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Running Head: T&A SURGERY 1 Tonsillectomy and Adenoidectomy Angeline M. Barbato Kent State University College of Nursing
Running Head: T&A SURGERY 1
Tonsillectomy and Adenoidectomy
Angeline M. Barbato
Kent State University College of Nursing
Running Head: T&A SURGERY 2
Abstract
A three year old child was examined for two days following a tonsillectomy and adenoidectomy.
Children who have had this type of surgery experience pain symptoms that must be managed in
order for successful treatment to occur. A main focus of T&A clinical therapy involves pain
management as will be discussed in this paper. Maintaining the child’s airway, by preventing
obstruction, is of focus immediately following surgery. A common reason behind
rehospitalization for T&A’s is dehydration. Pain, airway, and dehydration correlate together to
form a basic care plan for the child. (Ball, Binder, and Cowen, 2010).
Keywords: tonsillectomy, adenoidectomy, pain management, airway obstruction,
dehydration
Running Head: T&A SURGERY 3
Tonsillectomy and Adenoidectomy Nursing Process Paper N30020
Description of Child and Family
Patient M.H. is a 41 month old African American female admitted June 15, 2010 to
Aultman Hospital in Canton, Ohio. M.H. was born on January 8, 2007, she has no known
allergies, and is on a full clear liquid diet. Her mother accompanied her during her entire stay.
M.H. has a history of snoring, apnea, bronchitis, and apraxia. As a result of her history, a
Tonsillectomy and Adenoidectomy was scheduled to take place on June 15, 2010.
M.H. has had one previous hospitalization experience prior to her Tonsillectomy and
Adenoidectomy. In March of 2009, she was hospitalized for one month for viral meningitis.
She was admitted because of seizures. While hospitalized, the healthcare team could not
correctly diagnose M.H. She reached a point where she was unable to sit up in bed, feed herself,
or speak. During hospitalization, M.H. developed Apraxia. Bowen, Hesketh, and Mumby
(2006) stated that Apraxia is a communication impairment that can occur as a result to brain
injury. Individuals suffering from apraxia have difficulty forming speech sounds which are
understandable by others. (Bowen, Hesketh, and Mumby, 2006). The nurse caring for M.H.
whom reported off to me stated that, “M.H. doesn’t speak well and what she says is difficult to
understand.” This speech impairment was due to her previous diagnosis of viral meningitis in
which the brain is affected. After her hospital stay, M.H. was referred to a physical therapist, an
occupational therapist, and a speech therapist to get her back on a normal course for her
developmental age.
M.H. lives in Canton, Ohio with her mother, five year old brother, and uncle. The mother
is currently a student at Brown Mackie College and is studying Medical Coding and Billing. Her
mother is in her last class before she is eligible to graduate. Following graduation, her mother
Running Head: T&A SURGERY 4
plans to enroll at Stark State College for nursing. M.H.’s family is covered by health insurance.
When performing her morning assessment, M.H.’s vitals were: Blood pressure 104/53,
temperature 97.3 F, pulse 114, respirations 32, and her pulse oximetry was 100% on room air.
Developmental Assessment
M.H. was 96.70 cm. tall with a BMA of 20.43 m^2. M.H. is three years old, which
places her as a preschool aged child. A preschool child is between three and six years old. Erik
Erikson describes preschool aged children’s psychosocial stage as autonomy versus shame and
doubt. During this period of life, the child’s independence greatly increases. Children have now
developed the ability to control body excretions. They now also express the ability to say no and
display direct motor activity. (Ball et al. , 2010). According to M.H.’s mother, she was potty
trained prior to her hospitalization in March of 2009. During her hospital stay, she had
developed incontinence and her potty training was put on hold. Now she is currently potty
trained again. After receiving her vitals, I witnessed M.H. wake her mother when she needed to
use the restroom. This shows that when considering body excretion control, M.H. is within
normal limits for her developmental age. I was also able to witness M.H. repeatedly state “no”
when she did not want to take a drink of her juice which is also a normal finding for her
developmental age.
During this stage of development, children learn a great deal of social skills through
socialization I childcare settings and schools. (Ball et al., 2010). I was told by M.H’s mother
that she was not yet enrolled in a preschool program due to her previous hospitalizations. I was
able to interact with M.H. both alone and with her mother present. Despite the fact that she is
not enrolled in a preschool program, her social skills seem to be on track. She cooperatively
interacted with me, her brother, and other nurses involved in her care.
Running Head: T&A SURGERY 5
At this point of a child’s maturity, language skills should be well developed as evidenced
by the child’s ability to understand and speak clearly. (Ball et al., 2010). Ball et al. (2010) noted
that “vocabulary grows to over 2000 words”. By this point, children are normally able to use all
parts of their speech to form several words. (Ball et al, 2010). M.H. was capable of
understanding speech but manifested difficulties with expressing speech which was acquired
from her previous history of viral meningitis. I noticed that M.H. spoke minimal words and was
complicated to understand. The mother stated that M.H. went through a process of hearing tests
to rule out a hearing impairment. The hearing exams came back normal, proving M.H. is able to
hear what is being said. Despite the apparent speech apraxia, M.H. was still able to establish
communication with me and the other nurses. If she was in pain, I witnessed her grabbing her
throat. She also expressed this pain nonverbally through uncomfortable facial expressions and
outbursts of crying. After administering her pain medication, I was able to hear her speak more
often. Her words became slurred and I had to gain clarity through her mother.
When considering physical growth related to a child classified as preschool aged, M.H.
presented as normal. During the preschool ages, children grow steadily and at a slower pace.
(Ball et al., 2010). The majority of the child’s growth takes place in the long bones such as the
arms and legs. (Ball et al., 2010). The once chubby child becomes taller and thinner in
appearance. The more physical tasks develop further in this stage. These gross motor skills
were apparent in M.H.’s ability to pull herself up in a chair and pulling the wagon in the
playroom. Her fine motor skills included helping dress herself, using a spoon, and lifting her cup
to her mouth. During her morning care, her mother did the majority of her hygienic tasks with
some assistance by M.H. This is a normal developmental milestone for preschool aged children.
(Ball et al., 2010).
Running Head: T&A SURGERY 6
The preschool child experiences play in a new way involving the interaction with others.
This was demonstrated as M.H. played a game with bubbles which included me. Once her
brother arrived, she also interacted with him in the play room by building blocks. This is
classified as associative play. (Ball et al., 2010). This type of play is characterized by children
playing and interacting with other individuals. (Ball et al., 2010). Children classified as
preschool aged also demonstrate increased manual dexterity which can be shown through
drawing or playing with blocks. (Ball et al., 2010). M.H. played with building blocks for a short
period of time during our trip to the playroom.
Nutritional Assessment
M.H. ate poorly during hospitalization due to her sore throat secondary to her T&A. She
was ordered to be on a full liquid diet. As a result, for breakfast she was brought apple juice and
some jello. She refused both the juice and the jello prior to her pain medication administration.
We then attempted to get her to take some bites of her ice drink which was simply a Popsicle,
ice, and Sierra Mist mixed together. Once her pain medication provided relief, it was much
easier to encourage her to drink and maintain her fluids.
M.H.’s mother stated, “At home, she is normally a picky eater.” More often, she eats
smaller snacks throughout the day as opposed to a set breakfast, lunch, and dinner. For
breakfast, she usually eats cereal, Cheerios being her favorite. For lunch and dinner, M.H. sticks
to simple sandwiches, but she loves McDonalds. I asked her what her favorite food was and she
responded, “ice cream”. Throughout the day, she also enjoys drinking juice. As discussed by
Ball et al., (2010) mealtimes for preschool children are a more social event. Typically at meal
times, M.H. is joined by her mother, brother, and uncle. Her mother mentioned, “She usually
cleans her plate.” At this age group, it is also helpful to instruct the child to participate in food
Running Head: T&A SURGERY 7
preparation to offer them more responsibilities as well as independence through choices. (Ball et
al., 2010). M.H. is a very active little girl. I was told by her mother that she is always running
around the house and playing with her older brother. I was able to talk to her about some
summertime activities she enjoyed. M.H. mentioned that she loves to go swimming and play
hide and seek around the house.
