Admission date Current assessments Student

11/04/2019 14/04/2019 Lê Phương Thảo

NAME: TRAN MINH DUC

GENDER: MALE [ √ ] FEMALE: [ ] BIRTHDAY : [ 2014 ]
AGE:[ 05 ]
MARITAL STATUS: single
JOB: no
RELIGION: no.

ADDRESS : But Thap, Dinh To, Thuan Thanh, Bac Ninh

Cheif Complaints on Admission: snoring, sleep apnea

Present history :
patients often runny nose, stuffy nose, fever, sore throat, swallowing pain(> 7 times / year),
snoring much, sleep apnea.
DIAGNOSTICS OR SIGNIFICANT INFORMATION:
- 11/04/2019
+ Results of ENT:
Ear: normal
Nose: normal
Nasopharynx: normal
Throat: Adenoiditis level 3
Larynx: Grade 4 tonsillitis
Result: Chronic Adenoiditis and tonsillitis
+ Heart, lungs: normal
+ X-ray: normal
- 11/04/2019
 Hematology:
o MONO%: 10.30% increased
o MONO: 0.86
 Normal biochemistry test, normal

MEDICAL INFORMATION (eg Weight: __19___ height:_95cm__ BMI =

diagnosis, history, allergy): 21,05
Diagnosis: Chronic Adenoiditis and BP:__ 100/60 mmHg___ Pulse: 72 b.p.m
tonsillitis Temperature: ___36.9• C______ RR: 17 b.p.m
History: Chronic Adenoiditis and tonsillitis
Allergy: no

