Nursing Care Plan

A Client with Peritonsillar Abscess

Monica Wunderman, age 27, was recently treated for tonsillitis caused by infection by group A streptococcus. She presents to the emergency department 10 days later appearing acutely ill. She states that her throat is so sore that she has difficulty swallowing even liquids.Barbara Ironhorse,the ED nurse,completes an assessment of Ms. Wunderman.

ASSESSMENT
Findings include T 102F (38.8C). An acutely swollen and reddened area of the soft palate is noted in her mouth, half occluding the orifice from the mouth into the pharynx. Yellow exudate is present. CBC reveals an elevated WBC of 16,000/mm3. A diagnosis of peritonsillar abscess is made. (continued)

Nursing Care Plan

A Client with Peritonsillar Abscess (continued)
Needle aspiration of the abscess is performed. Advise to avoid citrus juices, hot or spicy foods, and roughtextured foods for 1 week. Teach pain management strategies such as applying an ice collar as desired and gargling with warm saline or mouthwash solution every 1 to 2 hours for the first 24 to 48 hours after aspiration of the abscess. Instruct to take medications as prescribed.

DIAGNOSIS
The following nursing diagnoses are identified for Ms.Wunderman. Acute pain related to swelling Risk for ineffective airway clearance related to pain and swelling Deficient fluid volume related to fever and difficulty in swallowing fluids

EVALUATION
When Ms. Ironhorse contacts Ms. Wunderman by telephone 2 days after her visit to the emergency department, she reports complete relief of symptoms. She is afebrile, taking fluids without difficulty, and has had no difficulty breathing. She has not experienced any pain.

EXPECTED OUTCOMES
The expected outcomes for the plan of care are that Ms. Wunderman will: Have minimal or no pain. Maintain a patent airway as demonstrated by normal respiratory rate and rhythm. Maintain optimal fluid intake as evidenced by consumption of fluids and semiliquid foods, moist mucous membranes, normal skin turgor, and normal temperature.

Critical Thinking in the Nursing Process

1. Describe common symptoms of infectious or inflammatory diseases of the upper airway and discuss methods of symptom relief. 2. Describe common pharmacologic interventions for these disorders. 3. What themes of nursing diagnoses emerge for these clients? See Critical Thinking in the Nursing Process in Appendix C.

PLANNING AND IMPLEMENTATION

Ms. Ironhorse plans and implements the following interventions in preparing Ms. Wunderman to care for herself at home. Teach that ice-cold fluids may be easier to swallow than hot or room-temperature beverages and may provide a local analgesic effect.