COLLEGE OF NURSING Silliman University Dumaguete City RESOURCE UNIT ON TONSILLECTOMY Prepared by Jaymielle Ces C. Corro Facilitator: Asst. Prof. Kathleah S. Caluscusan Teaching Date & Time: TBA Venue: Virtual Classroom Topic Title Tonsillectomy Topic Description This topic provides an overview of the care of perioperative tonsillectomy patients, including causes, risk factors, and clinical manifestations of conditions that require the said operation. Furthermore, this topic aims to emphasize the appropriate medical and nursing management. Time Allotment 60 minutes Placement Level 3 Student Nurses Learning Outcomes At the end of the discussion, the learners will gain the necessary knowledge, skills and attitudes in providing perioperative nursing care for tonsillectomy patients. Specific Objectives Content TeachingLearning Time Allotted Evaluation Method Activities At the end of discussion period, learners will be able to: I. Background Define the tonsillectomy A. Tonsils Interactive utilizing own The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. They filter discussion understanding of concepts. and protect the respiratory and alimentary tracts from invasion by pathogenic organisms and play a role in antibody formation. Although their size varies, children generally have much larger tonsils than adolescents or adults. This difference is thought to be a protective mechanism because young children are especially susceptible to URIs. class 2 minutes B. Tonsillitis Tonsillitis occurs when the filtering function becomes overwhelmed with a virus or bacteria and infection results. It is an inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat. Tonsillitis is a contagious airborne infection. C. Tonsillectomy Tonsillectomy is the surgical removal of the palatine tonsils. The procedure may involve complete tonsil removal or a partial tonsil removal. Correctly causative tonsillitis. II. Causes identify The causative agent may be viral or bacterial; most commonly group A, beta-hemolytic Lecture agents for Streptococcus. Other bacterial causes include Staphylococcus aureus, Haemophilus influenzae, and Pneumococcus. Viruses also cause tonsillitis, such as the viruses that cause the common cold or flu virus. Enumerate the risk factors III. Risk Factors A. Age - Acute or chronic tonsillitis can occur in any age-group, but it is less 2 minutes 2 minutes 10 item quiz at 76% level of competency associated with tonsillitis. common in adults. Most common in children ages 5 to 15. B. Location - The incidence of streptococcal infections is greatest between late autumn and spring, especially in cold climates. Viral tonsillitis may occur in epidemics in people living in crowded conditions, such as children in boarding schools. IV. Pathophysiology (found in the concept map) At 75% satisfactory level, discuss the mechanisms involved in the condition leading to its clinical manifestations Presentation using concept map with pictures 5 minutes V. Clinical Manifestations In tonsillitis, the tonsils appear bright red and oedematous. White exudate is present on the tonsils; pressing on a tonsil may produce purulent drainage. The uvula may also be reddened and swollen. Cervical lymph nodes are usually tender and enlarged. The person with tonsillitis complains of a sore throat, difficulty swallowing, general malaise, fever and otalgia (pain referred to the ear). 5 minutes VI. Diagnostic Tests A. Throat Swab Name the appropriate The doctor rubs a sterile swab over the back of the throat to get a sample of diagnostic exams needed in secretions. The throat swab is obtained and examined for streptococcus determining tonsillitis. antigen. These tests allow rapid identification of the antigen but are not highly sensitive. When the test is positive, treatment for strep throat is initiated. If the test is negative, the swab is cultured to ensure that streptococcus organisms are not present. 