care Plans
- Spina Bifida | 7 Care Plans
- Tonsillitis and Adenoiditis | 4 Care Plans
- Umbilical and Inguinal Hernia | 4 Care Plans
- Vesicoureteral Reflux (VUR) | 5 Care Plans
- Wilms Tumor (Nephroblastoma) | 4 Care Plans