Pathophysiology
M.H. was previously diagnosed with adenotonsillar hypertrophy/sleep apnea. She has
experienced multiple tonsillitis attacks. Ball et al., (2010) noted that “Tonsillitis is an infection
or inflammation (hypertrophy) of the palatine tonsils” (p. 830). Her adenoids, which were also
affected, are lymphatic tissue located on the posterior pharyngeal wall sometimes referred to as
the pharyngeal tonsils. (Ball et al., 2010). Reviewing M.H.’s history, a Tonsillectomy and
Adenoidectomy was developed as her course of treatment. Supporting evidence included her
recurrent tonsillitis infections, her history of snoring, and her history of sleep apnea.
Ball et al., (2010) explained that tonsillitis and adenoiditis may be caused by either a
virus or bacterium. The tonsils are in fact that primary site for infection. (Ball et al., 2010).
Symptoms of these infections include frequent throat infections with breathing and swallowing
difficulties, breathing through the mouth continuously, dry and irritated mucous membranes,
adenoiditis characterized by nasal stuffiness, discharge, postnasal drip, and excessive clearing of
the throat. (Ball et al., 2010). Symptomatic treatment includes antibiotics first, followed by
surgery. (Ball et al., 2010). In M.H.’s case, surgery would be beneficial due to her persistent
problems. When I was able to assess M.H., she had already gone through surgery. In looking at
her throat, redness and swelling were present. I noticed swelling around her neck which can be
expected following surgery. I observed that she tried to breathe mainly through her mouth. I
Running Head: T&A SURGERY 8
was also able to hear present nasal stuffiness upon assessment. She had slight clear nasal
drainage. I also noted excessive drooling. This was related to M.H.’s fear of swallowing even
her own saliva. Prior to surgery, M.H. was diagnosed by her pediatrician based on physical
inspection of her throat. Her mother stated, “Her tonsils have been large for a while.” With the
clinical manifestations and her history of apnea, surgery was her decided course of treatment.
Treatment
The treatment of tonsillitis and adenoiditis includes symptomatic treatment, surgical
treatment, supportive care, and antibiotics. (Ball et al., 2010). Symptomatic treatment is aimed
towards providing maximum pain relief for the child to maintain comfort. Following M.H.’s
surgery, we provided a large variety of these interventions. Acetaminophen administration is a
common pain management drug prescribed after T&A’s. M.H. was prescribed Tylenol 300mg
every six hours as needed. When we first recognized evidence of pain, we quickly administered
her recommended dose. Nonpharamacological methods for pain relief along with pain
medications are very helpful. These include ingesting cool, nonacidic fluids, ingesting soft
foods, providing ice chips or frozen juice pops, humidification, chewing gum, gargling salt
water, and providing rest periods. (Ball et al., 2010). Our main treatment goal for the morning
was to initiate pain control methods to ensure she was receiving adequate fluid intake. Braun,
Crandall, Lammers, Senders, and Savedra (2008) noted that “children’s pain intensity versus pre-
operative education regarding the importance of drinking may likely be more influential in
determining the amount of fluids children drink post-operatively” (p. 1530). This provides a
better understanding towards the relationship between a child’s pain level and the amount of
fluids they will take in after surgery. Along with M.H.’s Acetaminophen dose, we encouraged a
flavored ice drink, jello, and cold juice to relieve some of the pain M.H. was experiencing.
Running Head: T&A SURGERY 9
Prior to surgical intervention, it is important for we as nurses to prepare both the family
and the child for surgery. This involved fully explaining the procedure to M.H. and her mother.
In preschool aged children, it is also helpful to provide teaching methods through use of a doll
and by allowing them to touch any equipment that is going to be used during their surgery. (Ball
et al., 2010). The parents should be informed of the possibility that following a T&A, the child
may have to stay overnight. In M.H.’s case, she was admitted onto the pediatric floor for
observation. Before performing this surgery, it is crucial to ensure the child has been free of sore
throat, fever, or an upper respiratory infection one week prior. (Ball et al., 2010). According to
Ball et al. (2010), the child should not be given any medication that may alter bleeding time two
weeks before the scheduled surgery such as Aspirin or Ibuprofen.
