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    Nursing Diagnosis Nursing Interventions Rationale: Independent

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    Jessica Surmieda
    The document provides nursing interventions and rationales for a child at risk for volume deficit following a tonsillectomy. Key interventions include hourly monitoring of intake and output to assess fluid balance, monitoring the surgical site for signs of bleeding, discouraging activities that could promote bleeding like coughing or straw use, administering IV fluids as needed, and educating parents on post-op care. The goal is to replace fluid losses from surgery and prevent dehydration while protecting the integrity of the surgical site during healing.

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    Nursing Diagnosis Nursing Interventions Rationale: Independent

    Uploaded by

    Jessica Surmieda
    41 views2 pages
    The document provides nursing interventions and rationales for a child at risk for volume deficit following a tonsillectomy. Key interventions include hourly monitoring of intake and output to assess fluid balance, monitoring the surgical site for signs of bleeding, discouraging activities that could promote bleeding like coughing or straw use, administering IV fluids as needed, and educating parents on post-op care. The goal is to replace fluid losses from surgery and prevent dehydration while protecting the integrity of the surgical site during healing.

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    Tonsillitis.doc

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    The document provides nursing interventions and rationales for a child at risk for volume deficit following a tonsillectomy. Key interventions include hourly monitoring of intake and output to assess fluid balance, monitoring the surgical site for signs of bleeding, discouraging activities that could promote bleeding like coughing or straw use, administering IV fluids as needed, and educating parents on post-op care. The goal is to replace fluid losses from surgery and prevent dehydration while protecting the integrity of the surgical site during healing.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    41 views2 pages

    Nursing Diagnosis Nursing Interventions Rationale: Independent

    Uploaded by

    Jessica Surmieda
    The document provides nursing interventions and rationales for a child at risk for volume deficit following a tonsillectomy. Key interventions include hourly monitoring of intake and output to assess fluid balance, monitoring the surgical site for signs of bleeding, discouraging activities that could promote bleeding like coughing or straw use, administering IV fluids as needed, and educating parents on post-op care. The goal is to replace fluid losses from surgery and prevent dehydration while protecting the integrity of the surgical site during healing.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    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/

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