Tonsillitis is a common medical condition that affects the tonsils, which are located at the back of the throat. The condition is usually caused by a bacterial or viral infection and can result in a range of symptoms, such as sore throat, fever, difficulty swallowing, and swollen glands. As a nurse, you play an essential role in the assessment, diagnosis, and management of patients with tonsillitis. In this article, we will discuss the nursing diagnosis for tonsillitis, including how to assess and manage patients with this condition.
What is Tonsillitis?
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 make swallowing and talking difficult and force 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, analgesics, and a 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 are also sometimes removed by adenoidectomy.
Table of contents
- What is Tonsillitis?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- See also
Nursing Care Plans and Management
Nursing care plans and management for a child experiencing tonsillitis include maintaining a patent airway, preventing aspiration, relieving pain, especially while swallowing, encouraging fluid intake, and understanding post-discharge care and possible complications.
Nursing Problem Priorities
The following are the nursing priorities for patients with tonsillitis:
- Manage pain and discomfort
- Promote rest and adequate hydration
- Provide education on home care, including proper hygiene, pain management, and when to seek medical attention.
- Provide a calm and comfortable environment to support healing and reduce anxiety.
- Monitor for complications, such as difficulty breathing or worsening symptoms.
Assess for the following subjective and objective data:
- Sore throat and difficulty swallowing
- Red, swollen tonsils with white or yellow patches
- Pain or tenderness in the throat and neck
- Enlarged and tender lymph nodes in the neck
- Fever and chills
- Hoarse voice or loss of voice
- Headache and ear pain
- Fatigue or general malaise
- Difficulty sleeping due to discomfort
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with tonsillitis based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The child will maintain a patent airway as demonstrated by normal respiratory rate and rhythm and clear breath sounds.
- The child will state level of pain is decreased and will appear more relaxed/comfortable.
- The parents will gain the knowledge to care for the postoperative child safely at home.
- The client will experience adequate fluid volume as evidenced by pulse and blood pressure within normal limits, absence of profuse bleeding, and intake and output within acceptable parameters.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with tonsillitis may include:
1. Maintaining Patent Airway Clearance and Effective Respiratory Function
Airway and respiratory compromise can occur in patients with tonsillitis due to the swelling and inflammation of the tonsils, which can obstruct the airway and impede normal respiratory function. The enlarged tonsils can partially block the passage of air, leading to difficulties in breathing, especially during sleep or when lying down. In severe cases, tonsillitis can cause complete airway obstruction, requiring urgent medical intervention to restore airway patency.
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 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.
See Pharmacologic Management
2. Managing Pain
Patients with tonsillitis often experience significant pain and discomfort in the throat, making it difficult to eat, drink, and maintain adequate fluid intake. This can lead to a risk of dehydration and compromised fluid volume status. Nursing interventions aim to manage pain through the administration of prescribed analgesics, provide throat soothing measures, and encourage the consumption of cold or warm fluids that are easier to swallow.
Assess pain using an appropriate pain scale for child’s age and development.
The use of a pain scale allows objective measurement of subjective pain perception.
Observe child for nonverbal indications of pain such as crying, grimacing, and irritability.
Provides additional information about pain. The child may find discomfort in speaking.
Avoid hot, spicy, and coarse food such as chips or crackers.
Aggravate the pain and can cause bleeding
Apply an ice collar on the neck or encourage the child to eat popsicles.
Cold promotes vasoconstriction and decreases swelling that contributes to pain.
Suggest diversional activities such as watching a video, reading a book, or listening to music.
Provides a distraction from discomfort.
Administer pain medications as prescribed such as acetaminophen (Tylenol), ibuprofen (Advil). Monitor for effectiveness and side effects.
See Pharmacologic Management
Administer throat lozenges and sprays.
See Pharmacologic Management
Measure and record intake and output hourly. Assess skin turgor and moisture of mucous membranes.
Provides information about physiologic fluid balance and signs of dehydration.
Monitor child’s responsiveness and vital signs, especially blood pressure and pulse.
Restlessness, tachypnea, and tachycardia are early signs of hypovolemia.
