About
Removal of the tonsils, usually as a result of recurrent and increased frequency of tonsillitis, infection, swelling of the tonsils.
Assess
Airway, vital signs, throat pain, bleeding.
Complications
Hemorrhage, Infection.
Diagnosis
Pain related to actual tissue damage.
Knowledge deficit related to surgical procedure.
Risk for infection related to surgical intervention.
Impaired airway clearance related to edema.
Goals
The client will be able to state understanding of pre-, intra-, and post-operative activities.
The client will be able to identify signs and symptoms of complications.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.
The client will maintain a patent airway.
Interventions
Assess vital signs post operatively every 15 minutes X's 2, every 30 minutes X's 2, every 1 hour X's 2, than every four hours.
Assess airway, pulse oximetry, lung sounds, incision frequently post-operatively.
Monitor for any evidence of bleeding which could indicate potential complications.
Teach client to refrain from activities that put pressure on the incision sites.
Keep client NPO until gag reflex has returned.
Monitor for aspiration and implement aspiration precautions post-operatively.
Maintain suction equipment at the bedside and perform suctioning frequently to remove excess secretions.
Administer analgesics, antibiotics as indicated by physician.
Teach client signs and symptoms of complications and when to seek immediate follow-up.
Teach client to avoid heavy-lifting or exertion for at least ten days post-operatively.
Teach client to use humidifier post-operatively in the home setting.
Teach client components of a soft, bland diet that should be followed post-operatively until follow-up.
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