Nursing Care Plan for Tonsillitis

Print

Pathophysiology

The tonsils are oval-shaped masses of tissue found on both sides of the back of the throat and help the immune system fight off bacteria and viruses that enter through the mouth. Tonsillitis occurs when the tonsils become inflamed or infected. Many cases resolve on their own, but some bacterial infections require treatment. Repeated bacterial infections, or those that do not respond to treatment, may result in surgery to remove the tonsils.

Etiology

Viruses account for the majority of cases of tonsillitis and are usually seen in young children, under the age of five. The most common bacterial infection is Streptococcus pyogenes (strep throat). This is easily spread by being in close contact with other affected individuals and is especially common in school aged children.  As the tonsils become swollen, the airway may become blocked which is an emergency. Complications of untreated tonsillitis include rheumatic fever and inflammation of the kidneys (poststreptococcal glomerulonephritis). Practicing good hand hygiene can help prevent the spread of viruses and bacteria that cause tonsillitis.

Desired Outcome

Patient will be free from pain and infection; patient will have adequate nutritional intake and hydration; patient will maintain adequate respiratory status

Tonsillitis Nursing Care Plan

Subjective Data:

  • Pain in the throat > 24-48 hours
  • Irritability
  • Refusing food or drink
  • Difficulty swallowing

Objective Data:

  • Drooling
  • Bad breath
  • Fever
  • Palpable lymph glands in neck
  • Swollen tonsils
  • Erythema or pustules in the throat

Nursing Interventions and Rationales

  • Assess vital signs

 

Get baseline to determine if interventions are effective. Assess for fever which can lead to tachycardia, tachypnea and elevated blood pressure

 

  • Assess mouth and throat

 

Look for erythema, pustules or petechiae that may indicate infection. Assess for adequate airway. Note any post-nasal drip that could cause throat pain.

 

  • Assess for signs of dehydration

 

Throat pain in children often causes them to refuse food and drink because swallowing is painful. Note mucous membranes.

 

  • Assess for pain using appropriate pain scale for age (FLACC / FACES) and provide non-pharmacological pain relief methods

 

Throat pain is the most common symptom of tonsillitis, but patients may not be able to verbalize complaints.

Note nonverbal cues such as crying, mouth breathing, irritability or refusal to eat or drink.

 

  • Administer medications as appropriate

 

Viral tonsillitis requires only symptom management and will resolve on its own.

Bacterial tonsillitis (strep) will require antibiotics.

Give analgesics such as acetaminophen orally or rectally as appropriate for age,  for pain relief.

 

  • Prepare patient for and assist with surgery as required

 

Repeated infections or those that are resistant to treatment may require surgical removal of the tonsils.

 

  • Encourage patient to eat and drink; avoid dairy products

 

It is important to maintain adequate nutrition to help the immune system fight off disease.

Dairy products coat the throat and may cause the patient to cough which will further irritate the throat and cause pain, especially after surgery

 

  • Provide patient and parent education for home care and prevention

 

  • Demonstrate and educate parents and patient about good hand hygiene to avoid spread of germs.
  • Encourage patient to avoid playing with other children when they feel sick.
  • Encourage rest to help the immune system work.
  • Parents should keep child home from school or daycare while running a fever.

 


References

NRSNG is the BEST place to learn nursing. Save 4+ hours of studying per week.

Start a 24 hour full access trial for just $1.

Start NRSNG Academy Trial

Module 0 – Nursing Care Plans Course Introduction

Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

Study Plans are available to NRSNG Academy Members only.Upgrade Now