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Tonsillectomy: Procedure and Nursing Care
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
Tonsillectomv d
PROCEDURE AND NURSINGCARE
Jeanne I? Sant, RN
A
pproximately 1 million tonsillectomiesare performed annually, with a mortality rate of 1:16,000, the major cause of death is anoxia due to airway obstruction and bleeding.’ Although local anesthesia is used, a tonsillectomy cannot be considered a routine or a minor procedure; the patient is conscious and anxious and needs the skills of a caring and competent surgical team. The trend is toward performing tonsillectomies on an outpatient basis. Some outpatient centers keep their patients eight to 10 hours after a tonsilloadenoidectomy, which is what the American Academy of Otolaryngology-Head and Neck Surgery recommends.* Although controversy surrounds the indications for tonsillectomy, there are some general indications and contraindications for performing this procedure. (See “Tonsillectomy Candidates.”) For example, enlarged tonsils are not an absolute indication for tonsillectomy; tonsils can be enlarged without being infected, and one tonsil can be larger than the other in the same patient? There is no “normal” size for a tonsil. A tonsillectomy is most commonly performed if the patient has recurrent episodes of tonsillitis and does not respond to medical treatment, and hypertrophy begins to obstruct the airway. The procedure is performed a month or longer after the infection has cleared? A tonsillectomy for adults is usually performed under local anesthesia unless the patient has an active throat reflex or is extremely anxious, which would make him or her uncooperative during the procedure. If the adenoids are removed in addition to the tonsils, general anesthesia is used. 782
Preoperative Care
B
efore surgery, the perioperative nurse explains the preoperative instructions: hospital routine, functions of team members, use of premedication and intravenous (IV) fluids, monitoring of vital signs, administration of local anesthesia, postoperative routine, and postoperative discomfort. The nurse tells the patient to abstain from food or drink from midnight the night before to prevent nausea and vomiting during and immediately after the procedure. Before surgery, the patient undergoes a general physical examination and laboratory studies. These tests ensure that blood coagulation is within normal limits. To instill a sense of confidence in the idea that the procedure will be “painless,” the nurse explains that after the initial injection of local anesthetic the patient will feel no pain-there will be only a sensation of pressure and “tugging” on the tissue.5 The patient is premedicated and taken to the
Jeanne I? Sant, RN,MS,is a clinical coordinator, operating room, Naval Hospital! Oakland Calif: She received her bachelor of science degree in nursing from the University of New Mexico, Albuquerque, and her master of science degree in education from National University, San Diego. She t3 a commander, Nurse Coy, US Navy.
me opinions or assertom contained in this article are those of the author and are not to be construed as reflecting the views of the US Navy.
NOVEMBER 1986, VOL. 44, NO 5
holding area where the nurse greets the patient and checks the chart for accuracy and a valid consent, notation of allergies, and laboratory results. The nurse completes the preoperative checklist and talks with the patient to answer any last-minute questions or to discuss concerns. The administration of IV fluid is begun before taking the patient into the operating room. To prevent delays that might increase the patient’s anxiety, the nurse ensures that the instruments necessary for the surgery are functioning. Also, the nurse checks that the emergency equipment is functioning, such as suction, endotracheal tubes, resuscitation equipment and drugs, laryngoscope, equipment to administer oxygen, and the defibrillator.