2 minutes B. Complete Blood Count The profile of what's elevated, what's normal or what's below normal can indicate whether an infection is more likely caused by a bacterial or viral agent. A CBC is not often needed to diagnose strep throat. However, if the strep throat lab test is negative, the CBC may be needed to help determine the cause of tonsillitis. VII. Indications List at least 2 absolute and Absolute indications for a tonsillectomy are recurrent peritonsillar abscess, airway 2 relative indications for obstruction, tonsillitis resulting in febrile convulsions, and tonsils requiring tissue tonsillectomy. pathology. Relative indications include three or more tonsil infections per year, persistent foul taste or breath caused by chronic tonsillitis, unilateral tonsil hypertrophy presumed to be malignant, and chronic tonsillitis in a streptococcus carrier who fails to respond to antibiotics (American Academy of Otolaryngology—Head and Neck Surgery, 2011). A. Peritonsillar abscess, or quinsy is a potential complication of tonsillitis. It usually results from group A beta-haemolytic streptococcus infection extending from the tonsils to the surrounding tissue. The abscess causes pus formation behind the tonsil with marked swelling and asymmetric deviation of the uvula. The degree of swelling may make it difficult to swallow anything other than liquids. The person may exhibit thickening of the voice, drooling and trismus (a tonic contraction of the muscles of mastication). B. Chronic tonsillitis may result from an unresolved acute infection, chronic infections that do not respond to antibiotics or recurrent infections. C. Infection can extend to the middle of ears by way of the auditory (eustachian) tubes and may result in acute otitis media, which can lead to, spontaneous rupture of the tympanic membranes (eardrums) and further extension of the infection into the mastoid cells, causing acute mastoiditis. The infection may also reside in the middle ear as a chronic, low-grade, smoldering process that eventually may cause permanent deafness. Discuss the VIII. Treatment different A. Tonsillectomy - Tonsillectomy techniques can be divided into 2 general 5 minutes methods of treatment. categories: extracapsular (total tonsillectomy, subcapsular) and intracapsular Video presentation (partial tonsillectomy). In an extracapsular tonsillectomy, dissection is performed lateral to the tonsil in the plane between the tonsillar capsule and the pharyngeal musculature, and the tonsil is generally removed as a single unit. In contrast, an intracapsular tonsillectomy involves removal of the tonsil in piecemeal fashion, from medial to lateral, with care taken to preserve the capsule. The most common extracapsular techniques use a monopolar electrocautery, bipolar cautery (or bipolar scissors), “cold” knife (sharp dissection), or harmonic scalpel. Intracapsular techniques may use the microdebrider, bipolar radiofrequency ablation (which can also be used to remove the entire tonsil), and carbon dioxide laser. ➢ Techniques: i. Monopolar/bipolar electrocautery - This method burns the tonsils away. It simultaneously removes the tonsil and cauterizes the area to stop bleeding. ii. “Cold” knife - In this technique, the tonsil and capsule are dissected from surrounding tissue using scissors and/or knife. Bleeding is then stopped with sutures or with electrocautery. iii. Harmonic scalpel - This method uses ultrasonic vibrations to cut and stop bleeding from the tonsils at the same time. iv. Bipolar radiofrequency ablation (aka coblation, low-temperature plasma excision, ionized field ablation) - Bipolar refers to the method in which energy is transferred to tissue. An ionized (or charged) saline layer is charged with radiofrequency waves. This breaks molecular bonds in the tissue and separates it without causing harm to the surrounding tissue. v. Microdebrider tonsillectomy - A microdebrider is a rotary device that “shaves” tissue away. When this method is removed, the entire tonsil is not removed. A layer of tonsil tissue is left over the throat muscles. vi. Carbon dioxide laser - CO2 laser is used to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. 20 minutes ➢ Instruments i. Backhaus towel clamp ii. Allis clamp iii. White tonsil clamp (similar to a curved Allis clamp) iv. Schnidt tonsil forceps v. Foerster-Ballenger sponge holding forceps vi. Baum tonsil needle holder vii. Metzenbaum scissors viii. DeBakey forceps ix. #7 knife handle x. Fisher tonsil knife and dissector xi. Hurd dissector and Pillar retractor xii. Wieder tongue depressor/ retractor xiii. Yankauer suction xiv. Andrews-Pynchon suction xv. Tonsil snare xvi. Mouth gag with blades (Dingman, Jennings, Davis or McIvor with multiple size blades) xvii. Medicine cup ➢ Procedure The anesthesia induction and positioning of the patient is similar for most patients undergoing tonsillectomy, regardless of which technique is used to remove the tonsils. The patient is placed in the supine position and orally intubated. The endotracheal tube is taped to the patient’s chin in the midline. The patient is positioned