During M.H.’s stay, I was able to interpret much of this data into my care plan. As I have
mentioned, a main priority is pain management to aid in the reassurance that the child is taking in
adequate fluids. I was able to administer her Acetaminophen prescription as well as provide
nonpharmacological methods. Before a child with a T&A is discharged from the facility, proper
parent education is essential. This is involves teaching pain management, fluid and nutrition
intake, activity restrictions, and possible post-operative complications. (Ball et al., 2010). As
stated by Ball et al. (2010), it is normal for a child following a T&A to experience throat pain for
seven to ten days. Therefore, the parent should be informed that throat pain as a symptom is
normal. Before M.H. was discharged, we emphasized the importance of fluid intake
management to her mother. She was also given a list of foods that were acceptable for M.H. to
eat. M.H. was prescribed the antibiotic Amoxicillin after discharge. When administering
antibiotics, the parents should be instructed on the proper dose, route, and time of administration.
Running Head: T&A SURGERY 10
(Ball et al., 2010). Ball et al. (2010), also emphasizes the importance of instructing the parents
on full completion of the antibiotic therapy.
Medications
M.H. received oral fluids and medications. Before her surgery, she was prescribed
Zofran at 2mg IV push every eight hours. She was ordered this to prevent nausea she may
experience following surgery. This medication is an antiemetic which decreases the incidence
and severity of nausea and vomiting. The action of this medication is to block the effects of
serotonin at 5-HT3. The recommended dose for a child one to twelve years old is 0.1 mg/kg.
M.H. weighs 19.10 kg. To calculate her dose, 0.1 mg/kg is calculated by her weight of 19.10 kg.
M.H.’s dose of 2 mg is just slightly higher than her recommended safe dose.
19.10 kg x 0.1 mg/kg= 1.91 mg
M.H. was prescribed Morphine 0.4775 mg every ten minutes as needed immediately
following her surgery. She was ordered this to help with pain control following surgery.
Morphine is an opioid analgesic. The action of this medicine is it binds to opiate receptors in the
central nervous system and alters the perception of a painful stimulus. The recommended safe
dose for a child M.H.’s age is 0.1-0.2 mg/kg/dose every two to four hours with the maximum
dose being 15 mg. To calculate a safe range for M.H., her weight of 19.10 kg is multiplied by
0.1 mg and then 0.2 mg. Her prescribed dose is lower that her safe range for her current weight.
19.01 kg x 0.1 mg/kg/dose= 1.91 mg
19.10 kg x 0.2 mg/kg/dose= 3.82 mg
During M.H.’s hospitalization, she was prescribed Tylenol 300 mg every six hours as
needed. Tylenol is an antipyretic and a nonopioid analgesic. She was ordered this for pain
management to fever prevention due to the effects of her surgery. It acts by inhibiting the
Running Head: T&A SURGERY 11
synthesis of prostaglandins that serve as mediators of pain and fever primarily in the central
nervous system. The recommended safe dose for a child M.H.’s age is 10-15 mg/kg/dose every
four to six hours as needed. To calculate M.H.’s safe dose range, her weight of 19.10 kg is
multiplied by 10 mg and then by 15 mg. Her prescribed dose was slightly higher than her safe
dose. We were also told to administer this medication closer to every four hours despite the
doctor’s order. This was due to her increase in apparent pain.
19.01 kg x 10 mg/kg/dose= 191 mg
19.10 kg x 15 mg/kg/dose= 286.5 mg
A final medication that M.H. was prescribed was given to her mother upon discharge.
She was given a prescription for Amoxicillin, which is an anti-infective. She was ordered this to
prevent the occurrence of infection. Amoxicillin works by binding to the bacterial cell wall,
causing cell death. This creates a bactericidal action. Her order read Amoxicillin 400 mg twice
a day for five days. The recommended safe dose for a child M.H.’s age is 25-50 mg/kg/day
divided three times a day. Her safe dose is calculated by multiplying her weight of 19.10 kg by
25 mg and 50 mg.