Intraoperative Care
I
n the operating room, the surgical team creates a quiet, supportive environment to decrease the patient’s anxiety and provide emotional support. The team re-evaluates the physical and emotional needs of the patient continually throughout the procedure. Team members help alleviate the patient’s fears by explaining the surgical interventions. The room is kept quiet, though, because sounds of instruments or equipment may frighten the patient. The nurse transfers the patient to an examining chair and remains at his or her side. The presence of the nurse holding a hand or touching a shoulder calms the patient while he or she is being prepared for surgery. Preparations include: a blood pressure cuff on the arm, a roll underneath the shoulder, and a towel over the eyes. The nurse hyperextends the patient’s neck and sprays the throat with a topical anesthetic of lidocaine hydrochloride (Xylocaine hydrochloride) 10% oral spray or cocaine 5% of tetracaine hydrochloride 1% that the patient spits out after a few moments. Before the local anesthesia is administered, the nurse double-checks the name and strength of the drug@)and announces the name@)before handing it to the surgeon. If several drugs are used together, the nurse separates them on the back table and labels them to avoid error. Many drugs are premixed and available in ampules, which may
AORN JOURNAL
Tonsillectomy Candidates The patient may be a candidate for a tonsillectomy if he or she has suffered from one or more of the following: recurrent episodes of tonsillitis that do not respond to medical treatment, tonsillitis resulting in febrile convulsions, peritonsillar abscess, tonsillar hypertrophy causing obstruction or deglutition, repeated attacks of purulent otitis media, suspected hearing loss due to serous otitis media, or if the patient is a diptheria carrier or needs a biopsy. A tonsillectomy is not advised if the patient has any of the following contraindications: blood dyscrasias (leukemia, purpuras, aplastic anemia, hemophelia), uncontrolled systemic disease (diabetes, heart disease, seizure disorder), cleft palate, frank or submucosal, acute infections (tonsillitis, respiratory infections), or if the patient is less than 3 years old. prevent error. The surgeon injects the local anesthetic, administering a nerve block of local 1% lidocaine hydrochloride with 1:1OO,OOOepinephrine into the anterior and posterior pillars on both sides. Then the surgeon tests the tissue by pinching the surrounding tissue with an Allis forcep. The surgeon may ask the patient to hold an emesis basin to observe his or her condition and level of consciousness. If, at any time, the patient feels faint or becomes pale, the procedure should be stopped. The nurse lowers the patient’s head between knees or helps him or her stretch out with feet elevated, if possible. The nurse assesses the patient throughout the 783
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
A small amount of blood is expected, but any bright red bleeding should be reported immediately. procedure for drug reactions and behavioral and physiological changes. The nurse must be familiar with the drugs used and be able to recognize normal and abnormal reactions to drugs.
Procedure
T
he surgeon grasps one tonsil, usually with an Allis forcep, and separates and dissects the tissue around the anterior and posterior surfaces and the superior and lateral walls. The surgeon applies a tonsil snare over the clamp and removes the tonsil. By using the snare, minimal injury occurs to the surrounding tissue; it is considered a rapid and effective technique.6 The surgeon uses suction throughout the procedure and may use an absorbable suture, if necessary. Bleeding is controlled by placing a cotton roll or pack into the fossa. The procedure is repeated to remove the other tonsil. At the end of procedure, the cotton packing is removed, and the tonsils are labeled and sent to the pathology department. All hospitals have their own procedures, though. During the procedure, the nurse documents patient care: allergies, effect of premedication,level of consciousness before and during surgery, vital signs every 15 minutes, time when local anesthetic is administered, time when the procedure begins and ends, and an intraoperativeelectrocardiogram strip (if monitored). Drugs used, including IV fluids, are also documented type, time administered, amount, and effect.
Postoperative Care
T
he patient is placed on a bed in a prone position with the head to one side or in a semisitting position until fully recovered. To check the presence of cotton packing or to check for bleeding, the nurse uses a flashlight and tongue blade to look into the throat. The nurse 784
checks vital signs every 15 minutes for one hour, and every two hours for 12 hours. The nurse observes the postoperative patient for respiratory distress and signs of hemorrhage, aspiration, and shock. Signs of hemorrhage include: bright red drainage, frequent swallowing, hypotension, and tachycardia. A small amount of blood is expected, but any bright red bleeding should be reported immediately. A “rattle” during the patient’s respiration indicates that he or she has swallowed blood; blood can be swallowed without any external sign of bleeding, and may later cause vomiting. Suction equipment and additional packing should be available. The nurse watches for signs of airway obstruction: restlessness, choking, or respiratory changes. To prevent dislodging blood clots, the nurse tells the patient to avoid coughing or sneezing for eight to 10 hours, and to avoid gargling until healing begins (a gentle rinse with water every one to two hours is recommended). When necessary, an ice collar is used to help control pain, control bleeding, and constrict blood vessels. The patient may have analgesics that do not contain aspirin. If the patient is not nauseous and the gag reflex has returned, he or she can eat ice chips and have small amounts of water. Large amounts of water may cause nausea and vomiting. Later, when the patient can eat and drink freely, large swallows are less painf~l.~ The patient is discharged within 12 to 24 hours. The nurse gives all instructions verbally and in writing. The patient is told to: observe for bleeding, especially between day five and day 10 when tissue sloughs, report any bright red drainage to the physician, follow physician’s orders regarding medications or treatments, avoid smoking, avoid lifting heavy objects for two weeks, follow a cool-liquid diet for 24 hours, then
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
a soft-and-liquid bland diet, and return to a normal diet between seven and 10 days, and return to normal activity after one to two WeekS.8 For the first few days, the patient will experience a sore throat, earache,low-grade fever, or halitosis; this is normal.
