Question

The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately? A. Reluctance to swallow B. Drooling of blood-tinged saliva C. An axillary temperature of \(99^{\circ} \mathrm{F}\) D. Respiratory stridor

Short answer

Answer: Respiratory stridor

Step-by-step solution

Analyze each answer choice

In order to determine the correct answer, we will break down each answer choice and analyze its implications for the patient. A. Reluctance to swallow: Postoperative pain and discomfort are common after a tonsillectomy, making swallowing uncomfortable and potentially painful for the patient. This finding, while noteworthy, is not necessarily an immediate cause for concern. B. Drooling of blood-tinged saliva: Some bleeding is expected after a tonsillectomy, and blood-tinged saliva could be an indication of this normal postoperative bleeding. However, excessive bleeding should be monitored closely. C. An axillary temperature of \(99^{\circ} \mathrm{F}\): A mild fever can be a common occurrence after surgery. An axillary temperature of \(99^{\circ} \mathrm{F}\) indicates a mildly elevated body temperature, but not a dangerous level of fever. D. Respiratory stridor: Respiratory stridor is a high-pitched, wheezing sound that indicates an obstruction in the airway. This finding is potentially life-threatening and should be reported immediately.

Choose the correct answer

After analyzing each answer choice and its implications for the patient, the most concerning finding is respiratory stridor (option D). This is a potentially life-threatening condition that needs to be reported immediately.

Key concepts

Postoperative Care

Postoperative care is a critical component of the recovery process following any surgical procedure, including tonsillectomy. Proper care ensures that complications are identified and managed promptly, enhancing the patient’s recovery and comfort.

After a tonsillectomy, it is important for nurses to regularly assess the patient's pain level and provide adequate pain relief, as pain can hinder the ability to swallow and drink fluids. Furthermore, maintaining hydration and encouraging gentle throat-clearing techniques can also be beneficial.

In addition, nurses should monitor for signs of bleeding, such as blood-tinged saliva, and assess the patient’s temperature to manage fever, which may indicate infection. The patient’s respiratory status must be closely observed for any signs of obstruction, as manifested by respiratory stridor, which is an immediate cause for concern requiring swift intervention.

• Maintain hydration
• Manage pain and fever
• Monitor signs of bleeding and respiratory function
• Encourage gentle throat-clearing

Effective postoperative care facilitates a smoother recovery and minimizes the risk of severe complications.

Tonsillectomy Complications

Tonsillectomy, while generally safe, can result in several complications that require vigilant observation and management by healthcare professionals, particularly in pediatric nursing.

The primary concerns post-tonsillectomy include bleeding, infection, and airway obstruction. Bleeding can range from mild oozing to more significant hemorrhage and is often indicated by blood-tinged saliva. The nurse must differentiate between the expected slight bleeding and more concerning bleeding that may necessitate further treatment.

Infection can manifest through symptoms such as fever or increasing pain, and requires prompt medical attention to prevent it from worsening. Respiratory stridor, a high-pitched wheezing sound due to airway obstruction, is considered a medical emergency. It is critical for nurses to be adept at recognizing these complications early to ensure timely and appropriate intervention.

• Bleeding: differentiate between normal and excessive
• Infection: monitor for fever and increasing pain
• Airway obstruction: recognize respiratory stridor and act quickly

Understanding and promptly acting upon these complications are essential for safe recovery from tonsillectomy.

Pediatric Nursing

Pediatric nursing entails specialized care for infants, children, and adolescents, focusing on nurturing and supporting young patients through their medical journeys. A child’s physiological and psychological responses to medical interventions, including surgery, differ from those of adults, necessitating a tailored approach.

Nurses caring for pediatric patients must provide not only advanced clinical care but also address the needs of the whole child, taking into consideration their developmental stage and providing emotional support. Effective communication with both the child and their family is paramount, as it builds trust and helps in educating them about care processes and expectations postoperatively.

In the context of post-tonsillectomy care, pediatric nurses must use child-friendly techniques to assess pain, monitor for complications, and encourage the child to maintain adequate hydration and nutrition. While being alert to the signs of postoperative complications, nurses should also provide reassurance and comfort to alleviate the fears and anxieties that commonly accompany a hospital stay for young patients.

• Adapt care to the child’s developmental stage
• Communicate effectively with the child and family
• Monitor for complications with a child-friendly approach
• Provide emotional support and comfort

Skilled pediatric nursing care can significantly improve the patient's experience and outcome following surgery like a tonsillectomy.