Tonsillectomy Case Study: Psychosocial and Nursing Care

Psychosocial Impacts of the Surgery

The most immediate psychosocial challenge is the novelty of the experience itself. Amy has not had prior surgeries or hospital stays and has never been away from home. This has created apprehension in her and in her parents, who both work and must also care for a younger son. Despite the demands on their presence, neither parent can stay with her overnight for the double surgery. At the same time, Amy misses school and time with her classmates and friends. Her parents must endure — and ask her to endure — the temporary separation the situation requires of them all, as they cannot afford to lose income by taking time off work.

The impact on Amy includes a perceived loss of control over the consequences of her surgery. The tonsillectomy and adenoidectomy proceeded and ended without significant problems. Afterwards, however, she became distressed and disoriented, complained of a sore throat, and asked for her mother. She groaned, breathed noisily, and swallowed excessively. She was required to stay in the hospital overnight to await review the following morning before discharge.

Parents of children who must undergo tonsillectomy are often apprehensive about its psychological effects on their children (Kim et al., 2008). A study of 43 children aged 3–11 who underwent the procedure surveyed participants for 21 days on its psychological impact. They were evaluated on sociality, total behavioral problems, externalizing problems, anxiety and depression, social immaturity, and emotional lability. By 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 mental or emotional health (Kim et al., 2008).

An earlier prospective study, conducted at a tertiary care children's hospital for the same objective, reached an opposite conclusion (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 a standard post-surgery survey and a 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 (OSAS) among 10 of the volunteer children. Parents reported symptoms including 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, right-sided heart failure, systemic hypertension, failure to thrive, enuresis, and neuro-cognitive and behavioral disorders (Goldstein et al., 2000).

Recovery Process and Airway Management

For her recovery, Amy will receive a 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 4–6 hour intervals. For pain relief, she will be given oral codeine 28.5 mg and IV tramadol 57 mg. She will also receive dexamethasone 5.7 mg and ondansetron 4 mg, as well as cephalexin antibiotics at 570 mg for five days following an intraoperative IV dose.

A systematic review of 10 randomized controlled trials involving 1,035 participants was conducted to determine the impact of perioperative antibiotics on reducing pain and other morbid conditions during recovery from tonsillectomy (Dhiwakar, 2012). Results suggest that antibiotics do not reduce pain or bleeding, though they do reduce fever. Risks of adverse events such as skin rash and diarrhea were higher among those who received antibiotics. The study recommended against routinely prescribing antibiotics to patients undergoing tonsillectomy (Dhiwakar, 2012).

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 of the tonsils when there is no upper airway obstruction, and it is likewise no longer recommended for acute bacterial tonsillitis. It is indicated for sleep-disordered breathing caused by adenotonsillar hypertrophy, based on clinical assessment, medical history, and sleep history (Stuck et al., 2008).