The most immediate is the novelty of the experience itself. Amy has not had prior surgeries or hospital stay and has not been away from home. It has created apprehension in her and her parents who both work and must also take care of a younger son. Despite the demand for their presence, neither parent can stay with her overnight for the double surgery. At the same time, Amy misses school and fun with her classmates and friends. Her parents must endure and ask her also to endure the temporary separation it is costing them all. They cannot afford to lose income by omitting work. The impact on Amy includes a foreseen loss of control over the consequences of her surgery. The tonsillectomy and adenoidectomy proceeded and ended without significant problems. But afterwards, she became distressed, disoriented, complained of a sore throat and asked for her mother. She groaned, breathed noisily and swallowed excessively. She has to stay in the hospital overnight to await review the following morning and before discharge.
Parents of children who must undergo tonsillectomy are often apprehensive about its psychological effects on the children (Kim et al., 2008). A study of 43 children, aged 3-11, who underwent the procedure were surveyed for 21 days on its psychological impact on them. They were evaluated on sociality, total behavioral problems, externalizing problems, anxiety and depression, social immaturity and emotional lability. In the third week, however, their general emotional and social conditions appeared to have improved. The study concluded that tonsillectomy itself does not produce harmful effects on children's mind or emotion (Kim et al.).
An earlier prospective study, conducted at a tertiary care children's hospital for the same objective, gave an opposite finding (Goldstein et al., 2000). The 36 volunteer children were aged 2-18 and had symptoms of nighttime snoring, apneas and daytime mouth breathing. Their parents completed the standard post-surgery survey and checklist of child behavior. Results showed a high 28% prevalence of abnormal behavior consisting of behavioral, emotional and neuro-cognitive difficulties in children with obstructive sleep apnea syndrome or OSAS in 10 volunteer children. Parents reported symptoms of snoring, apneic pauses, choking, gasping, struggling for breath, restlessness during sleep, unusual sleeping positions and frequent awakenings. OSAS in children is associated with cor pulmonale and right-sided heart failure, systemic hypertension, failure to thrive, enuresis, and neuro-cognitive and behavioral disorders (Goldie et al.).
II. Recovery Process, Airway Management
For her recovery, Amy will be given 0.9% sodium chloride infusion for hydration at 90 ml per hour until she can tolerate oral fluids. She is scheduled to receive regular oral Paracetamol 855 mg. At a 4-6 hours interval. For pain relief, she will be given oral Codeine 28.5 mg and IV Tramadol 57mg. Dexamethasone 5.7mg and Ondansteron 4mg She will also be given Cephalexin antibiotics at 570 mg for 5 days after receiving an IV dose intraoperatively.
A systematic review of 10 randomized controlled trials, involving 1,035 participants, was conducted to determine the impact of perioperative antibiotics in reducing pain and other morbid conditions during recovery from tonsillectomy (Dhiwakar, 2012). Results suggest that antibiotics do not reduce pain or bleeding but they reduce fever. Risks of adverse events like skin rash and diarrhea were higher among those who received antibiotics. The study recommended against routinely prescribing antibiotics to patients undergoing tonsillectomy (Dhiwakar).
Tonsillectomy is a common procedure that must be performed only selectively because of possible fatal complications (Stuck et al., 2008). A literature search showed that it is indicated for selected infectious diseases and airway obstruction, such as tonsillar hypertrophy, and suspected malignancy. It is not indicated for viral infections for the tonsils if there is no upper airway obstruction. It is likewise no longer recommended for acute bacterial tonsillitis. It is also indicated for sleep-disordered breathing caused by adenotonsillar hypertrophy, based on clinical assessment, medical history, and sleep history (Stuck et al.).
III. Pain Assessment and Nursing Intervention
Another study evaluated the effect of administering post-anasthesia analgesic treatment for intense pain, nausea and vomiting among tonsillectomy and adenoidectory children patients (Rodica et al., 2007). The 92 respondent children patients, aged 3-18 received one of the 5 analgesic treatments post-surgery. These were intravenous fentanyl alone, intravenous fentanyl combined with an oral analgesic, intravenous morphine alone, intravenous morphine combined with an oral analgesic, and oral analgesics alone. Results showed no significant differences in pain levels, in the incidence of nausea and vomiting or the amount of oral intake among the respondent groups. Of the total, 29% experienced nausea and vomiting. More morphine equivalents were given to those who reported pain in the phase I recovery phase than those who did not report pain. The study concluded the patients received adequate pain control despite the differences in analgesics and amounts (Rodica et al.).
Intervention should focus on pain control to enable the child to drink much fluid
(UWHealth, 2011). Any prescription given should be administered as directed for the first 24 hours after surgery. If acetaminophen is allowed or suggested, the child should be given this every 4 hours continuously for the first 2 days. The doctor may have also prescribed a dose for administering every 3 hours. Pain medicine should be given 1 hour before meals to decrease pain when he or she swallows food and drink. An ice pack under the throat, chewing gum or a humidifier or vaporizer may also help (UWHealth).
IV. Post-Operative Nursing Care Plan for the First 24 Hours for Amy
At her age, Amy may be discharged after surgery. Taking fluids is very important in the first 24 hours (UWHealth, 2011). It must be started right after surgery. He should be given pain medication if pain prevents him from eating. Tylenol or acetaminophen with or without codeine may be given an hours before he is offered food. Any pain prescription given should be given as directed in the first 24 up to 48 hours. It may be acetaminophen or another for administering every 3 or 4 hours, whichever the doctor recommended on the day of surgery. All efforts should concentrate on pain control and management in the first 24 hours after surgery. Prescribed painkillers should be given even if the child does not ask for it in these first 24 hours (UWHealth).
All his or her activity should be limited in the first week (UWHealth, 2011). Especially on his or her first day, he should not be allowed to engage in any strenuous exercise or another activity, such as lifting. Instead, he should rest completely. He should stay out of school or day care for at least one week. He may lose weight but this is normal as long as he is drinking lots of fluids. The tonsillectomy diet should be served from day one to day 7 or for one week. This diet begins with clear liquids, such as water, broth, apple juice, popsicles, or kool aid. He should be allowed to choose the comfortable temperature of the drink. He may prefer to sip frequently rather drink in gulps in big gaps. He may like to eat his other favorites, such as pudding, ice cream, milk shakes or cream soup. He should be allowed to eat soft foods if he is able to do so. These may be scrambled eggs, mashed potatoes, macaroni and cheese, cooked cereal, yogurt and apple sauce. He may also express preference for solid foods this early. He should be allowed to eat what he can swallow even at this time. It is normal if he does not eat solid foods in the first week, though. What is important is that he drinks plenty of fluids. Sour or spicy foods may make his sore throat worse but will not harm him. However, do not give rough and crunchy foods…