19.10 kg x 25 mg/kg/day= 477.5 mg
19.01 kg x 50 mg/kg/day= 955 mg
Medication Drug
Classification
Action Side Effects Safe
Pediatric
Dose Zofran Antiemetic, 5-
HT3 antagonists
-Blocks the
effects of
serotonin at 5-
HT3
-Receptor sites
(selective
antagonist)
located in vagal
nerve terminals
-Headache,
dizziness,
drowsiness, fatigue,
weakness,
constipation,
diarrhea, abdominal
pain, dry mouth,
increased liver
enzymes,
0.1 mg/kg
Running Head: T&A SURGERY 12
and the
chemoreceptor
trigger zone in
the CNS
-Decreased
incidence and
severity of
nausea and
vomiting
following
surgery
extrapyramidal
reactions
Morphine Opiod analgesics,
Opiod agonists
-Binds to opiate
receptors in the
CNS
- Alters the
perception of
and response to
painful stimuli
while producing
generalized CNS
depression
- Decrease in
severity of pain
-Confusion,
sedation, dizziness,
dysphoria, euphoria,
floating feeling,
hallucinations,
headache, unusual
dreams, blurred
vision, diplopia,
respiratory
depression,
hypotension,
bradycardia,
constipation, nausea,
vomiting, urinary
retention, flushing,
itching, sweating,
physical
dependence,
psychological
dependence,
tolerance
0.1-0.2
mg/kg/dose
q2-4h:
Maximum
dose= 15 mg
Tylenol
Antipyretics,
Nonopiod
Analgesic
-Inhibits
synthesis of
prostaglandins
that may serve
as mediators of
pain and fever,
primarily in the
CNS
-Produces
analgesia and
antipyresis
-hepatic failure,
hepatotoxicity, renal
failure, neutropenia,
pancytopenia,
leucopenia, rash,
urticaria
10-15
mg/kg/dose
q4-6h as
needed
Amoxicillin Anti-infectives, -Binds to -Seizures, 25-50
Running Head: T&A SURGERY 13
Antiulcer Agents bacterial cell
wall, causing
cell death
-Bactericidal
action, spectrum
broader than
penicillins
pseudomembranous
colitis, diarrhea,
nausea, vomiting,
elevated liver
enzymes, rashes,
urticaria, blood
dyscrasias, allergic
reactions, serum
sickness,
superinfection
mg/kg/day
divided three
times a day
Physical Assessment
The focused assessment for M.H.’s physical assessment would include a pain assessment,
monitoring her airway, and monitoring her fluid status to prevent dehydration. The first step we
took upon entering M.H.’s room was inspecting her throat with the use of a pen light to monitor
for swelling which can obstruct the airway. This is included in a normal mouth assessment.
When evaluating the mouth, use a bright light and a tongue blade to inspect the mucous
membranes, teeth, gums, and the tonsils. (Craven and Hirnle, 2009). M.H.’s throat was slightly
swollen, red, and had a small amount of white exudate present. It is also important to perform a
respiratory assessment through inspection, palpation, auscultation, and percussion of the lungs.
(Craven and Hirnle, 2009). Auscultating the lung sounds ensures there is no fluid in the lungs
related to the T&A and her surgery. M.H.’s lung sounds were clear to auscultation. Her
prescribed Morphine may cause a decreased respiratory rate so monitoring her respirations is
vital. Bowel sounds should also be assessed through auscultation and percussion. The effects of
anesthesia, her medications, and her liquid diet may alter her bowel sounds. It is important to
make sure bowel sounds are present. Her bowel sounds were present in all four quadrants, and
she was not experiencing any abdominal pain. Monitoring for signs of dehydration are also
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crucial related to her limited fluid intake. This is performed by assessing skin turgor, her urine
output, sunken eyes, texture and temperature of her skin. (Ball et al., 2010).