Monitor post-tonsillectomy client for signs of bleeding such as frequent swallowing, bright red blood oozing from the mouth or nose. Use a flashlight, mirror, gauze, hemostatic clamp, and basin in examining the surgical site.
Excessive swallowing may indicate bleeding from the operative site; Provides information about the integrity of the surgical site.
Administer IV fluids via infusion pump as ordered. Monitor IV site hourly.
Replaces losses from surgery and maintains hydration if the child is unable to drink.
Provide clear cool non-citrus fluids in small amounts (e.g., crushed ice, popsicles); Avoid red, purple, or brown liquids.
Small quantities may be more easily tolerated. Red, purple, or brown may stimulate the appearance of blood if the child vomits.
Discourage the use of straws or any sharp object inside the mouth.
Refraining from drinking through a straw lessens the risk of physical trauma in the operative site and suction produced in sucking may cause bleeding.
Utilize creative, developmentally proper techniques to make a game of drinking (e.g., playing a board game, or creating a sticker or reward chart).
Since swallowing is uncomfortable post-surgery, these ideas will encourage the child to drink.
Discourage excessive coughing, nose blowing, or clearing of throat. Administer antiemetics as prescribed to prevent vomiting.
Excessive coughing, nose blowing, clearing the throat, or vomiting may promote bleeding in the operative site.
Provide parents with discharge instructions on diet, fluid intake, activity, and when to notify medical team.
Teaching ensures that parents will continue to monitor fluid balance.
3. Initiating Patient Education and Health Teachings
Patient education for patients with tonsillitis is essential to promote understanding of the condition and empower individuals to manage the symptoms effectively. Education may include information about the causes, signs, and symptoms of tonsillitis, proper hygiene practices to prevent the spread of infection, and guidance on pain management techniques, such as the use of analgesics and throat soothing measures.
Assess parents’ knowledge of the condition and management.
Provides baseline information about parents’ understanding of illness.
Allow time for teaching, use a variety of methods (written instructions, pictures, verbal instruction), encourage questions and reassure parents about child’s condition.
Facilitates learning by ensuring parents’ comfort. A variety of methods guarantees that even illiterate parents will receive appropriate teaching.
Provide information about the surgery as needed. Teach parents that an important risk after a tonsillectomy is excessive bleeding from the operative site. Teach to observe for excessive swallowing and to not give the child any straws, forks, or anything sharp object that can be put in the mouth, and to discourage excessive coughing and clearing the throat.
Provides important information for parents to recognize and prevent complications.
Instruct parents to refrain child from performing strenuous physical activity following surgery and may return to school once comfortable.
Provides information to prevent complications.
Instruct parents to encourage the child to drink clear liquids during the first day, then shift to soft foods as per physician’s preference. Teach parents how to evaluate for dehydration; how to monitor intake and output and examine skin turgor.
Provides information to avoid dehydration.
Provide medication teaching as needed and instruct parents to avoid giving the child aspirin.
Specify action and side effects of medications. Aspirin may interfere with blood clotting.
Provide phone numbers in case parents have additional questions after discharge.
Provides additional information as needed.
4. Administer Medications and Provide Pharmacologic Support
Medications commonly used for patients with tonsillitis include antibiotics, such as penicillin or amoxicillin, to treat bacterial infections. Analgesics, such as acetaminophen or ibuprofen, may be prescribed to alleviate pain and reduce fever. Throat lozenges or sprays containing local anesthetics or numbing agents can also be recommended to provide temporary relief from throat discomfort.
Antibiotics (e.g., penicillin, amoxicillin, or erythromycin)
These are prescribed to treat bacterial tonsillitis, which is commonly caused by Streptococcus bacteria. These medications work by killing or inhibiting the growth of bacteria, helping to resolve the infection.
This is used to reduce inflammation and swelling of the tonsils, leading to symptom relief and improved comfort for the patient.
Analgesics (e.g., acetaminophen (Tylenol), ibuprofen (Advil))
These are used to relieve pain, reduce fever, and alleviate inflammation associated with tonsillitis.
Throat Lozenges or Sprays
Throat lozenges or sprays containing local anesthetics, such as benzocaine or lidocaine, can be used to temporarily numb the throat and provide relief from soreness and discomfort. They can help soothe the irritated throat and make swallowing easier.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
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.
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