Timby's MedSurg 14e

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UNIT 5 Caring for Clients With Respiratory Disorders

NURSING PROCESS FOR THE CLIENT UNDERGOING TONSILLECTOMY AND ADENOIDECTOMY

Assessment Assess the client’s understanding of the procedure and obtain baseline vital signs. Ask if the client wears dentures and when the client last had food or drink. Pay special attention to labo ratory results for hematocrit, platelet count, and clotting time because of the high risk for postoperative hemorrhage. Ask the

client about bleeding tendencies and recent use of aspirin, non steroidal anti-inflammatory drugs (NSAIDs), or other medica tions that prolong bleeding time. Some herbal supplements such as feverfew or ginkgo may also prolong bleeding, so it is also important to ask about the use of these supplements.

Diagnosis, Planning, and Interventions Following surgery, implement the postoperative standards described in Chapter 14. Additional nursing care is discussed as follows and in Client and Family Teaching 20-2. Aspiration Risk: Related to impaired swallowing from throat surgery and reduced gag reflex secondary to anesthesia Expected Outcomes: (1) Client will maintain a patent airway with clear breath sounds. (2) Client will expectorate secretions and vomitus as needed.

Altered Tissue Integrity Risk: Related to injury to the suture line Expected Outcome: Client will maintain an intact suture line. • After surgery, position client, until alert, on either side with emesis basin to catch drainage or vomitus. Retained secretions/vomitus can obstruct airway and cause aspiration. • Assess gag reflex and ability to swallow. A depressed gag reflex and inability to swallow increase the risk for aspiration. • Elevate head of bed 45 degrees when client is fully awake. This position decreases surgical edema and increases lung expansion. • Monitor for respiratory rate, rhythm, and effort at least every hour. Increased respiratory rate, decreased breath sounds, or both indicate an increased respiratory effort, possibly related to a partially obstructed airway, aspiration, both. • Monitor client for bloody drainage from mouth or frequent swallowing. These findings indicate increased bleeding from suture site and require immediate attention. • Instruct client not to cough, clear throat, blow nose, or use a straw in the first few postoperative days. These actions in crease pressure on the suture line and may cause disruption and bleeding. • Instruct client to avoid carbonated fluids and fluids high in citrus content. Such fluids are caustic to the surgical site and may traumatize tissue, disrupting the suture line.

• Auscultate breath sounds for crackles at least every hour. Aspiration of small amounts may occur without evidence of coughing or respiratory distress. • Encourage client to spit secretions/vomitus into the emesis basin. Removal of secretions/vomitus promotes a clear airway and prevents aspiration. • Assess for lethargy, behavior changes, or disorientation. Decreased level of consciousness indicates poor air exchange. • Have oral suction equipment available. Prompt oral suctioning removes secretions/vomitus from the mouth, preventing aspiration.

• Encourage client to first try ice chips, then small sips of cold fluids, and then popsicles and full liquids as tolerated. Gradual introduction of increasingly thick fluids provides client with an opportunity to slowly try swallowing, without disrupting the suture line. • Add soft food, such as gelatin and sherbet, as tolerated, after the first 24 hours postoperatively. As the diet advances, small amounts of soft foods are less likely to traumatize the suture line.

Acute Pain: Related to the surgical incision in the throat Expected Outcome: Client will acknowledge relief from pain medications and demonstrate improved ability to swallow.

• Anticipate the need for pain relief, medicating client as ordered. Early treatment of pain assists to decrease its intensity. • Apply ice collar as ordered. Cold reduces swelling and inflammation in the soft tissues surrounding the surgical

incision. The ice pack will help control bleeding, reduce edema and inflammation, and block pain receptors. • Encourage client to gently gargle with warm saline three to four times daily. Gentle gargling cleanses the surgical site and helps reduce inflammation and pain, remove thick mucus, and improve swallowing.

Evaluation of Expected Outcomes

Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. Client maintains a clear airway, can expectorate secretions and vomitus, and experiences minimal postoperative bleeding. The suture line remains intact. Client reports relief of pain and ability to swallow effectively.