Tuesday, October 18, 2011

Nursing Care Plan Tonsillectomy

Tonsillectomy


Tonsillectomy is surgery to remove the tonsils. These glands are at the back of your throat. Often, tonsillectomy is done at the same time as adenoidectomy, surgery to remove the adenoid glands.

Etiology of Tonsillectomy

The cause of tonsillitis is viral and bekteri, mostly caused by a virus which is also a predisposing factor of bacterial infection.

Virus Type:
  • Adenovirus
  • Virus echo
  • The influenza virus
Bacteria Type:
  • Streptococcus
  • Mycrococcus
  • Corine bacterium diphterial

The degree of tonsillar enlargement:
a. Grade I (Normal)
Tonsils are behind tonsil pillars (soft structure, cut by the soft palatine).
b. Grade II
Tonsils are among the pillars and uvula.
c. Grade III
Touching tonsils uvula.
d. Grade IV
One or two tonsil extends ketengah uvofaring.



Nursing Assessment of Tonsillectomy
  • Assess difficulty swallowing, easy to choke.
  • Assess sore throat acute / chronic.
  • Assess the history of sore throats and influenza.
  • Assess allergy history.
  • Assess the bleeding by mouth.
  • Assess the presence of asthma, cystic fibrosis.




Nanda Nursing Diagnoses for Tonsillectomy

1. Risk for infection related to the factors of surgery

2. Acute Pain related to surgical operations

3. Fluid Volume Deficit related to decreased fluid intake secondary to pain on swallowing

4. Imbalanced Nutrition Less Than Body Requirements related to reduced input secondary to pain on swallowing

5. Risks to the ineffectiveness of therapeutic management related to inadequate knowledge about the complications, pain, positioning and management activities.
http://nandanursingdiagnoses.blogspot.com/



Interventions Nursing Care Plan Tonsillectomy

Risk for infection related to the factors of surgery

Objectives:
- There is no infection.
- There were no complications.
Intervention:
- Monitor temperature every 4 hours, the state of injury when performing maintenance.
- Give an antibiotic is prescribed, give at least 2 liters of fluid every day while implementing antibiotic therapy.
- Give antipyretics are prescribed if there is fever.

Pain related to surgical operations

Objectives:
- The client states lost pain / controlled.
- The client indicates to relax, rest / sleep and increased activity appropriately.Iintervention:
- Monitor vital signs
- Provide comfort measures, eg changes in position, music, relaxation.
- If prescribed analgesics, analgesics are routinely set during the first 24 hours, not waiting for patients to ask for it.
- Tell your doctor if analgesics can not eliminate the pain.
 

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