4 Tonsillitis Nursing Care Plans

ADVERTISEMENTS

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
ADVERTISEMENTS

Risk for Deficient Fluid Volume

Nursing Diagnosis

May be related to

  • Inadequate oral intake
  • Blood loss from surgery
  • Effect of anesthesia (nausea and vomiting)

Possibly evidenced by

ADVERTISEMENTS
  • Child verbalizes difficulty in drinking
  • Poor fluid intake
  • Risk for hemorrhage post-tonsillectomy

Desired Outcomes

  • Client will experience adequate fluid volume as evidenced by pulse and blood pressure within normal limit, absence of profuse bleeding, and intake and output within acceptable parameters.
Nursing Interventions Rationale
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 quantity may be more easily tolerated. Red, purple or brown may stimulate the appearance of blood if the child vomits.
Discourage the use of a straw 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, 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.

ADVERTISEMENTS

See Also

You may also like the following posts and care plans:

Pediatric Nursing Care Plans


Nursing care plans for pediatric conditions and diseases: 

Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.

Leave a Comment