Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide Nursing assessment for tonsillitis: • Full assessment of the head and neck; feel for lymph nodes and visualize the inside of the throat • Vital signs: temperature, pulse, and respiration • Assess pain levels using faces scale • Inquire about history of tonsillitis episodes • Review laboratory reports: CBC and throat culture; rapid strep for results in five minutes Nursing diagnosis for tonsillitis: • Altered body temperature related to fever, secondary to infection • Altered nutritional status with less than body requirements related to throat pain and swallowing difficulty • Pain related to throat inflammation • Risk for fluid volume deficit related to inadequate intake, secondary to throat pain • Ineffective breathing pattern related to swelling of tonsils • Knowledge deficit of caregivers related to treatment plan and homecare Nursing interventions for tonsillitis: • Monitor vital signs frequently, especially temperature • Give antipyretics per MD order to keep body temperature low and prevent febrile seizures • Assess for pain frequently and give analgesics per MD order; do not give aspirin or ibuprofen due to risk of bleeding in case surgery is needed • Give antibiotics per MD order for acute bacterial infection; Penicillin is usually the drug of choice, but for penicillin allergies cephalosporin or Azithromycin may beused • Prepare patient for surgical removal of tonsils; provide emotional support to patient and family to reduce anxiety; post-operative instructions should be discussed with parents; keep patient NPO • After surgery, monitor for s/s bleeding, throat clearing, vomiting blood, restlessness, and tachycardia • Give ice chips and place ice packs on the neck to reduce swelling and pain • Discourage orange juice and acidic fluids or foods as they can irritate the throat • Discourage coughing and excessive talking to help rest the throat and reduce pain • Offer liquid (viscous) lidocaine per MD order to “swish and swallow” for throat pain • Offer warm salt water gargles • Keep patient side-lying or prone to allow for patent airway and drainage of secretions • After throat and neck surgery, it is imperative to keep an emergency oral airway close by • Provide basin for patient to expectorate secretions and drainage

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