Lab Values/Diagnostic Tests
M.H. did not have any labs drawn up prior to or following her T&A. She also did not
have any diagnostic tests performed. I found this to be surprising. I assumed blood work should
be taken prior to a surgical procedure to ensure M.H. was free from infection, but this was not
the case. Perhaps this is related to the now very shortened stays of post-operative tonsillectomy
and adenoidectomy patients. (Ball et al., 2010).
Normal Growth/ Normal Development
The child’s growth would not be affected by this condition. As discussed by Ball et al.,
(2010) T&A care is relatively simple and children experiencing the procedure are remaining in
the hospital for a much shorter time period than previously. Since the hospital stay is short,
M.H. is at minimal risk for regression of development such as potty training. Since M.H.’s
mother remained with her in the hospital for her stay, she was kept on her normal routine.
Therefore, M.H.’s growth and development would not be affected in the future.
Nursing Diagnosis
The client has acute pain related to inflammation of the pharynx secondary to surgery.
The client possesses the following characteristics: difficulty swallowing, a reddened and swollen
throat, refusal to drink, full liquid diet, prescribed Morphine and Acetaminophen, and holding
her throat to express pain. These symptoms for M.H. are present because of her post-operative
T&A clinical manifestations as discussed in Ball et al. Pain management is of top priority so that
the child is able to drink adequate amounts of fluids. Newcomb, Shaffer, Smith, and Sundberg
(2009) noted that “lack of pain management can lead to delays in children taking orals fluids, a
Running Head: T&A SURGERY 15
requirement for discharge” (p. 86). A main reason for rehospitalization following a T&A is
dehydration. (Ball et al., 2010). The client will be unable and unwilling to drink these fluids
comfortably if she is experiencing pain in her throat. Newcomb et al. (2008) used statistics to
conclude that pain assessments should be recorded at thirty to forty-five minute intervals with
frequent reassessment.
Diagnosis
Statement:
Acute Pain
Related to: inflammation of the
pharynx secondary to
surgery.
Supporting Data
(AEB):
Full clear liquid
diet
Ice application
Prescribed
Tylenol
Pain Assessment
q2h
M.H. Held throat
and expressed
fear of
swallowing.
Goals
Short Term Goal: The client will
express decreased
pain symptoms
before lunch time
AEB drinking fluids
before discharge.
Long Term Goal: The client will be
free of sore throat in
10 days.
Evaluation:
The short term goal
was met. The client
was able to drink the
required amount of 2
ounces of fluid in
order to be
discharged. Prior to
pain medication
administration, she
was unable to
swallow. After
administering
Tylenol, she showed
improved signs of
pain within 15
minutes.
Nursing
Interventions
#1. Administer
prescribed pain
medication q4-6h
prn.
#2. Apply an ice
collar around the
child’s neck when
pain symptoms
develop.
#3. Encourage the
child to drink
adequate cool
liquids at all times.
#4. Avoid citrus
juices for 7 days
post-operatively.
#5. Teach mother
about the
importance of pain
Rationales with
References
(EBP Citation)
#1. Administering
pain medications
helps to alleviate pain
symptoms and
encourages the child
to take in fluids. (Ball
et al, 2010).
#2. Ice application
helps to control
bleeding related to
surgery by allowing
vasoconstriction. (Ball
et al, 2010).
#3. Cool fluids reduce
spasms in the muscles
surrounding the
throat. (Ball et al,
2010).
#4. Citrus juices may
produce a burning
sensation of the
throat. (Ball et al,
2010).
#5. Pain management
allows the child to
swallow without
Running Head: T&A SURGERY 16
The long term goal
was not yet met. The
client was
discharged on the
first post-operative
day. It will be
important to
maintain pain
management through
the interventions in
order to ensure she
will be free from
sore throat pain in 10
days.
management and
how to relieve
child’s throat pain
prior to discharge.
#6. Encourage
ingestion of soft
foods such as
gelatin, applesauce,
frozen juice pops,
and mashed potatoes
as tolerated.
#7. Assess the
child’s amount of
pain before and 30-
60 minutes after
analgesia is
administered to
ensure pain relief.
# 8. Inform mother
that ear pain,
especially when
swallowing, may
occur between 4 and
8 days post-
operatively.
difficulty. (Craven
and Hirnle, 2009).
#6. Soft foods are
easily ingested by the
child to maintain
nutritional status and
adequate hydration.
(Ball et al, 2010).
# 7. The child’s pain
rating is the best
indicator of pain
relief. Maintenance of
pain control requires
less analgesia than
treating each acute
pain episode. (Ball et
al, 2010).
#8. Ear pain following
a Tonsillectomy and
Adenoidectomy is a
result of referred pain
from the tonsillar
area, but does not
indicate an ear
infection. (Ball et al,
2010).
The client has a risk for deficient fluid volume related to decreased fluid intake secondary
to pain on swallowing. The client possesses the following characteristics: held her hand over her
throat to communicate she was in pain, held liquids in her mouth due to her fear of swallowing,
full liquid diet, mother stating, “she has only taken a few sips of her drink”, refusal of her ice
drink, and loss of intravenous access in the evening of June 15, 2010. Dehydration is very
Running Head: T&A SURGERY 17
common in post-operative T&A children. Black and Hawk (2009) noted that “dehydration is
loss of water from the extracellular fluid volume; loss is from the vascular and interstitial fluids”
(p. 127). M.H. was uncooperative when it came to drinking her needed fluids. She was
instructed to drink two ounces of fluids before being allowed to be discharged. During report,
the doctor mentioned, “if M.H. is not drinking by 1400, her IV is going to have to be restarted.”
Since her care was to be received at home, it is crucial for her mother do understand the
possibilities of dehydration and what she can do to prevent it from occurring.
Diagnosis
Statement:
Risk for Deficient Fluid
Volume
Related To: decreased
fluid intake secondary
to pain on swallowing.
Supporting Data
(AEB):
M.H. held her
hand over her
throat to
communicate
she was in pain.
M.H. held
liquids in her
mouth and
refused to
swallow related
to pain.
Full liquid diet
Mother and
nurse stated
Goal(s)
Short Term Goal: The client will
exhibit adequate
hydration while in
the hospital by
drinking 2 ounces
prior to discharge.
Long Term Goal: The client’s mother
will seek health care
if signs and
symptoms of
dehydration are
present.
Evaluation:
The short term goal
was met. The client
was able to drink the
required 2 ounces of
liquid prior to
discharge making it
so her IV did not
have to be
Nursing
Interventions
#1. Administer
prescribed pain
medication q4h to
allow ease of
swallowing.
#2. Monitor daily
weights while the
child is in the
hospital.
#3. Monitor Intake
and Output every
shift. Offer fluids that
are desired hourly to
ensure M.H. is
drinking.
#4. Provide the
mother with a list of
foods or fluids, such
as ice cream or
pudding, to offer the
child hourly.
Rationales With
References
(EBP Citation)
#1. Pain management
allows child to
swallow without
difficulty. (Ball et al,
2010).
#2. A major indicator
to the degree of
dehydration is percent
of weight loss. (Ball
et al, 2010).
#3. Monitoring of
intake and output will
help to evaluate
hydration status early.
(Ball et al, 2010).
#4. Providing options
the child may like
ensures adequate
fluid intake. (Ball et
al, 2010).
Running Head: T&A SURGERY 18
“M.H. has only
taken a few sips
of her drink.”
M.H refused ice
drink
M.H.’s IV fell
out sometime in
the evening of 6-
15-10.
reinserted.
The long term goal
was not yet met.
Education prior to
discharge for the
mother is crucial to
prevent dehydration
and the correlating
symptoms from
occurring. By
educating the
mother, I am helping
to ensure the long
term goal is too met.
#5. Assess heart rate,
postural blood
pressure, skin turgor,
and capillary refill
time q2h.
#6. Teach mother to
recognize symptoms
of dehydration such as
lethargy, poor skin
turgor, sunken eyes,
or absent tears.
#7. Reward the child
by taking her to the
playroom after she
takes a sip of her
drink.
#8. Instruct the
mother on proper pain
medication
administration, route,
and dosage prior to
discharge.
