CARE AND MANAGEMENT OF PATIENTS UNDERGOING TONSILLECTIOMY

BY SR HAJIJAH ALI & SN FLORENA PETER

WHAT ARE TONSILS?

The tonsils are a pair of small almond-shaped organs located of the mouth on both sides of the throat.

DEFINITION

Tonsillitis is an infection of the tonsils. It is caused by either a virus or a bacterium (usually the bacterium known as streptococcus - the same bacterium that causes "strep throat"). Tonsillitis mostly occurs in young children and adult.

Enlarged, red tonsils and exudative white patches of tonsillitis

TYPESThere are 3 main types of tonsillitis:- acute, subacute and chronic.

1. Acute tonsillitis can either be bacterial or viral (75%) in origin.

Subacute tonsillitis (which can last between 3 weeks and 3 months) is caused by the bacterium Actinomyces.

3. Chronic tonsillitis, which can last for long periods if not treated, is almost always bacterial.

INFECTION OF THE TONSILSUSUALLY BY VIRUSES 70% TO 80 %PART OF AN INFECTION OF THE WHOLE UPPER RESPIRATORY TRACTBACTERIA LESS THAN 30 %COMMONEST BACTERIUM STREPTOCOCCUS PYOGENESLESS COMMON HAEMOPHILUS INFLUENZAE - STREP PNEUMONIAE - BRANHAMELLA CATARRHALIS

ETIOLOGY

Tonsillitis may be caused by Group A streptococcal bacteria, resulting in strep throat. Viral tonsillitis may be caused by numerous viruses such as the Epstein-Barr virus (the cause of infectious mononucleosis) or the Adenovirus. Sometimes, tonsillitis is caused by a superinfection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina. Although tonsillitis is associated with infection, it is currently unknown if the swelling and other symptoms are caused by the infectious agents themselves, or by the host immune response to these agents. Tonsillitis may be a result of aberrant immune responses to the normal bacterial flora of the nasopharynx.

SIGN AND SYMPTOMSymptoms of tonsillitis include a severe sore throat (which may be experienced as referred pain to the ears).Painful/difficult swallowing, headache, fever and chills, and change in voice causing a "hot potato" voice. Complain of general aches and pains, loss of appetite and may vomit. Have bad smelling breath. Tonsillitis is characterized by signs of red, swollen tonsils which may have a purulent exudative coating of white patches (i.e. pus). There may be enlarged and tender neck cervical lymph nodes.

BACTERIAL

- HIGH FEVER- PAIN MORE SEVERE- PROMINENT LYMPHADENITIS- PUS DISCHARGE FROM TONSILLAR CRYPTS- ERYTHEMA CONFINED TO TONSILS

VIRAL- LESS SEVERE CONSTITUTIONAL SYMPTOMS- SORE THROAT LESS SEVERE- NASAL & LARYNGEAL SYMPTOMS PRESENT- DIFFUSE ERYTHEMA- MINIMAL SWELLING OF THE TONSILS

DIPTHERIA-CAUSED BY BACTERIA-RARE NOW BECAUSE OF IMMUNISATION-GREYISH WHITE , TOUGH MEMBRANE OVER THE TONSILS AND PHARYNX-BULLS NECK-AIRWAY OBSTRUCTION-NEUROLOGICAL AND CARDIAC COMPLICATIONS DUE TO EXOTOXINS

HERPANGINACOXSACKIE A VIRUSVESICULAR RASH IN THE ORAL CAVITYFEVER ,SORE THROAT MILDRECOVERY FAST

IMMUNE COMPROMISEDCANDIDA ALBICANSVERY YOUNGVERY OLDPAINFUL DYSPHAGIAWHITISH MEMBRANE COVERS THE TONSILS AND PHARYNX

BACTERIAL TONSILLITISVIRAL TONSILLITIS

INVESTIGATION

1) Throat swab FOR c+s to determine the infection and the source of infection.

2) Complete blood cell count (CBC)

TREATMENT

Medication: - Antipyretics and analgesic (relief throat pain and associated myalgias).-Antibiotic Penicillin, Erythromycin, Clarithromycin.Incision and drainage or needle aspiration for peritonsillar abscess.