Complications
T
he 1986 study reported by the American Association of Otolaryngology-Head and Neck Surgery noted that recurrent vomiting, usually caused by swallowing of blood, is the most common complication of tonsillectomy and adenoidectomy, and that hemorrhage is the most serious complication? Vomiting can lead to dehydration, requiring special nursing care to administer liquids and medications during 0 hospitalization. Noh I . J A McCurday, Jr, “The tonsillectomyadenoidectomy dilemma,” American Fmih Physician 16 (September 1977) 137-141; J C Snow, Manual of A n e s t M , semnd ed (Boston: Little, Brown and Co, 1982) 375-376. 2. C A Raymond, ”study questions safety, economic benefits of outpatient tonsil/adenoid surgery,” Journal of American Medical Associarion 256 (July 18, 1986) 31 1-312. 3. T R BuU, Color A h of Ear, Nose, Throat Diagnosis (Chicago: Year Book Medical Publishers, 1974) 174-176. 4. W Saunders et al, Nursing Care in Eye, Eor, Nose, and Thoat Disorders (St Louis: C V Mosby Co, 1979) 243-248. 5. Ibd 6. Bull, Color A t h of f i r , Nose, Throat Diagnosis, 174-176; Saunders et al, Nursing Care in Eye, Ear, Nose, and Throat Disorders 224. 7. B Bates, A Guide to Physial Examination, third ed (Philadelphia: J B Lippincott, 1983). 8. D F Saxton, “Nursing care of adults and children with problems of the respiratory system,” in The AaWon-Wesley Manual of Nursing h a k e (Menlo Park, Calif: Addison-Wesley Publishing Co, 1983) 240. 9. Raymond, “Study questions safety, economic benefits of outpatient tonsil/adenoid surgery.” Suggestedraoding Brunner, L S; Suddarth, D S. Textbook of
Medical-
Surgical Nursing, fifth ed. Philadelphia: J B Lippincott, 1984,429. Hood, G H.TotalPatientCare:Foundationandhatice sixth ed. St Louis: C V Mosby, 1984,294. Paparella, M M Shumrick, D A. Otohtyngologv, second ed. Meyerhoff, W L; %id, A B, eds. Philadelphia: W B Saunders Co, 1980,2285.
Sterility of Preloaded Insulin Syringes Studied The increased use of preloaded insulin syringes led to a study to determine their sterility after storage at room and refrigeration temperatures for up to 28 days. The findings were reported in the August issue of the American Journal of Infection Control. According to the researchers, syringes preloaded with either neutral protamine Hagedorn (NPH) insulin or regular purified pork insulin can remain sterile for up to 28 days. Of 1,536 syringes, only seven (0.46%)were found to contain bacteria. The organisms were primarily saprophyticstaphylococci,streptococci, or Cotynebacterium. Six syringes stored at rmm temperatures (mean 24.4 “C [76 OF]) had bacterial growth, while only one syringe stored at refrigeration temperature (mean 4.4 “C [40O F ] ) had a positive bacterial culture. Although the incidence of bacteria present at room temperature was low, the researchers recommend storage at refrigeration temperatures after sterile preparation to further reduce the risk of bacterial contamination. The researchers concluded, however, that their study had two limitations to applying this data to clinical practice. First, the insulin contained in these syringes was not used in actual patient care. Additionally, even though only a few contaminated syringes were found, the impact of the contamination on a patient’s therapy is not known. Other research has shown that insulin in polypropylene syringes remains chemically stable for up to 14 days; therefore, the researchers in this study recommend additional investigation on the clinical efficacy of insulin stored for more than 14 days.
