Tonsillectomy

Tonsillectomy and adenoidectomy are the surgical removal of the adenoidal and tonsillar
structures, part of the lymphoid tissue that encircles the pharynx. These are the most
frequently performed surgical procedures in the child. The most common disease processes
that require tonsillectomy and adenoidectomy are obstructive sleep apnea; chronic, persistent
tonsillitis or adenoiditis; and chronic persistent otitis media.

Management
Appropriate antibiotics are given, and the decision is made to perform surgery. Tonsillectomy
and adenoidectomy may be performed together or separately. Debate continues over
indications for and benefits of surgery.

Indications for Tonsillectomy

1.Conservative.
a. Recurrent or persistent tonsillitis with documented
streptococcal infection four times in 1 year.
b. Marked hypertrophy of tonsils, which distorts speech,
causes swallowing difficulties, and causes subsequent
weight loss.
c. Tonsillar malignancy.
d. Diphtheria carrier.
e. Cor pulmonale due to obstruction.
2. Controversial.
a. Peritonsillar abscess or retrotonsillar abscess.
b. Suppurative cervical adenitis with tonsillar focus.
c. Persistent hyperemia of anterior pillars.
d. Enlarged cervical lymph nodes.
Indications for Adenoidectomy
1. Conservative.
a. Adenoid hypertrophy resulting in obstruction of airway leading to hypoxia, pulmonary
hypertension, and cor pulmonale.
b. Hypertrophy with nasal obstruction accompanied by breathing difficulty and severe speech
distortion.
c. Hypertrophy associated with chronic suppurative or serous otitis media and sensorineural or
conductive hearing loss, chronic mastoiditis, or cholesteatoma.
d. Mouth breathing due to hypertrophied adenoids.
2. Controversial.
a. Enlarged adenoids.
b. Chronic otitis media, and no evidence of complications.
Contraindications to Surgery
1. Bleeding or coagulation disorders. 2. Uncontrolled systemic disorders (eg,
diabetes,rheumatic fever, cardiac or renal disease). 3. Child younger than age 4 years, unless
life-threatening situation. 4. Presence of upper respiratory infection in the child or immediate
family. 5. Specific for adenoidectomy—certain palate abnormalities (ie, cleft palate or
submucous cleft palate).

Nursing Assessment
Preoperative Assessment
1. Assess the child’s developmental level. 2. Assess the parents’ and child’s understanding of
the surgical procedure.
3. Assess psychological preparation of the child for hospitalization and surgery.
a. Does the child understand what will happen?
b. Do the parents know the importance of telling the child the truth, and do they have a good
understanding of the procedure?
c. Does the child have preconceived ideas from peers that may pose a threat?
4. Obtain thorough nursing history from the child and parents to gather any pertinent
information that would impact the child’s care.
a. Has the child had a recent infection? It is desirable for the child to be free of respiratory
infection for at least 2 weeks.
b. Has the child recently been exposed to any communicable diseases?
c. Does the child have any loose teeth that may pose the threat of aspiration?
d. Are there any bleeding tendencies in the child or family?
5. Obtain the child’s baseline vital signs along with his height and weight.
6. Assess the child’s hydration status.

Postoperative Assessment
1. Assess respiratory status and pain often.
2. Assess frequently for signs of postoperative bleeding; monitor vital signs as warranted.
3. Assess oral intake.
4. Assess for indications of negative psychological sequelae related to the surgery and
hospitalization.

Immediate post op care:

1. The most comfortable position is prone with the head turned to the side to allow drainage
from the mouth and pharynx.
2. The surgical site is assessed with a light, a mirror, guaze, curved hemostats and a waste basin
3. The oral airway should not be removed unless the pts gag and swallowing reflexes have
returned.
4. The nurse apply ice collar to the neck and a basin and tissues are provided for the
expectoration of blood and mucus.
5. Symptoms of postop complications include fever, throat pain, ear pain, and bleeding.
6. Analgesics such as ibuprofen are administered.
7. If the pt vomit large amounts of dark blood or bright blood at frequent intervals of pluse and
tem rise the nurse notify the physician.
8. Once there is no bleeding, water and ice chips may be given.
9. The pt is refrained from too much talking or coughing because these can produce throat
pain.

Self Care for Patient.

Since the patient will be sent home after surgery because of the short length stay, the patient
ad family members must understand the clinical manifestation of hemorrhage, which usually
occur in the first 12-24hrs. Frank red bleeding is to be reported to the doctor. Alkaline
mouthwash and warm saline solution are useful in coping with thick mucus and halitosis that
may be present after surgery. The nurse should advice the pt that a sore throat, stiff neck, and
vomiting may occur in the first 24hrs. A liquid or semi liquid diet is given such as gelatin. Foods
that are spicy,hot, acidic or rough foods are contraindicated, milk also because of the mucus
removal difficult. The nurse advice the pt about vigorous tooth brushing or gargling bx they can
cause bleeding.

Nursing diagnosis: _Risk for Deficient Fluid Volume related to reduced intake
postoperatively and blood loss

Maintaining Adequate Fluid Volume

1. Assess the child frequently for postoperative bleeding. Check all secretions and emesis for the
presence of fresh blood. These are indications of hemorrhage:
a. Increased pulse.
b. Frequent swallowing while awake and asleep.
c. Pallor.
d. Restlessness.
e. Clearing of throat and vomiting of blood.
f. Continuous slight oozing of blood over a number of
hours.
g. Oozing of blood in back of throat.
2. Have suction equipment, oxygen, and packing material readily available in case of emergency.
3. Provide adequate fluid intake.
a. Give ice cubes 1 to 2 hours after awakening from anesthesia.
b. When vomiting has ceased, cautiously advance to clear liquids.
c. Offer cool fruit juices without pulp at first because they are best tolerated; then offer ice pops and
cool water for the first 12 to 24 hours. Avoid red and brown fluids.
d. There is some debate regarding the intake of milk and ice cream the evening of surgery. It can be
soothing and can reduce swelling; however it coats the mouth and throat, causing the child to clear the
throat more often, which may initiate bleeding.

Nursing diagnosis: Acute Pain related to surgical incision

Improving Comfort
1. Give analgesics as ordered, parenteral or rectally.
2. Rinse the child’s mouth with cool water or alkaline solution.
3. Keep the child and environment free from blood-tinged drainage to help decrease anxiety.
4. Encourage the parents to be with the child when the child awakens. This is the most
important comfort measure the nurse can provide for the child.
5. When the parents must leave, reassure the child that they will return.

Nursing diagnosis: Ineffective Airway Clearance related to pain and effects of

anesthesia

Promoting Effective Airway Clearance

1. Assist the child in maintaining a patent airway by draining secretions and preventing
aspiration of vomitus.
2. Assess the child for signs and symptoms of airway obstruction and respiratory distress
(stridor, drooling, restlessness, agitation, tachypnea, and cyanosis), which may result from
edema or the accumulation of secretions.
a. Place the child prone or semi-prone with his head turned to side while still under the effects
of anesthesia.
b. Allow the child to assume a position of comfort when alert. (The parent may hold the child.)
c. The child may vomit old blood initially. If suctioning is necessary, avoid trauma to the
oropharynx.
d. Remind the child not to cough, clear throat, or blow nose.