Acute Tonsillitis - 6 Nursing Diagnosis Care Plan

Definition;

Tonsillitis is a common presence of inflammation and swelling of the tonsillar tissue with a collection of leucocytes, dead epithelial cells and pathogenic bacteria in the crypts (Adam Boeis, 1994: 330).

Tonsillectomy is an invasive procedure that is performed to take out tonsils with or without adenoid (Adam Boeis, 1994: 337).


Etiology 

1. Haemolytic streptococcus group A.
2. Pneumococcus.
3. Staphylococci.
4. Haemophilus influenzae.

Symptoms 

1. Sore throat and dysphagia.
2. Patients do not want to eat or drink.
3. Malaise.
4. Fever.
5. Breath odor.
6. Otitis media is one of the originators factor.

Management of Acute Tonsillitis

1. Bed rest.
2. Provision of adequate fluids and light diet.
3. Giving medications (analgesics and antibiotics).
4. If there is no progress then the alternative actions that can be done is surgery.

Nursing Assessment for Acute Tonsillitis

1. Medical history factors associated with the occurrence of tonsillitis as well as supporting the bio-psycho-socio-spiritual.

2. Circulatory
Palpitations, headache at the time of a change in position, drop in blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination (incontinence uri / Alvi), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia, tiredness, difficulty in recuperating from muscle spasms and pain or spasm. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea, vomiting due to increased ICP (intracranial pressure), impaired swallowing, and loss of sensation on the tongue.

6. Nerves system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the face and extremities. Mental status coma, kelmahan in the extremities, facial muscles paralise, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychology
Denial, disbelief, anguish, fear, anxiety.



Nursing Diagnosis and Interventions for Acute Tonsillitis


1. Ineffective breathing pattern related to tissue damage or trauma to the respiratory center.

Goal: The patient demonstrated the ability to perform adequately the respiratory blood gas results show stable and good as well as the loss of signs of respiratory distress.

Interventions

1. Clear the airway patent (keep the head position in a state parallel to the spine / as indicated).
2. Perform suction if necessary.
3. Assess the function of the respiratory system.
4. Assess the patient's ability to perform cough / discharging effort.
5. Observation of vital signs before and after the action.
6. Observation for signs of respiratory ditress (skin becomes pale / cyanosis).
7. Collaboration with therapists in the provision of physiotherapy.

2. Impaired physical mobility related to neuromuscular weakness in the extremities.

Goal: Patients showed an increased ability to perform physical activity.

Interventions:

1. Assess the patient's ability to perform the activity.
2. Teach the patient about the range of motion that can still be done.
3. Perform active and passive exercises at akstrimitas to prevent stiffness and muscle atrophy.
4. Instruct the patient to take a straight position.
5. Assist patients in performing ROM gradually according to ability.
6. Collaboration in the provision antispamodic or relaxant if necessary.
7. Observation of the patient's ability to perform the activity.

3. Ineffective Cerebral Tissue Perfusion related to the brain, bleeding in the brain.

Goal: The patient showed an increase in awareness, cognitive and sensory function.

Interventions:

1. Assess neurologic status and note the changes.
2. Give the patient supine position.
3. Collaboration in the provision of oxygenation.
4. Observation level of consciousness, vital signs.

4. Acute pain related to physical trauma.

Goal: The patient expresses pain is reduced and shows a relaxed and calm state.

Interventions:

1. Assess the level or degree of pain felt by the patient using a scale.
2. Help the patient in finding factor in precipitation of pain felt.
3. Create a quiet environment.
4. Teach and demontrasikan to patients about several ways to do relaxation techniques.
5. Collaboration in the provision of appropriate indications.

5. Impaired verbal communication related to the effects of damage to the area to talk to the cerebral hemispheres.

Goal: The patient was able to communicate to meet their basic needs and showed improvement in their communication capabilities.

Interventions:

1. Do a personal communication with the patient (often but short and easy to understand).
2. Create an atmosphere of acceptance of the changes experienced by the patient.
3. Instruct patients to improve communication techniques.
4. Use non-verbal communication techniques.
5. Collaboration in the implementation of speech therapy.
6. Observation of the patient's ability to communicate both verbally and non-verbally.

6. Self-concept Disturbance related to a change of perception.

Goal: The patient showed improvement in the ability to accept the circumstances.

Interventions:

1. Assess the patient's degree of self-concept change.
2. Mentor and listen to patient complaints.
3. Give support to actions that are positive.
4. Assess the patient's ability to rest (sleep).
5. Observation of the patient's ability to receive state.