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

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

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

2. 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 TONSILS
USUALLY BY VIRUSES 70% TO 80 %
PART OF AN INFECTION OF THE WHOLE UPPER
RESPIRATORY TRACT
BACTERIA LESS THAN 30 %
COMMONEST BACTERIUM STREPTOCOCCUS
PYOGENES
LESS 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 SYMPTOM
Symptoms 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
HERPANGINA
COXSACKIE A VIRUS
VESICULAR RASH IN THE ORAL CAVITY
FEVER ,SORE THROAT MILD
RECOVERY FAST
IMMUNE COMPROMISED
CANDIDA ALBICANS
VERY YOUNG
VERY OLD
PAINFUL DYSPHAGIA
WHITISH MEMBRANE COVERS THE TONSILS AND PHARYNX


BACTERIAL
TONSILLITIS
VIRAL 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:
1. Recurrent or chronic infection that have not responded to
antibiotic therapy.
2. Hypertrophy of the tonsils with risk of airway obstruction.
3. Peritonsillar abscess or quinsy.
4. Repeated attacks of purulents otitis media.
5. Tonsil malignancy.


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

ANTIBIOTICS ?
- ONLY WHEN BACTERIAL INFECTION IS
SUSPECTED
TYPE 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

1. BLEEDING

2. DEHYDRATION

PROCEDURE

Two removed tonsils

PROCEDURE

Throat 1 day after a tonsillectomy.










Throat some days after
tonsillectomy


COMPLICATIONS
Untreated tonsils:

1. 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.

-POOR ORAL INTAKE
- REHYDRATION
- IV ANTIBIOTICS

COMPLICATIONS PRESENT / SUSPECTED

TONSILLECTOMY INDICATED
- RECURRENT INFECTION - > 4 ATTACKS IN ONE
YEAR
- RECURRENT PERITONSILLAR ABSCESS 2
ND

ATTACK
- RECURRENT TONSILLITIS IN PATIENTS WITH
RHEUMATIC FEVER OR GLOMERULONEPHRITIS


NURSING CARE PLAN (Assessment)

Name of patient:
MS T
Medical Diagnosis:
CHRONIC TONSILITIS
Past Medical History
(Where relevant)
(Med./Surg./Obs./Gynae/Pa
ed):
Past Medical History: NIL

LSCS (Lower Segmental
Caesarian Section) year
1993

Date of admission:
2 NOVEMBER 2009
Present History:
Complain of sore throat once
a month.
Elective admission for
tonsillectomy under General
Anaesthesia on 4 November
2009.
Pain History: Yes/No
Head 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: 126/77mmHg
PR: 78/min
RR: 18/min
Temp: 36.6C
Pain score : 0
Urine for Albumin & Glucose
: Negatif

Time: 1545 HOURS
Registration number:
730912-13-6264
Mode of admission:
Walking
Wheelchair
Stretcher Social history:
Married having 3 children.
Jururawat Masyarakat at
Kapit Hospital.
Non alcoholic and non
smoker.
Stayed with family.
Carried
Accompanied by:
JAMES LEO (COUSIN)
Allergies
Drugs: NIL
Food: NIL
Other: NIL
Special information: NIL
Signature of Admitting
Nurse:
( CHOP AND SIGN )

Referred by:
KAPIT HOSPITAL
Name of patent: MS T
Reg. No: 730912-13-6264
Date
Time
Nursing Problem Goal Nursing Action Evaluation
02/11/09
1545 hrs
1) 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 & SIGN
STAFF NURSE
Patient verbalised
less anxiety.
Achieved on
03/11/2009 @
1600 hours
CHOP & SIGN
STAFF NURSE
Date
Time
Nursing Problem Goal Nursing Action Evaluation
04/11/09
1210
hrs
2) Pain in
swallowing
Patient will
experience
less pain .
1. Monitor and record pain
score finding
2. 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 & SIGN
STAFF NURSE
No pain in
swallowing
noted.
Achieved on
07/11/2009@
1210 hours
CHOP & SIGN
STAFF NURSE
Name of patent: MS T
Reg. No: 730912-13-6264

