Nursing Care Plan (NCP) for Tonsillitis

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Study Tools

Outline

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 and is especially common in school-aged children.  As the tonsils become swollen, the airway may become blocked causing an emergency. Complications of untreated tonsillitis include rheumatic fever and inflammation of the kidneys (post-streptococcal glomerulonephritis). Practicing good hand hygiene can help prevent the spread of viruses and bacteria that cause tonsillitis.

Desired Outcome

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

Tonsillitis Nursing Care Plan

Subjective Data:

  • Sore throat >24-48 hrs
  • Difficulty/painful to swallow
  • Irritability
  • Refusing to drink/eat

Objective Data:

  • Red/swollen tonsils 
  • White spots/patches/pustules on tonsils 
  • Fever 
  • Enlarged/tender lymph nodes in the neck
  • Scratchy/muffled voice 
  • Bad breath
  • Drooling

Nursing Interventions and Rationales

Nursing Intervention (ADPIE) Rationale
Assess vital signs  Get a baseline to determine if interventions are effective. Assess for fever which can lead to tachycardia, tachypnea, and elevated blood pressure 
Assess mouth/throat/nose look for any white spots/patches/pustules that may indicate infection. 

Assess for adequate airway clearance

Assess for any post-nasal drip that could be causing the sore throat 

Assess nares for signs of infection/drainage

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 germs that cause tonsillitis is contagious. So, teaching good hand hygiene is essential

Wash his or her hands thoroughly and frequently, especially after using the toilet and before eating

Avoid sharing food, drinking glasses, water bottles or utensils

Replace his or her toothbrush after being diagnosed with tonsillitis

Writing a Nursing Care Plan (NCP) for Tonsillitis

A Nursing Care Plan (NCP) for Tonsillitis starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

https://www.mayoclinic.org/diseases-conditions/tonsillitis/symptoms-causes/syc-20378479

https://my.clevelandclinic.org/health/diseases/21146-tonsillitis

Join NURSING.com to watch the full lesson now.

Transcript

Hey everyone. Today, we are going to be creating a nursing care plan for tonsillitis. So let’s get started. First, we’re gonna go over the pathophysiology. So tonsillitis occurs when the tonsils become inflamed or infected. In many cases, they 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. Some nursing considerations: assess vital signs, observe the nose, mouth and throat, encourage food and drink intake, give medications and educate the family or the caregiver. Some desired outcomes: the patient will be free from pain and infection; the patient will have adequate nutritional intake and hydration; and the patient will maintain an adequate respiratory status. So here is an example of what tonsillitis looks like: you’re gonna notice in this patient that the tonsils are very red, swollen, inflamed. And one of the classic signs you’re going to notice with this are these white patches; these white spots on the tonsils are very classic of this type of disorder. So we’re going to move on to the care plan. So we’re going to have some of our subjective data and our objective data. Some of the most common subjective that you’re going to see is the patient’s going to complain of a sore throat that lasts longer than 24 to 48 hours. 

The objective is gonna be red, swollen tonsils. And, as you saw in that picture, you’re also going to see some white patches and spots; these are very, very common with tonsillitis. We also want to mention, too, is irritability in young kids, or refusing to eat or drink because it hurts to swallow. Also very common is a fever in the large lymph nodes and the neck. Sometimes they might have a muffled voice, bad breath, and some drooling. One of the first things we want to do: assess the vital signs. You want to get a baseline to determine if the interventions are effective. You want to assess for fever, which can lead to increased heart rate and an elevated blood pressure. 

Next thing we wanna do is we want to assess the ear, throat and the mouth. It is very important to do a thorough assessment. You’re looking for like those white spots that we saw, or those patches on the tonsils, and that might indicate the infection. Or we want to assess for adequate airway clearance, making sure that it’s not affecting their airway or blocking their airway from breathing. We want to assess for any sort of post nasal drip that could be causing the sore throat for the patient and assess the nares for any sort of signs of infection or drainage coming from the nose. Another thing that we want to assess for is dehydration. Unfortunately, whenever you’re not eating or drinking anything, it can cause dehydration. And usually that’s because of pain. So children often will say that they’re not hungry or they’re not thirsty, and it’s just because it’s painful to swallow. So note with children, especially any dry membranes, mucus membranes. Another intervention that we want to look at is about giving proper medications. 

So viral tonsillitis requires only symptom management and will resolve on its own over time. Bacterial tonsillitis, which is strep, I’m gonna put strep throat here, is very common and usually will require antibiotics. So you wanna give analgesics for the pain and you’ll wanna give antibiotics for the bacterial affection. If it’s bacterial. Another thing that we want to assess is where we really want to encourage the patient to eat or drink. So you wanna encourage food, you wanna encourage drinking. But you want them to avoid dairy. Why dairy? Well, dairy, as much as it’s really good, dairy products can coat the throat, and but they may cause the patient to cough, which will further irritate the throat and cause further pain, especially if they end up having surgery on their tonsils. And as always, eating food and drinking is just going to hydrate the patient and make sure that they’re getting enough nutrition in their diet. Another thing we want to do is provide education for the parents or the caregivers. We want to talk about prevention, making sure that they’re washing their hands thoroughly and frequently, especially after using the restroom and before eating. You want to avoid sharing food, sharing glasses and water bottles, or any utensils because that’s just spreading the bacteria. You also want to be mindful to replace a toothbrush because unfortunately those germs stay on a toothbrush; it can cause further infection, or it might stay a lot longer. 

So, that is a further care plan completed here. We’re going to go into the key points here. So the patho, again, tonsillitis occurs when the tonsils are inflamed or are infected. Typically viruses or bacteria are a cause. Bacteria is caused by streptococcus, which is strep throat. That’s very common. What you’re going to see: patients are going to complain of a sore throat – very, very common. This lasts 24 to 48 hours. They’ll have difficulty swallowing. And, above everything, on the objectives: the main thing they’re going to have are red swollen tonsils with those white spots that we saw – patches. Large lymph nodes of the neck will be noticed, along with a fever and muffled voice. I want to make sure we’re doing a thorough assessment. So assess those vital signs, the nose, throat, mouth. Very, very key. You want to encourage taking in more drinks, food and proper nutrition – making sure they’re getting enough nutrition, making sure they’re not dehydrated. And again, you want to avoid dairy products that will further complicate things. Medication. Education. If it’s a viral cause, it’s all going to be about symptom management. If it’s bacterial, it’s going to be  about giving antibiotics and any sort of antipyretics for the pain. Make sure you’re educating on proper hand hygiene, always washing hands so you’re not spreading germs. Also not sharing food items or any sort of utensils for just spreading the germs. 

And that’s the end of that care plan. You guys did great. We love you guys. Go out, be your best self today and, as always, happy nursing.

 

Join NURSING.com to watch the full lesson now.