#5. Frequent
assessment of
hydration status
facilitates rapid
intervention and
evaluation of the
effectiveness of fluid
replacement therapy.
(Ball et al, 2010).
#6. Early recognition
and intervention to
prevent severe
dehydration from
occurring. (Ball et al,
2010).
#7. Rewarding the
child reinforces their
behavior and makes
the want to continue
to take in fluids. (Ball
et al, 2010).
#8. The parent is
responsible for
providing pain
management so the
child is able to
swallow without
difficulty. Correct
pain medication
administration
technique by the
mother is important
for the safety of the
child. (Ball et al,
2010).
Running Head: T&A SURGERY 19
Nursing Action (Implementation)
I was able to perform many of the interventions stated while caring for M.H. When I first
entered her room, it was clear to me that she was in pain and was fearful of swallowing. I
assessed her pain level and then exited the room to make her an ice drink out of Popsicles, ice,
and Sierra Mist. I offered her a few bites and she seemed to enjoy it, however I found later that
she was holding the liquid in her mouth without swallowing it. I then checked how long ago her
last dose of Tylenol was administered. She was due for another dose after her vital signs. I was
able to draw up her medication and administer it which I found to be fairly tricky at times since it
was clear she was nervous. We discovered the best way to do this way by having her sit on her
mother’s lap as her mother helped to keep her mouth open. I had to administer small amounts of
this liquid medicine at a time to prevent aspiration. Within minutes after her medication
administration, it was obvious she was feeling better. To reward her for taking her medicine, we
gave her a bottle of bubbles which she played with for the majority of the day after that. After
that, her and her mother’s breakfast came so I left the room and reminded the mother to keep her
throat moist by providing her with liquids. After the mother was done eating, I came back into
the room to offer M.H. more of her drink. It was ordered that she must drink two ounces of
fluids before discharge. To help with this process, we filled exactly two ounces of fluid in a cup
and made a little game out of it. M.H. would blow bubbles and I would pop them. I would then
periodically ask her to take a sip of her juice which she willingly did. We then switched up roles
and I would blow the bubbles for her to pop which she enjoyed. I continuously asked her to take
a drink of her juice until eventually the whole two ounces of fluid was gone and she was allowed
to be discharged. Before discharge, I printed off some information on Amoxicillin for her
mother to take home with her. I also provided her with a pamphlet about proper foods and fluids
Running Head: T&A SURGERY 20
to provide to M.H. following a T&A. Finally, I stressed to her mother how important it was to
keep M.H. drinking and her throat moist. I explained that this would be easier if she was sure to
keep up on pain management through proper administration of the Tylenol. Educating her
mother was a very important intervention to perform to prevent dehydration from occurring and
to aid in pain control.
Running Head: T&A SURGERY 21
References
Ball, J. W. & Binder, R. C. & Cowen, K. J. (2010). Child health nursing: Partnering with
children and families. Upper Saddle River, NJ: Pearson Education.
Black, J.M., Hawk, J.H. (2009). Medical-surgical nursing: Clinical management for positive
outcomes. (8th
ed). St. Louis, MO: Saunders, an imprint of Elsevier Inc.
Bowen, A., Hesketh, A., & Mumby, K. (2007). Apraxia of speech: how reliable are speech and
language therapists’ diagnoses? Clinical Rehabilitation, 21, 760-767.
Braun, J.V., Crandall, M., Lammers, C., Savedra, M., & Senders, C. (2008). Children’s pre-
operative tonsillectomy pain education: Clinical outcomes. International Journal of
Pediatric Otorhinolaryngology, 72, 1523-1533.
Craven, R.F. & Hirnle, C.J. (2009). Fundamentals of nursing: Human health and function. (6th
ed). Philadelphia: Lippincott Company.
Newcomb, P., Shaffer, P., Smith, J., & Sundberg, E. (2009). Relationship of opioid analgesic
protocols to assessed pain and length of stay in the pediatric postanesthesia unit following
tonsillectomy. Journal of PeriAnesthesia Nursing, 21(2), 86-91.
Running Head: T&A SURGERY 22