Date
Time
Nursing
Problem
Goal Nursing Action Evaluation
04/11/0
9
1210
hrs
3) 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 & SIGN
STAFF NURSE
No bleeding
reported.
Achieved on
05/11/2009
@ 0700
hours
CHOP &
SIGN
STAFF
NURSE
Name of patent: MS T
Reg. No: 730912-13-6264

Date
Time
Nursing
Problem
Goal Nursing Action Evaluation
04/11/
09
1210
hrs
4) Risk factor
for nausea and
vomiting .
Patient
will
experienc
e 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 & SIGN
STAFF NURSE
No nausea
& vomiting
noted.
Achieved on
05/11/2009
@ 0900
hours
CHOP &
SIGN
STAFF
NURSE
Name of patent: MS T
Reg. No: 730912-13-6264


Clinical Notes

02/11/09 @ 1600hrs
Patient 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 & SIGN
02/11/09 @ 2000hrs
Patient comfortable. Blood result for back ,due for reviewed.. Tolerating
orally well . Vital signs stable.BP P T Pain score:
CHOP & SIGN
02-03/11/09 a@ 0600hrs
Patient 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 SIBU
MS T
730912-13-6264
Clinical Notes
03/11/09 @ 1300hrs
Patient . Blood investigation was seen by doctor. Vital signs stable. BP P
R T. Pain score : Taking orally well.
CHOP & SIGN
03/11/09 @ 1930hrs
Patient 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 & SIGN
03-04/11/09 @ 0610hrs
Patient condition stable. Able to sleep well . Nil per orally maintained. IV line
patent and no pain noted . Vital signs stable. BP 120/70 pr 80
Tempt- 36.9c. Pain score
CHOP & SIGN
04/11/09 @ 0730hrs
Patient was proceed to OT . Vital signs taken .NPO maintained.
CHOP & SIGN
ENT & EYE WARD HOSPITAL SIBU
MS T
730912-13-6264
Clinical Notes
04/11/09 @ 1200hrs
Patient 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
. 1
st
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 & SIGN
04/11/09 @ 2000hrs
Patient 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 SIBU
MS T
730912-13-6264
Clinical Notes
04-05/11/09
0030hrs
Ice 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 &
SIGN
0600hrs
Patient 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 @ 1300hrs
Patient 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 & SIGN
05/11/09 @ 1930hrs
Resting. 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 SIBU
MS T
730912-13-6264
Clinical Notes
05-06/11/09 @ 0615hrs
Stable. Able to sleep at night. Medication crushed and served. Pain score -
1. Tolerating orally well Vital signs stable.
CHOP & SIGN
06/11/09@ 1315hrs
Patient 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 & SIGN
06/11/09 @ 2015hrs
Resting. Took dinner. C/o mild pain on swallowing. No bleeding noted. Vital
signs stable.
CHOP & SIGN
06-07/11/09 @ 0620hrs
Stable. 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 SIBU
MS T
730912-13-6264
Clinical Notes
07/11/09 @ 0800hrs
Seen 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
ENT & EYE WARD HOSPITAL SIBU
MS T
730912-13-6264
DISCHARGED SUMARRY
Date of Discharge: 7 NOVEMBER 2009
Discharged by: DR SIA KIAN JOO
Follow 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 up
To 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) SURGERY
Month Numerator (N) Denominator (D) Rate (N/D)
January
0 2 0%
February
1 3 33.3%
March
0 7 0%
April
0 3 0%
May
0 6 0%
June
0 1 0%
Sub-total (Jan.-
June)
1 22 4.5%
July
0 2 0%
August 0 0
0%
September 0 1
0%
October 0 2
0%
November 0 2
0%
December
Indicator:No 4 Occurrence of Post-Tonsillectomy Haemorrhage Standard
<5% 1000 operation
Thank you for your
attention
SALAM SATU
MALAYSIA