The main complaint : Pain in the throat, painful swallowing, fever etc.
History of present illness : an attack, characteristics, incidence, progression, therapeutic effect, etc.
Past medical history :
Birth history
Immunization history
Who had suffered disease (recurrent pharyngitis, respiratory infection, otitis media)
History of hospitalization
General assessment :
Age, level of consciousness, antopometri, vital signs, etc.
Breathing
Difficulty breathing, coughing
Nutrition : Sore throat, painful swallowing, decreased appetite, refusing to eat and drink, less turgor
Activity / rest : Appear weak, lethargic, irritable, malaise
Security / comfort : Anxiety of children to hospitalization
Nursing Diagnosis and Nursing Intervention for Tonsillitis
Hyperthermia related to inflammatory processes in the pharynx and tonsils
Nursing Intervention :
Monitor the child's body temperature (degrees and patterns), note the presence of chills
Monitor the temperature of the environment
Limit the use of linen, clothing worn client
Give a warm compress
Give plenty of fluids (1500 - 2000 cc / day)
Collaboration of antipyretic
Pain related to swelling of the tonsils
Nursing Intervention :
Monitor the client's pain (scale, intensity, depth, frequency)
Assess vital signs
Provide a comfortable position
Give relaxation techniques with a long inhale through nose and release it slowly through mouth
Provide distraction techniques to divert the attention of child
Collaboration of analgesic
Source : http://blog-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-tonsillitis.html
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