NURSING PROCESS

Nursing Outcomes Nursing intervention Rationale

diagnosis
Risk for  Surgical site  Assess skin colour, level Bleeding usually means
hemorrhage will remain of consciousness and vital the scabs have fallen off
post- free from signs too early and this needs
tonsillectomy bleeding  Assess hemodynamic immediate attention.
related to stability … get access if Every reasonable attempt
surgical necessary. will be made to control
procedure  Inspect the area for signs the bleeding in the
of hemorrhage or blood Emergency Department.
blot. Some children may need
 Evacuate as much of the to be taken to the
clotted blood as possible Operating Room to
so you can get to the control the bleeding.
tonsillar fossae.
 Apply direct pressure on
the tonsillar fossae with
the gauze wrapped
 Discourage crying,
 coughing, frequent
clearing of throat
 Avoid hard objects in
mouth
 Avoid sucking
 Do not eat spicy, hot
 Treat post-operative
vomiting promptly
 Notify Physician
immediately if any
bleeding is noted.
Risk for  There is no  Monitor temperature
infection infection every 4 hours, the state of
related to the  The parents injury when performing
factors of will state maintenance
surgery and understandin  Administer antibiotics if
knowledge g of prescribed , give at least 2
deficit about preventive liters of fluid every day
infection in measures while implementing
children. antibiotic therapy
 Give antipyretics are
prescribed if there is fever
 Washing hands before
and after providing care.
 Wearing gloves to
maintain asepsis when
providing direct care.
 Assist child in
maintaining good oral
hygiene
 Report signs of infection
to Physician. The patient
may have a smell to their
breath post-op. If the
breath smell gets stronger
after they are discharged
then they should notify
the physician
 Teach family members to
 Hand washing is the
single best way to
avoid spreading
pathogens.
 Gloves offer
protection when
handling wound
dressing or carrying
out various
treatments.
 Sustained temperature
elevation after surgery
may signal onset of
pulmonary
complications, wound
infection or
dehiscence.
 Provides thorough
assessment of patients
clinical status
including vitals,
surgical wound, and
comfort to ensure
complications can be
detected early and
immediate
interventions can be
initiated
 cover mouths and noses
when sneezing or
coughing and to wash
hands frequently.
 Have parents isolate sick
children.
 Encourage optimal
nutrition, rest, and
exercise.
 Eliminate allergens and
upper respiratory irritants
such as tobacco, smoke,
and dust.
Acute pain  Child will  Assess pain using
related to state level of appropriate pain scale for
surgical pain is child’s age and
procedure decreased development.
and will  Observe child for
appear more nonverbal indications of
relaxed. pain such as crying,
grimacing, irritability.
 Instruct patient not to eat
rough and spicy foods
such as rice, pepper, peas,
corn, nuts., seasonings,
foods with garlic pepper
or chili.
 Administer pain
medications as prescribed.
Ensure ordered analgesic
dosage is appropriate for
patient’s weight
 Offer small amounts of
cool fluids, popsicles, ice
chips frequently
 Suggest diversional
activity such as watching
a video, reading a book or
listening to music.
 Use of a pain scale
allows objective
measurement of
subjective pain
perception.
 Provides additional
information about
pain. The child may
find discomfort in
speaking.
 Aggravate the pain
and can cause
bleeding
 Cold promotes
vasoconstriction and
decreases swelling
that contributes to
pain.
 Provides a distraction
from discomfort.
 Talking and coughing
can cause great
pressure on the area
which can lead to
bleeding.
 Fatigue can decrease
  Instruct patient to refrain:
talking, coughing
 Minimize environmental
activity and noise to
promote rest: proper
lighting, quite
environment, cool
ventilation
Risk for  Client will  Measure and record
Deficient experience intake and output hourly.
Fluid Volume adequate Assess skin turgor and
related to fluid volume moisture of mucous
decreased as evidenced membranes.
fluid intake by pulse and  Monitor post-
secondary to blood tonsillectomy client for
pain on pressure signs of bleeding such as
swallowing. within frequent swallowing,
normal limit, bright red blood oozing
absence of from the mouth or nose.
profuse Use a flashlight, mirror,
bleeding, and gauze, hemostatic clamp,
intake and and basin in examining
output within the surgical site.
acceptable  Monitor child’s
parameters. responsiveness and vital
signs, especially blood
pressure and pulse.
 Administer IV fluids via
infusion pump as ordered.
Monitor IV site hourly.
 Provide clear cool non-
citrus fluids in small
amounts.
 Discourage the use of a
straw or any sharp object
inside the mouth.
the client’s threshold
and tolerance for pain
and thereby heighten
the perception of pain.
If the client is well-
rested, she after
experiences decrease
pain and increase
effectiveness of pain
management
measures.
 Provides information
about physiologic
fluid balance and
signs of dehydration.
 Excessive swallowing
may indicate bleeding
from the operative
site; Provides
information about the
integrity of the
surgical site.
 Restlessness,
tachypnea, and
tachycardia are early
signs of hypovolemia.
 Replaces losses from
surgery and maintains
hydration if the child
is unable to drink.
 Small quantity may be
more easily tolerated.
Red, purple or brown
may stimulate the
appearance of blood if
the child vomits.
 Refraining from
drinking through a
straw lessens the risk
  Discourage excessive
coughing, nose blowing
or clearing of throat.
Administer antiemetics as
prescribed to prevent
vomiting.
 Provide parents with
discharge instructions on
diet, fluid intake, activity,
and when to notify
medical team
Deficient  Parents will  Assess parents’
knowledge gain the knowledge of the
related to lack knowledge to condition and
of exposure to care for the management.
information postoperative  Provide information about
regarding child safely the surgery
tonsillectomy at home  as needed. Teach parents
and that an important risk
postoperative after a tonsillectomy
care  is excessive bleeding
from the operative site.
Teach to observe for
excessive swallowing and
to not give the child any
straws, fork, or anything
sharp object that can be
put in the mouth, and to
discourage excessive
coughing and clearing the
throat.
 Instruct parents to refrain
child from performing
strenuous physical
activity following surgery
of physical trauma in
the operative site and
suction produced in
sucking may cause
bleeding.
 Excessive coughing,
nose blowing,
clearing the throat, or
vomiting may
promote bleeding in
the operative site.
 Teaching ensures that
parents will continue
to monitor fluid
balance.
 Provides baseline
information about
parents’
understanding of
illness.
 Provides important
information for
parents to recognize
and prevent
complications.
 Provides information
to prevent
complications.
 Provides information
to avoid dehydration.
 and may return to school
once comfortable.
 Instruct parents to
encourage the child to
drink clear liquids during
the first day, then shift to
soft foods as per
physician’s preference.
Teach parents how to
evaluate for dehydration;
how to monitor intake and
output and examine skin
turgor.
 Provides additional
information as needed

Medical: