Tonsillitis and Adenoiditis Nursing Care Management

Most tonsillitis is supportive care: keep the child hydrated, control pain and fever, and watch the airway. The condition that lands them in your unit is the obstructed or surgical case. After tonsillectomy your single biggest job is catching postoperative bleeding early, because the child swallows the blood and it hides until they vomit it.

What is Tonsillitis?

Tonsillitis is inflammation of the pharyngeal tonsils, a common childhood illness resulting from pharyngitis. The inflammation usually extends to the adenoids and the lingual tonsils.

Pathophysiology

A ring of lymphoid tissue encircles the pharynx as a protective barrier against upper respiratory infection. It is made of the faucial tonsils (the commonly known tonsils), the pharyngeal tonsils (adenoids), and the lingual tonsils. This tissue normally enlarges progressively in childhood between the ages of 2 and 10 years and shrinks during preadolescence. When the tissue itself becomes a site of acute or chronic infection, it can hypertrophy and interfere with breathing, cause partial deafness, or become a source of infection in itself.

Statistics and Incidences

Tonsillitis occurs most often in children but rarely in those younger than 2 years. Recurrent tonsillitis was reported in 11.7% of Norwegian children in one study and in 12.1% of Turkish children in another. The mean carrier rate among schoolchildren for group A Streptococcus, a cause of tonsillitis, was 15.9% in one study. Children account for approximately one-third of peritonsillar abscess episodes in the United States. Incidence rises during childhood, peaks in teenagers, and falls gradually until old age. Until age 14 years girls are more affected than boys, after which the condition is more frequent in males.

Causes

Viral and bacterial infections and immunologic factors drive tonsillitis and its complications. Epstein-Barr virus (EBV) can cause tonsillitis without systemic mononucleosis and was responsible for 19% of exudative tonsillitis in children in one study. Most bacterial tonsillitis is caused by group A beta-hemolytic Streptococcus pyogenes (GABHS), which adheres to receptors on the tonsillar epithelium; anaerobic bacteria also play a role, and immunoglobulin coating of pathogens may matter in the initial induction. Local immunologic mechanisms are important in chronic tonsillitis, with altered distribution of dendritic and antigen-presenting cells (fewer on the surface epithelium, more in the crypts and extrafollicular areas).

Clinical Manifestations

Expect a fever of 101°F (38.4°C) or more and a sore throat, often with dysphagia. The tonsils are tender and inflamed in acute tonsillitis, and exudate may be visible. Airway obstruction shows up as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnea.

Assessment and Diagnostic Findings

Test when GABHS infection is suspected. Throat cultures identify the causative organism. When acute tonsillitis is suspected to have spread to deep neck structures (beyond the fascial planes of the oropharynx), get plain films of the lateral neck or CT with contrast.

Medical Management

Treatment of acute tonsillitis is largely supportive: maintain hydration and caloric intake and control pain and fever. When the child cannot keep up oral intake, IV hydration, antibiotics, and pain control are needed, and IV corticosteroids may reduce pharyngeal edema. Airway obstruction may require a nasal airway device, IV corticosteroids, and humidified oxygen; keep the patient in a monitored setting until obstruction is clearly resolving.

Tonsillectomy is indicated for more than six (6) episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5 episodes in each of 2 consecutive years, or 3 or more tonsil and/or adenoid infections per year for 3 years running despite adequate medical therapy, or chronic or recurrent tonsillitis with a streptococcal carrier state unresponsive to beta-lactamase-resistant antibiotics. Because adenoid tissue shares the bacteriology of the pharyngeal tonsils and adds minimal morbidity, most surgeons remove inflamed adenoids at the same time. Adequate hydration (usually oral) and rest accelerate recovery.

Pharmacologic Management

Corticosteroids reduce inflammation that impairs swallowing and breathing. Antibiotic therapy must cover all likely pathogens for the setting. Immune globulins stimulate immune cells and reduce infection severity. Analgesics with antipyretic properties (acetaminophen, ibuprofen) control pain and fever and keep the child comfortable.

Nursing Management

Nursing Assessment

Most preoperative work, including labs, is done on a preadmission outpatient basis. Ask about bleeding tendencies, because postoperative bleeding is the main concern. Record baseline vital signs for postoperative monitoring; the temperature helps confirm the child has no upper respiratory infection.

Nursing Diagnoses

Based on the assessment data, major nursing diagnoses include risk for aspiration related to impaired swallowing and bleeding at the operative site; acute pain related to inflammation and the surgical procedure; deficient fluid volume related to inadequate oral intake from painful swallowing; and deficient knowledge related to caregivers' understanding of postdischarge home care and complication signs.

Nursing Care Planning and Goals

Goals are to prevent aspiration, relieve pain (especially while swallowing), improve fluid intake, and increase understanding of postdischarge care and possible complications.

Nursing Interventions

To prevent aspiration, position the child partially prone with the head turned to one side until fully awake, encourage expectorating secretions, discourage coughing, and keep the head slightly lower than the chest to facilitate drainage. To relieve pain, apply an ice collar postoperatively, give pain medication as ordered, and keep the caregiver at the bedside; crying irritates the raw throat, so avoid it where possible.

When the child is fully awake, give small amounts of clear fluids or ice chips. Avoid irritating liquids such as orange juice and lemonade, and avoid milk and ice cream products, which cling to the surgical site and make swallowing harder. Record intake and output until adequate oral intake is established. For family teaching, keep the child relatively quiet for a few days, give soft foods and nonirritating liquids at first, teach the family to watch for signs of hemorrhage and notify the provider, and send written instructions and phone numbers home.

Evaluation

Goals are met when aspiration is prevented, pain is relieved (especially while swallowing), fluid intake improves, and the family understands postdischarge care and possible complications.

Documentation Guidelines

Document individual findings including recent antibiotic therapy and upper respiratory infections; current antibiotic therapy; cultural and religious beliefs and expectations; the plan of care; the teaching plan; responses to interventions and teaching; postoperative care; modifications to the plan; and progress toward desired outcomes.