NCP: Impaired Oral Mucous Membrane, Tonsillitis

Tonsillitis, ATP

Need
NUTRITIONAL-METABOLIC PATTERN

Nursing Diagnosis
Impaired oral mucous membrane related to infectious process as evidenced by inflamed tonsils.

Rationale:
Tonsillitis is a common occurrence during childhood. It occurs when the tonsils become inflamed as the body’s immune system attempts to fight off invading viruses or bacteria. Symptoms of tonsillitis include red, swollen tonsils that can be painful and make swallowing difficult. The tonsils may have whitish spots or white covering on them.

Sources:
http://pediatric.healthcentersonline.com/pediatriccoldflu/tonsillitis.cfm


Objective of Care
Within my 8 hours span of care my patient will be able to achieve the following:

a. demonstrate interventions that promote healthy oral mucosa;
b. show a decrease in symptoms such as temperature in normal range.

Nursing Interventions
1. Note presence of illness, disease or trauma.
® These conditions are most likely to cause inflammation of the tonsils.
2. Determine nutrition and fluid intake.
® Without proper nutrition and hydration the oral mucosa is more vulnerable to damage.
3. Evaluate client’s ability to provide self care.
® Self care places and important part in maintaining integrity of the oral cavity.
4. Review oral hygiene practice.
® Sometimes brushing is not enough or not properly done, professional care should be necessary.
5. Routinely inspect oral cavity for sores, lesions, and or bleeding.
® These are signs that the mucosa is impaired or damage.
6. Encourage fluids.
® To prevent dehydration.
7. Use soft-bristle toothbrush.
® Limit mucosal or gum irritation.
8. Instruct parents in oral hygiene techniques and proper dental care for infants or children.
® Encourages early initiation of good oral health practices and timely intervention for treatable problems.
9. Provide nutritional information.
® To correct deficiencies, reduce irritation/ gum disease, prevent dental caries.
10. Promote general health habits.
® Altered immune response can affect the oral mucosa.

Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed.
F.A. Davis Company, Philadelphia, PA, USA