University of the East
RAMON MAGSAYSAY MEMORIAL MEDICAL
CENTER INC
#64 Aurora Blvd., Barangay Dona Imelda Quezon
City
COLLEGE OF NURSING
NCM 109 – Skills Laboratory
Jabian, Patricia Jeanne M.
N1D
Tonsillitis
I. Description
The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. The tonsils
filter and protect the respiratory and alimentary tracts from invasion by pathogenic
organisms. They also play a role in antibody formation. Although the size of the tonsils
varies, children generally have larger tonsils than adolescents or adults. This difference is
thought to be a protective mechanism, since young children are especially susceptible to
upper respiratory infections.
Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the
frequency of URIs, tonsillitis is a common cause of illness in young illness. The causative
agent may be viral or bacterial.
II. Focus Assessment (Signs and Symptoms)
SIGNS SYMPTOMS
Difficulty swallowing Edema
Obstruction of breathing during
sleep
Dry and irritated tonsils
Impaired sense of taste and smell
III. Diagnostic and Laboratory Test
Patient with tonsillitis are tested for throat cultures for GABHS infection. It is important
to differentiate between viral and streptococcal infection in febrile, exudative tonsillitis.
IV. Risk Factors
V. Pathophysiology
VI. Nursing Diagnosis by Priority (5)
Ineffective Airway Clearance r/t swelling of tonsils possibly evidenced by
difficulty swallowing and breathing
Acute Pain r/t surgical incision
Risk for Infection
VII. Nursing Care Plan (3 Priority Problem)
Assessmen
Diagnosis Planning Intervention Rationale Evaluation
t
Ineffective Short Term: Independent: Independent: Short Term:
Airway After 3 hours Assess for Early signs of After 3 hours
Clearance r/t of nursing signs and hypoxia of nursing
swelling of interventions, symptoms of include interventions,
tonsils the patient will inadequate confusion, the patient will
possibly be able to oxygenation. irritability, be able to
evidenced by verbalize headaches, verbalize
difficulty understanding pallor, understanding
swallowing of causes and tachycardia, of causes and
and therapeutic and tachypnea. therapeutic
breathing management management
regimen. regimen.
Monitor Indicative of
Long Term: respirations respiratory Long Term:
After 24 hours and breath distress and/or After 24 hours
of nursing sounds. accumulation of nursing
interventions, of secretions. interventions,
the patient will the patient will
be able to Encourage the Hydration be able to
maintain a patient to drink loosens thick maintain a
patent airway fluids secretions or patent airway
as adequately. maintains the as
demonstrated secretions demonstrated
by normal moist to by normal
respiratory rate facilitate easy respiratory rate
and rhythm removal. and rhythm
and clear and clear
breath sounds. Teach and Promotes lung breath sounds.
demonstrate expansion,
breathing enhanced air
exercises. exchange and
prevents the
risk of
pneumonia.
Dependent: Dependent:
Administer Prevent an
antibiotics as infection
prescribed by caused by
the physician. bacteria.
Administer IV Reduce
fluids, as pharyngeal
prescribed. edema.
Collaborative: Collaborative:
Obtain sputum To point to
specimen, effective
preferable antimicrobial
before agent.
antimicrobial
therapy is
initiated.
Assess the To determine
guardian’s educational
and support
knowledge of
contributing
causes,
treatment plan, needs.
medications,
and therapeutic
procedures.
Assessmen
Diagnosis Planning Intervention Rationale Evaluation
t
Acute Pain Short Term: Independent: Independent: Short Term:
r/t surgical After 4 hours Assess pain Use of pain After 4 hours
incision of nursing using scale allows of nursing
interventions, appropriate objective interventions,
the patient’s pain scale for measurement the patient’s
guardians will child’s age and of subjective guardians will
be able to, development. pain be able to,
follow perception. follow
prescribed prescribed
pharmacologic Observe child Provides pharmacologic
al regimen. for nonverbal additional al regimen.
indications of information
After 6 hours pain such as about pain. After 6 hours
of nursing crying, of nursing
interventions, grimacing, and interventions,
the patient’s irritability. the patient’s
guardians will guardians will
be able to Suggest Provides be able to
demonstrate diversional distraction demonstrate
use of activity such as from pain and use of
relaxation reading a book, discomfort. relaxation
skills and watching a skills and
diversional video, or diversional
activities, as listening to activities, as
indicated. music. indicated.
Long Term: Dependent: Dependent: Long Term:
After 30 hours Administer Throat pain is After 30 hours
of nursing pain common of nursing
interventions, medications, as during first interventions,
the child will prescribed. several days the child will
state level of Monitor for post op. state level of
pain is effectiveness pain is
decreased and and side decreased and
will appear effects. will appear
more relaxed more relaxed
and Collaborative: Collaborative: and
comfortable. Discuss with Family comfortable.
the child’s members may
parents ways provide
in which they assistance to
can assist the enhance
patient with wellness and
pain health
management. management,
Assessment Diagnosis Planning Intervention Rationale Evaluation
Risk for Short Term: Independent: Independent: Short Term:
infection After 4 hours Assess vital To assess for After 4 hours
of nursing signs and any evidence of nursing
interventions, observe for of ongoing interventions,
the patient’s any signs of infection. the patient’s
guardians will infections Tonsillitis may guardians will
be able to: and/or cause blockage be able to:
respiratory of airways,
(1) verbalize distress. which may (1) verbalize
the lead to the
understanding respiratory understanding
of individual distress. of individual
risk factors. risk factors.
Perform an Tonsillitis can
(2) identify assessment to lead to (2) identify
interventions the patient’s peritonsillar interventions
to prevent and oropharyngeal abscess. The to prevent and
reduce the region, to infection can reduce the
risk of check for any cause pus risk of
infection. collection of production infection.
abscesses. which then
Long Term: collects behind Long Term:
After 32 the tonsils. After 32
hours of hours of
nursing Teach the To maintain nursing
interventions, patient how to patient safety interventions,
the patients’ perform proper and reduce the the patients’
guardians will hand hygiene. risk for cross guardians will
be able to contamination. be able to
avoid the avoid the
development Dependent: Dependent: development
of worsening Administer To treat of worsening
infection. antibiotics as underlying infection.
prescribed by infection and
the physician. to prevent the
risk of
developing
further
infection.
Collaborative: Collaborative
:
VIII. Nursing Management/Intervention
IX. Medical/Surgical Management
Tonsillectomy, is the surgical removal of the palatine tonsils may be indicated for
massive hypertrophy that results in difficulty breathing or eating. Indications includes,
peritonsillar abscess, airway obstruction, tonsillitis resulting in febrile seizures, and
tonsils requiring tissue pathology.
Adenoidectomy, is the surgical removal of the adenoids. This is recommended for
children who have hypertrophied adenoids that obstruct nasal breathing; additional
indications for adenoidectomy include recurrent adenoiditis and sinusitis.
X. Drug Analysis
Mechanism of Adverse Effects Contra- Nursing
Action indications Responsibilities
Acetaminiphen
tylemol
Ibuprofen advil
oxydocone