at the edge of the bed, and a small shoulder roll is placed. Either a Crowe-Davis, McIvor, or Dingman mouth gag is inserted and expanded to keep the mouth open for the duration of the procedure. The tonsillectomy can be performed using several different techniques, such as “hot knife” which uses electrocautery, coblation or “cold knife,” which uses a #12 blade and the #7 knife handle. During the “cold knife” technique, an Allis clamp or White tonsil clamp, which is similar to a curved Allis clamp, grasps the tonsil tissue. It is important to inspect the jaws of the clamp to confirm it can hold tonsil tissue and withstand the back-and-forth twisting movement that is required during the tonsil dissection. The #7 knife handle and #12 blade are used to make the initial cut from the superior pole to the anterior tonsil pillar. The Fisher tonsil knife and dissector is then used to help further dissect tonsil tissue from the tonsillar capsule. Nicks and burrs in the Fisher knife can also rip and tear tissue instead of cleanly dissecting tissue. A tonsil wire snare is then placed around the tonsillar tissue and the tonsil is removed. Testing of the snare is vital in this phase. The wire from the snare should pass smoothly and completely through the shaft of the snare, without hesitation. Snare wire that does not pass completely through the shaft can cause excessive bleeding and be difficult to remove, which can cause a delay during this critical portion of the procedure. The tonsil space can then be packed using the tonsil sponge and the procedure is repeated on the next tonsil. After both tonsils are removed, excess bleeding is then controlled with a suction electrocoagulator. A Hurd dissector and Pillar retractor can be used to retract the tonsillar pillar and improve visualization, in addition to suction with a Yankauer or Andrews-Phychon suction to remove B. Antibiotic therapy Antipyretics and mild analgesics such as aspirin or paracetamol provide symptomatic relief for throat pain and associated myalgias. Penicillin is the drug of choice for group A streptococci. Erythromycin, or amoxicillin, may be used if the person is allergic to penicillin. Antibiotic therapy is continued for at least 10 days. The person is no longer contagious after 24 hours of antibiotic therapy. C. Symptomatic treatment If a virus treatment. i. ii. iii. iv. v. vi. vii. Identify at least 3 complications that arise from tonsillectomy. Correctly enumerate 3 is the expected cause of tonsillitis, at-home care strategies are the only Emphasize importance of supportive therapy. Teach patient to rest, encourage patient to get plenty of sleep. To keep the throat most and prevent dehydration, increase fluid intake and maintain caloric intake. Home intravenous therapy under the supervision of qualified home health providers or the independent oral intake ability of patients ensures hydration. Humidify the air using a cool-air humidifier to eliminate dry air that may further irritate a sore throat. Gargle several times each day with warm saline. If the patient can gargle, a saltwater gargle of ½ teaspoon of table salt to 8 ounces of water can help soothe a sore throat. Use throat lozenges for children older than 4. Use analgesics for pain. IX. Complications i. Bleeding. It is normal to see small specks of dark blood from the nose or in the saliva, but any bright red blood requires a trip to the emergency room for a prompt evaluation and treatment. Surgery to stop bleeding may be necessary. ii. Fever. Call a doctor if the patient has a fever of 102 F (38.9 C) or higher as this may indicate infection. iii. Dehydration. Signs of dehydration include reduced urination, thirst, weakness, headache, dizziness or lightheadedness. Common signs of dehydration in children include urinating fewer than two or three times a day or crying with no tears. iv. Breathing problems. Snoring or noisy breathing is common during the first week or so of recovery. However, if the patient is having difficulty breathing, get emergency care. X. Nursing Management A. Preoperative 5 minutes 10 minutes perioperative nursing diagnoses and their respective interventions. ➢ Responsibilities i. Educating the patient on any preoperative instructions leading up the surgery ii. Ensuring that all pre-operatives tests and bloodwork are completed iii. Ensuring that the patient’s chart is comprehensive and all paperwork is completed and signed iv. Settling patient into the room and prepping the patient for surgery v. Interviewing and