Tonsillectomy:Surgical removal of the tonsils.Indications: Recurrent or chronic infection that have not responded to antibiotic therapy.Hypertrophy of the tonsils with risk of airway obstruction.Peritonsillar abscess or quinsy.Repeated attacks of purulents otitis media.Tonsil malignancy.

SYMPTOMATIC - PARACETAMOL - GARGLE BENZYDAMINE , THYMOL - ANTI HISTAMINES - COUGH MIXTURES

ANTIBIOTICS ?- ONLY WHEN BACTERIAL INFECTION IS SUSPECTEDTYPE OF ANTIBIOTICS - PENINCILLIN - ERYTHROMYCIN

PERITONSILLAR HYPERTROPHIC ABSCESS TONSILS

PRE OPERATIVE CARE

Admit patient to the ward one to two days before surgery for surgery preparation. Consent Blood investigation ex FBC/BUSE Orientation to the ward surrounding Vital signs monitoring Throat swab for culture and sensitivity to make sure patient is free from upper respiratory tract infection. (if needed) Ice cream ordering for post operative diet.

POST OPERATIVE CARE Airway patency. Put patient in lateral position Vital signs monitoring BP and pulse rate Check mouth and oropharynx for fresh blood (bleeding) Allow orally once tollerating. Avoid hot, spicy, hard food and citrus drinks. Starts with cold nourishing fluid or ice cream diet 100 gram/hourly for 10 hours then allow soft diet. Administer analgesic such as Paracetamol 1 gm QID or Ibuprofen 400mg TDS Difflam gargle 15 mls QID. Antibiotic as ordered such as Tablet EES 400mg BD.

POST OPERTIVE COMPLICATION

BLEEDING

2. DEHYDRATION

PROCEDURE

Two removed tonsils

PROCEDURE

Throat 1 day after a tonsillectomy.

Throat some days after tonsillectomy

COMPLICATIONSUntreated tonsils:

Airway obstruction, leading to sleeping apnea.

2. Also can lead to a collection of pus between a tonsil and the soft tissues around it (abscess).

3. Abscess may spread into the bloodstream or into the neck or chest.

WHEN TO REFER -POOR ORAL INTAKE - REHYDRATION - IV ANTIBIOTICS

COMPLICATIONS PRESENT / SUSPECTED

TONSILLECTOMY INDICATED - RECURRENT INFECTION - > 4 ATTACKS IN ONE YEAR - RECURRENT PERITONSILLAR ABSCESS 2ND ATTACK - RECURRENT TONSILLITIS IN PATIENTS WITH RHEUMATIC FEVER OR GLOMERULONEPHRITIS

NURSING CARE PLAN (Assessment)Name of patient:MS TMedical Diagnosis: CHRONIC TONSILITISPast Medical History (Where relevant) (Med./Surg./Obs./Gynae/Paed):Past Medical History: NIL

LSCS (Lower Segmental Caesarian Section) year 1993

Date of admission: 2 NOVEMBER 2009Present History:Complain of sore throat once a month.Elective admission for tonsillectomy under General Anaesthesia on 4 November 2009.Pain History: Yes/NoHead to toe examination finding: Appeared worries leaving her child at home.Skin normal. No URTI symptom. No any abnormalities detected.Vital signs on admission BP: 126/77mmHgPR: 78/minRR: 18/minTemp: 36.6CPain score : 0Urine for Albumin & Glucose : Negatif

Time: 1545 HOURSRegistration number: 730912-13-6264Mode of admission: WalkingWheelchair StretcherSocial history:Married having 3 children.Jururawat Masyarakat at Kapit Hospital.Non alcoholic and non smoker.Stayed with family. CarriedAccompanied by: JAMES LEO (COUSIN)Allergies Drugs: NIL Food: NIL Other: NILSpecial information: NILSignature of Admitting Nurse:( CHOP AND SIGN )

Referred by:KAPIT HOSPITAL

Name of patent: MS TReg. No: 730912-13-6264

DateTimeNursing ProblemGoalNursing ActionEvaluation02/11/091545 hrs1) Anxiety related to surgery and hospitalization.Patient will verbalised less anxiety.1. Orientate patient to ward surrounding.2. Inform patient regarding her treatment and any procedure perform.3. Provide emotional support by talking to patient and keep patient accompanied..4. Collaborate with family members to give moral support.5. Refer doctor to explain about the nature of disease and treatment.6. Explain to patient the mouth care after operation.CHOP & SIGNSTAFF NURSEPatient verbalised less anxiety.Achieved on 03/11/2009 @ 1600 hoursCHOP & SIGNSTAFF NURSE

Name of patent: MS TReg. No: 730912-13-6264

DateTimeNursing ProblemGoalNursing ActionEvaluation04/11/091210 hrs2) Pain in swallowingPatient will experience less pain .1. Monitor and record pain score finding2. Encourage patient to take cold nourishing fluid.

3. Advice patient on oral hygiene or gargle 4 hourly.4. Administered analgesic as prescribed by Dr.

CHOP & SIGNSTAFF NURSENo pain in swallowing noted.Achieved on 07/11/2009@ 1210 hoursCHOP & SIGNSTAFF NURSE

Name of patent: MS TReg. No: 730912-13-6264

DateTimeNursing ProblemGoalNursing ActionEvaluation04/11/091210 hrs3) Risk factor of bleeding related to surgery.Patient will not develop post operation bleeding 1. Monitor pt vital signs 2. Observe any signs of bleeding .3. To refer Dr if bleeding.4. Served ice cream hourly for 10 hours to prevent bleeding.

CHOP & SIGNSTAFF NURSENo bleeding reported.Achieved on 05/11/2009 @ 0700 hoursCHOP & SIGNSTAFF NURSE

Name of patent: MS TReg. No: 730912-13-6264

DateTimeNursing ProblemGoalNursing ActionEvaluation04/11/091210 hrs4) Risk factor for nausea and vomiting .Patient will experience no nausea &vomiting 1. Avoid hot & spicy hard food.2. Encourage fluid as tolerated.3. Advised patient on oral hygiene, gargle 4 hourly .4. Give anti emetic drug as ordered.CHOP & SIGNSTAFF NURSENo nausea & vomiting noted.Achieved on 05/11/2009 @ 0900 hoursCHOP & SIGNSTAFF NURSE

ENT & EYE WARD HOSPITAL SIBU MS T 730912-13-6264

Clinical Notes

02/11/09 @ 1600hrsPatient was admitted for elective tonsillectomy cm accompany by her cousin .Orientation to ward surrounding done. Vital signs was taken . BP 111/68 PR 65 Resp 18/pm .Temperature 36.9c. Pain score -0. Doctor was informed and patient was seen . Blood for FBC/BUSE taken and sent. Informed consent was obtained .Patient verbalised less anxiety after talking and given emotional support to her. Reinforce on the care of the mouth and the food after surgery done. CHOP & SIGN02/11/09 @ 2000hrsPatient comfortable. Blood result for back ,due for reviewed.. Tolerating orally well . Vital signs stable.BP P T Pain score: CHOP & SIGN02-03/11/09 a@ 0600hrsPatient condition stable. Able to sleep well at night. .Able to adapt herself to the ward environment . BP 120/80 PR 65/min temperature 36.8. Pain score 0 CHOP & SIGN

ENT & EYE WARD HOSPITAL SIBUMS T730912-13-6264

Clinical Notes

03/11/09 @ 1300hrsPatient . Blood investigation was seen by doctor. Vital signs stable. BP P R T. Pain score : Taking orally well. CHOP & SIGN03/11/09 @ 1930hrsPatient was reviewed by anaest MO at 1600hrs. Nil orally from 12MN was instructed to patient. IV line was inserted and the line patent. . Taken her dinner. Vital signs stable. BP P R T . Pain score : No difficulty in swallowing reported. CHOP & SIGN03-04/11/09 @ 0610hrsPatient condition stable. Able to sleep well . Nil per orally maintained. IV line patent and no pain noted . Vital signs stable. BP 120/70 pr 80Tempt- 36.9c. Pain score CHOP & SIGN04/11/09 @ 0730hrsPatient was proceed to OT . Vital signs taken .NPO maintained. CHOP & SIGN

