Nursing 211

N211: Health Differences Across the Lifespan I Include avoidance of alcohol and drugs that depress the respiratory system, weight reduction, tricyclic antidepressants, nasal continuous positive airway pressure (CPAP) may be used. Surgical removal of enlarged tonsils or adenoids may be performed. 2.32 Tonsillitis Tonsillitis is an inflammation of the tonsils. It may be viral or bacterial. Tonsillitis may be related to infection by a Streptococcus species. If related to strep throat, treatment is vital because of the risk of developing acute glomerulonephritis or rheumatic heart disease. Nursing Assessm nt Incudes sore throat, drooling, mouth breathing, lymphadenopathy, fever, enlarged tonsils which may or may not have purulent discharge. Breathing may be obstructed (tonsils may be touching, “kissing tonsils”). Diagnostics Include a throat culture to determine viral or bacterial cause. Nursing Diagnosis • Impaired swallowing related to… • Risk for injury related to… Nursing Interventions Include management of viral tonsillitis by symptom relief: promote comfort, pain relief with acetaminophen (Tylenol). Management of bacterial tonsillitis is antibiotic therapy as well as symptom relief. Soft, liquid diet including ice pops that is easy to swallow and is soothing to sore throat. Do not give citrus juices or other foods that can cause burning or increased irritation. Use saltwater gargles, throat lozenges, or analgesic sprays for pain relief. Medication Th rapy Includes analgesics (acetaminophen) for comfort and fever and antibiotics. Surgical I tervention Tonsillectomy, surgical removal of the tonsils if recurrent tonsillitis, peritonsilar abscess or respiratory comprise exists. Preoperative nursing management includes client and family teaching, baseline lab data including bleeding and clotting times. Teach that the highest risk for hemorrhage is during the first 24 hours and 5 to 10 days after surgery. Encourage soft foods and oral fluids (avoid red fluids that can mimic bleeding), and do not have client use a straw. Provide comfort measures with ice collar to help with pain and with vasoconstriction. Teach client and family that sore throat


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