assessing the patient on the day of the surgery ➢ Nursing Diagnosis and Interventions i. Anxiety r/t unfamiliarity with surgical procedures • Assess the patient’s level of anxiety. Fear/ anxiety may result to excessive stress reaction, potentiating risk of adverse reaction to procedure and/ or anesthetic agents. • Encourage communication by having the patient state feelings, fears, and concerns can help reduce anxiety. • Provide preoperative education and discuss anticipated things that may concern the patient. B. Intraoperative ➢ Responsibilities i. Scrub nurse: Assists the physician by selecting and passing instruments and supplies during the surgery ii. Circulating nurse: Manages the overall operating room as to ensure a safe and comfortable operating room environment iii. RN first assistant: Directly assists the surgeon C. Postoperative ➢ Responsibilities i. Monitoring the patient and addressing any signs of distress, infection, shock, bleeding, or other problems ii. Assisting patients by helping them deal with the effects of the surgical procedure iii. iv. Instructing the patient and patient’s family on at-home, post-operative care (discharge orders) Ensuring that the patient is comfortable ➢ Nursing Diagnosis and Interventions i. Ineffective airway clearance r/t presence of secretions • Following tonsillectomy, ensure a patent airway by placing the person in semi-Fowler’s position with the head turned to the side to allow secretions to drain from the mouth and pharynx. • Keep the airway in place until the gag and swallowing reflexes have returned. • Warm saline mouthwashes are helpful in managing thick oral secretions following tonsillectomy. • Suctioning, if necessary, should be done carefully to avoid trauma to the surgical site. ii. Acute pain r/t surgical procedure • Apply an ice collar to reduce swelling and pain. • To avoid trauma to the surgical site, discourage the child from coughing, clearing the throat, blowing the nose, and using straws. • Administer pain medications as ordered. iii. Deficient fluid volume r/t inadequate oral intake secondary to painful swallowing • Give small amounts of clear fluids or ice chips. • Encourage liquid or semiliquid diet. • Discourage intake of irritating liquids such as orange juice and lemonade; milk and ice cream products tend to cling to the surgical site and make swallowing more difficult; thus they are also poor choices. • Record intake and output until adequate oral intake is established. iv. Risk for bleeding r/t physiological processes (failed scab formation, sloughing process) • Inspect the throat for bleeding. Mucus tinged with blood may be • • expected, but fresh blood in the secretions indicates bleeding. Early bleeding may be identified by continuous swallowing of small amounts of blood while awake or sleeping. Monitor vital signs and other signs of hemorrhage including tachycardia, pallor, restlessness, frequent throat clearing, and emesis of bright red blood. Notify the surgeon immediately if excessive bleeding or hemorrhage occurs. REFERENCES: Anef, C. C. D. R. D., Faan, R. P. L. W. M., & Coi, R. M. P. C. R. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, Single Volume (9th ed.). Saunders. Claassen, J. (2012). The sore throat. Continuing Medical Education, 30(9), 306-313. Retrieved Febuary 01, 2021, from http://www.cmej.org.za/index.php/cmej/article/view/2447/2535 Faan, P. R. P. M. H. J., & C(Inc), R. D. (2012). Wong’s Essentials of Pediatric Nursing (9th ed.). Mosby. Kyle, T., & Carman, S. (2012). Essentials of Pediatric Nursing (2nd ed.). Lippincott Williams & Wilkins. LeMone, P. T., Burke, K. M., Faan, B. G. R. P., & Gubrud, P. (2014). Medical-Surgical Nursing: Clinical Reasoning in Patient Care (6th Edition) (Medical Surgical Nursing Lemone) (6th ed.). Pearson. Messner, A. H. (2005). Tonsillectomy. Operative Techniques in Otolaryngology-Head and Neck Surgery, 16(4), 224–228. https://doi.org/10.1016/j.otot.2005.09.005 PhD Rn, S. W. L. (2013). Pediatric Nursing Care: Best Evidence-Based Practices (1st ed.). F.A. Davis Company. Rn, K. M. L., & Rn, S. H. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). Mosby. RN to BSN and Prelicensure BSN Programs. (2020, June 5). BSNs in Surgical Nursing | Surgical Nurse Jobs | How to Become a Perioperative Nurse. RN to BSN and Prelicensure BSN Programs | What Is a BSN. https://www.bsnedu.org/surgical-nursing/ Tonsillectomy - Mayo Clinic. (2020, November 10). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/tonsillectomy/about/pac-20395141
