Question

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain

Short answer

A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain Answer: C. Risk for aspiration

Step-by-step solution

Understand the context of the question

To help in identifying the correct priority nursing diagnosis, it is essential to first understand what a tonsillectomy is and what are some common concerns or risks after surgery. In a tonsillectomy, the tonsils are removed to treat severe or recurrent tonsillitis or other upper respiratory tract conditions.

Analyze each option

We will now analyze each option to determine which is the most appropriate priority nursing diagnosis for the given scenario. A. Body image disturbance: This diagnosis might arise from the presence of surgical scars or physical changes. However, a tonsillectomy doesn't result in significant long-term visible changes, so it is not the priority diagnosis. B. Impaired verbal communication: As the patient has had their tonsils removed, temporary difficulty in verbal communication is possible. However, it is a short-term issue and not the most crucial concern when compared to other options. C. Risk for aspiration: After a tonsillectomy, the patient may experience altered swallowing abilities that can lead to the risk of aspiration (inhaling food or liquids into the lungs). Aspiration can cause severe complications such as pneumonia or respiratory distress. This might be a significant concern that needs to be addressed as a priority. D. Pain: In the postoperative period, the patient may experience pain due to the surgical procedure. Although it is essential to manage the pain, it is not considered the most urgent concern among the options mentioned.

Choose the correct priority nursing diagnosis

After analyzing each option, the most appropriate priority nursing diagnosis for a child being admitted from surgery following tonsillectomy is: C. Risk for aspiration This is because aspiration can lead to severe complications, and addressing it as a priority can prevent further postoperative issues.

Key concepts

Nursing Diagnosis

Nursing diagnoses are essential in planning care for patients post-surgery, such as after a tonsillectomy. They help identify potential complications and prioritize interventions to ensure a safe and smooth recovery for the patient. Nurses use critical thinking skills to assess the patient's condition and identify the most pressing issues that need attention. In a clinical setting, a nursing diagnosis involves three main components:

• Identifying the problem based on patient assessment
• Determining the cause or related factors
• Listing the defining characteristics or symptoms

In the context of a child recovering from a tonsillectomy, the nursing diagnosis must focus on the most immediate risks to the child's health and recovery process. For instance, while pain and impaired verbal communication are immediate effects of having the tonsils removed, they are not life-threatening and are usually temporary. Therefore, the risk for aspiration due to difficulty swallowing takes precedence as it could lead to serious complications such as respiratory distress or pneumonia that need urgent attention.

Postoperative Care

After a tonsillectomy, postoperative care is crucial for promoting healing, minimizing discomfort, and preventing complications. Nurses play an integral role in ensuring that children receive appropriate care by monitoring their condition, providing comfort measures, and offering guidance on recovery practices. Key aspects of postoperative care include:

• Monitoring vital signs to assess overall stability
• Ensuring effective pain management to enhance comfort
• Encouraging adequate hydration and proper dietary adjustments
• Observing for signs of bleeding, a common risk post-tonsillectomy

Nurses need to be vigilant about the risk of aspiration. They achieve this by guiding the child to take small sips of water and avoiding thick or sticky foods initially. The child should be placed in a semi-upright position to aid swallowing and minimize the risk of inhaling food or liquids into the lungs. Parental education is also a critical component, as they need to be informed about warning signs of complications and the importance of follow-up care.

Tonsillectomy Care

Tonsillectomies are common procedures aimed at removing the tonsils due to recurrent infections or breathing problems. Postoperative care following a tonsillectomy involves specific strategies to facilitate recovery while addressing potential complications. The immediate goals of tonsillectomy care include:

• Preventing postoperative bleeding by advising the child to rest and avoid vigorous activity
• Maintaining a soft diet to prevent irritation of the surgical site
• Ensuring a clean environment to minimize exposure to infections

Patients may experience throat pain, which can be managed by prescribed medications. It is also important to monitor for signs of dehydration and ensure the child is consuming enough fluids. Avoidance of dairy products is suggested initially, as they can coat the throat and promote mucus production, which complicates swallowing further. Furthermore, supportive care such as using a humidifier can help keep the throat moist and reduce discomfort. Comprehensive discharge planning should also include instructions for managing pain, guidelines for diet and activity level, and identifying symptoms that require immediate medical attention, to ensure a safe and timely recovery.