NURSING NURSING INTERVENTIONS RATIONALE

DIAGNOSIS

Risk For Volume INDEPENDENT:

Deficit Related to
Risk for Bleeding due Measure and record intake and Provides information about physiologic fluid
to Tonsillectomy output hourly. Assess skin turgor balance and signs of dehydration.
Operative Action and moisture of mucous
membranes. Restlessness, tachypnea, and tachycardia
are early signs of hypovolemia.
Monitor child’s responsiveness and
vital signs, especially blood
pressure and pulse.
Excessive swallowing may indicate bleeding
Monitor post-tonsillectomy client for from the operative site; Provides information
signs of bleeding such as frequent about the integrity of the surgical site.
swallowing, bright red blood oozing
from the mouth or nose. Use a
flashlight, mirror, gauze, hemostatic
clamp, and basin in examining the
surgical site. Refraining from drinking through a straw
lessens the risk of physical trauma in the
Discourage the use of a straw or operative site and suction produced in
any sharp object inside the mouth. sucking may cause bleeding.

DEPENDENT:

Administer IV fluids via infusion Replaces losses from surgery and maintains
pump as ordered. Monitor IV site hydration if the child is unable to drink.
hourly.

Discourage excessive coughing, Excessive coughing, nose blowing, clearing

nose blowing or clearing of throat. the throat, or vomiting may promote bleeding
Administer antiemetics as in the operative site.
prescribed to prevent vomiting.

INTERDEPENDENT:

Provide clear cool non-citrus fluids Small quantity may be more easily tolerated.
in small amounts (e.g., crushed ice, Red, purple or brown may stimulate the
popsicles); Avoid red, purple, or appearance of blood if the child vomits.
brown liquids.

Provide parents with discharge Teaching ensures that parents will continue
instructions on diet, fluid intake, to monitor fluid balance.
 NURSING NURSING INTERVENTIONS RATIONALE
DIAGNOSIS

activity, and when to notify medical References;https://nurseslabs.com/tonsillitis-

team. nursing-care-plans/5/