4 Tonsillitis Nursing Care Plans

By
Paul Martin, BSN, R.N.
-
4 Tonsillitis Nursing Care Plans
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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:

  1. Ineffective Airway Clearance
  2. Acute Pain
  3. Deficient Knowledge (Postoperative Home Care)
  4. Risk for Deficient Fluid Volume

1. Ineffective Airway Clearance

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Ineffective Airway Clearance

Nursing Diagnosis

  • Ineffective Airway Clearance

May be related to

  • Bleeding from surgery
  • Side effects of anesthesia
  • Swelling/edema

Possibly evidenced by

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  • 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:
  • Antibiotics (e.g., penicillin, amoxicillin, or erythromycin)
 Prevent an infection caused by bacteria.
  • IV Corticosteroids
 Reduce pharyngeal edema.
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1. Ineffective Airway Clearance

See Also

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