ENT & EYE WARD HOSPITAL SIBUMS T730912-13-6264

Clinical Notes

04/11/09 @ 1200hrsPatient back to ward @ 1200hrs. Came with IVF N/S 0.9% 450mls in progress . Condition slight drowsy No bleeding noted . Patient c/o slight nausea only. Pain score 2. Nursed patient in low fowlers position. Specimen x 2 for left tonsil and right tonsil for C&S &HPE received.. Vital signs done. BP 135/30 PR 70/min ,Resp 20/pm . temperature 36.5C. Ice cream diet due given. CHOP & SIGN@1300hrs. 1st dose of Ice cream served and tolerating well. Still c/o pain when swallowing. Analgesic crushed and served to patient. No vomiting noted. Difflam gargle given to patient with instruction every 6 hourly. Post operation vital signs stable. BP ranging from 120/70- 130/84 .PR 78-80 p/m .Temperature -36.5- 37.0C CHOP & SIGN04/11/09 @ 2000hrsPatient stable. Intake and output charting recorded .Tolerating ice cream . No bleeding or vomiting occur. Patient verbalise less pain after analgesic served. Medication served as ordered. Vital signs stable.Pain score 1 CHOP & SIGn

ENT & EYE WARD HOSPITAL SIBUMS T730912-13-6264

Clinical Notes

04-05/11/09 0030hrsIce cream completed at 2300hrs. Iv infusion off as patient was tolerating well. Able to sleep well. No bleeding noted. BP 120/70 pr 78. CHOP & SIGN0600hrsPatient stable. Medication crushed and served. Tolerating cold soft diet and fluid intake Pain score 1. No bleeding noted. Oral difflam gargle done by patient. Vital signs stable. BP P T Pain score. CHOP & SIGN

05/11/09 @ 1300hrsPatient stable. Reviewed by doctor . Patient tolerating soft diet today. Complaint of mild pain when swallowing. Pain score -1 . Medication served as ordered. Vital signs stable. CHOP & SIGN05/11/09 @ 1930hrsResting. Took porridge. No bleeding noted from post op site. Medication served as ordered. Pain score 1. vital signs stable. CHOP & SIGN

ENT & EYE WARD HOSPITAL SIBUMS T730912-13-6264

Clinical Notes

05-06/11/09 @ 0615hrsStable. Able to sleep at night. Medication crushed and served. Pain score -1. Tolerating orally well Vital signs stable. CHOP & SIGN06/11/09@ 1315hrsPatient comfortable. Seen by ENT specialist. To continue monitoring for bleeding. Tolerating soft diet. Pain score 1. vital signs stable. No bleeding noted. Medication served. CHOP & SIGN06/11/09 @ 2015hrsResting. Took dinner. C/o mild pain on swallowing. No bleeding noted. Vital signs stable. CHOP & SIGN06-07/11/09 @ 0620hrsStable. Able to sleep at night. Difflam gargle done by patient. No bleeding noted. Complaint of mild pain only. Medication served.

CHOP & SIGN

ENT & EYE WARD HOSPITAL SIBUMS T730912-13-6264

Clinical Notes

07/11/09 @ 0800hrsSeen by ENT specialist. .Patient was fit for discharge. Vital signs stable .To come to Kapit Hospital 1/52 & PRN for review . 1100hrs Health education on her diet re-enforced .To continue soft diet for 1/52. medication collected. To come stat if any problem arise to the nearest clinic Patient went home at 1045hrs after medication collected.

CHOP & SIGN

DISCHARGED SUMARRYDate of Discharge: 7 NOVEMBER 2009Discharged by: DR SIA KIAN JOOFollow up appointment: Date: PRN Time: PRN Venue: HOSPITAL KAPIT Nursing Discharge summary:Patient was admitted for elective Tonsillectomy operation done .Post op vital signs was stable. No bleeding noted. Condition was improving after operation . Able to tolerate orally. General condition stable .Patient was allowed discharge today. Iv line removed . Reinforcement on the care of mouth and food given.Advice on Discharge:Continue medication as ordered by doctor and important of follow upTo come to hospital as soon as possible if bleeding occurs at post op site.TCA @ the nearest Hospital.Signature of Discharge Nurse:(Chop and sign)

KEY PERFORMANCE INDICAQTORS (KPI) FOR CLINICAL DEPT.2009 OTORHINOLARYNGOLOGICAL (ENT) SURGERYIndicator:No 4 Occurrence of Post-Tonsillectomy Haemorrhage Standard

Thank you for your attentionSALAM SATU MALAYSIA

*****SALAM SATU MALAYSIA