Question

    You are on duty in the OPD when BV is a 7-year old schooler who went for doctor’s consult because of severely swollen tonsils. She was accompanied by her mother. Condition started 3 days prior to consult, becoming more progressive until she can hardly swallow. She also started having low grade fever the day before but became high grade in the morning of consult. Her mother said this problem is frequently occurring since she started going to school like almost every 3 to 4 months. She usually does not miss school unless she has fever like what happened the past days.

            Upon assessment, BV is a little bit restless and occasionally grimaces when she swallows. She remarks that mere swallowing of her saliva gives her pain. Though all aspects of her vital signs are bordering on maximum normal, her temperature registered at 39.4 C. Inspection of her throat shows erythema with exudates on both lateral walls.

            After completing history and assessment, the doctor did a throat swab then gave instructions on the following orders:

           Cephalexin (Keflex) 500 mg every 6 hours for 7 days.

           Betadine gargle 3 times a day.

           Paracetamol 500 mg every 6 hours for temperature 38.5 C and above

         

          They were told to come back after a week for follow-up. The doctor mentioned the need for referral to a throat specialist for a possible scheduling of her surgery. Upon hearing this, BV verbalized her concern to her mother about a coming Quiz Bee Contest where she is a contestant and her possible absence if she will undergo surgery. She is now more apprehensive than when she came in.

Questions

1. Give 5 nursing diagnoses applicable to BV based on her condition and stage of development and suggest applicable 3 nursing interventions for each diagnosis to address these problems. Risk problems may be included

Answer 1

Nursing diagnosis and interventions:

Nursing diagnosis	Interventions	Rationale
1.Ineffective airway clearance related to swelling in the throat .(evidenced by difficulty in swallowing)	-Assess for the vitals to rule out any respiratory compromise. -Teach the child about breathing exercises. -Encourage the child to take adequate fluids. -Teach the child and mother about the use of Betadine gargle. -Instruct the mother on antibiotics  (Cephalexin (Keflex) 500 mg) use for 7days	-Increased swelling can lead to changes in rate and depth of breathing. - Breathing exercises gives the techniques to ease the breathing. -Hydration helps in loosening the secretion and clear the airway. -It reduces the Inflammation and edema thereby facilitating a clear airway. -It reduces the infection and reduce the swelling of tonsils.

.2.Acute pain related to the swollen/inflamed throat.	-Assess the pain using faces pain scale. -Advice the mother for diversional activities while feeding egs-watching a tv program while feeding. -Instruct child's mother to administer analgesic paracetamol 500mg every 6 hours as per the prescription.	-Pain scale help to note the objective measurement of the reported pain. -provide distraction from the current symptom -Throat pain will be reduced with the analgesics.
3.pyrexia related to tonsillitis.(evidenced by elevated bodytemprature of 39.4C)	-Asses vitals -Apply cool compresses to patient’s forehead, hands and feet or place in tepid bath. -Administer antipyretics(paracetamol 500mg ) as prescribed.	- Get baseline to determine if interventions are effective. -cool compress and tepid baths help reduce fever through evaporative cooling. -Antipyretics helps in reducing the body Temperature.
4.Anxiety related to the health status.(as evidenced by verbalizing the concern of missing the quiz event in school)	-Assess the Childs expressions and concerns about the health status. -Reassure the child about the surgery dates will not interfere with the quiz programs. -Reassure the child that taking medications will improve the pain and will help her perform well.	-To identify and find solutions for the fear. -To reduce the concern over missing the school. -To gain the confidence of kids .
5.Risk for ear infection related to tonsillitis.	-Asses the ear for any signs of infection. -Educate the mother to report if the child complains of ear ache or itching . -Advice to watch for any oozing from external ears. -Administer antibiotics(Cephalexin (Keflex) 500 mg every 6 hours for 7 days)as prescribed.	-to identify the ear infection . -Ear infection may be precipitated with ear ache or itching in kids -Oozing from external ears indicates the infection of ear. -Antibiotics prevents the spread of infection to the ears.