NOVEMBER 1986, VOL. 44, NO 5
Tonsillectomv d
PROCEDURE AND NURSINGCARE
Jeanne I? Sant, RN
A
pproximately 1 million tonsillectomiesare performed annually, with a mortality rate of 1:16,000, the major cause of death is anoxia due to airway obstruction and bleeding.’ Although local anesthesia is used, a tonsillectomy cannot be considered a routine or a minor procedure; the patient is conscious and anxious and needs the skills of a caring and competent surgical team. The trend is toward performing tonsillectomies on an outpatient basis. Some outpatient centers keep their patients eight to 10 hours after a tonsilloadenoidectomy, which is what the American Academy of Otolaryngology-Head and Neck Surgery recommends.* Although controversy surrounds the indications for tonsillectomy, there are some general indications and contraindications for performing this procedure. (See “Tonsillectomy Candidates.”) For example, enlarged tonsils are not an absolute indication for tonsillectomy; tonsils can be enlarged without being infected, and one tonsil can be larger than the other in the same patient? There is no “normal” size for a tonsil. A tonsillectomy is most commonly performed if the patient has recurrent episodes of tonsillitis and does not respond to medical treatment, and hypertrophy begins to obstruct the airway. The procedure is performed a month or longer after the infection has cleared? A tonsillectomy for adults is usually performed under local anesthesia unless the patient has an active throat reflex or is extremely anxious, which would make him or her uncooperative during the procedure. If the adenoids are removed in addition to the tonsils, general anesthesia is used. 782
Preoperative Care
B
efore surgery, the perioperative nurse explains the preoperative instructions: hospital routine, functions of team members, use of premedication and intravenous (IV) fluids, monitoring of vital signs, administration of local anesthesia, postoperative routine, and postoperative discomfort. The nurse tells the patient to abstain from food or drink from midnight the night before to prevent nausea and vomiting during and immediately after the procedure. Before surgery, the patient undergoes a general physical examination and laboratory studies. These tests ensure that blood coagulation is within normal limits. To instill a sense of confidence in the idea that the procedure will be “painless,” the nurse explains that after the initial injection of local anesthetic the patient will feel no pain-there will be only a sensation of pressure and “tugging” on the tissue.5 The patient is premedicated and taken to the
Jeanne I? Sant, RN,MS,is a clinical coordinator, operating room, Naval Hospital! Oakland Calif: She received her bachelor of science degree in nursing from the University of New Mexico, Albuquerque, and her master of science degree in education from National University, San Diego. She t3 a commander, Nurse Coy, US Navy.
me opinions or assertom contained in this article are those of the author and are not to be construed as reflecting the views of the US Navy.
NOVEMBER 1986, VOL. 44, NO 5
holding area where the nurse greets the patient and checks the chart for accuracy and a valid consent, notation of allergies, and laboratory results. The nurse completes the preoperative checklist and talks with the patient to answer any last-minute questions or to discuss concerns. The administration of IV fluid is begun before taking the patient into the operating room. To prevent delays that might increase the patient’s anxiety, the nurse ensures that the instruments necessary for the surgery are functioning. Also, the nurse checks that the emergency equipment is functioning, such as suction, endotracheal tubes, resuscitation equipment and drugs, laryngoscope, equipment to administer oxygen, and the defibrillator.
Intraoperative Care
I
n the operating room, the surgical team creates a quiet, supportive environment to decrease the patient’s anxiety and provide emotional support. The team re-evaluates the physical and emotional needs of the patient continually throughout the procedure. Team members help alleviate the patient’s fears by explaining the surgical interventions. The room is kept quiet, though, because sounds of instruments or equipment may frighten the patient. The nurse transfers the patient to an examining chair and remains at his or her side. The presence of the nurse holding a hand or touching a shoulder calms the patient while he or she is being prepared for surgery. Preparations include: a blood pressure cuff on the arm, a roll underneath the shoulder, and a towel over the eyes. The nurse hyperextends the patient’s neck and sprays the throat with a topical anesthetic of lidocaine hydrochloride (Xylocaine hydrochloride) 10% oral spray or cocaine 5% of tetracaine hydrochloride 1% that the patient spits out after a few moments. Before the local anesthesia is administered, the nurse double-checks the name and strength of the drug@)and announces the name@)before handing it to the surgeon. If several drugs are used together, the nurse separates them on the back table and labels them to avoid error. Many drugs are premixed and available in ampules, which may
AORN JOURNAL
Tonsillectomy Candidates The patient may be a candidate for a tonsillectomy if he or she has suffered from one or more of the following: recurrent episodes of tonsillitis that do not respond to medical treatment, tonsillitis resulting in febrile convulsions, peritonsillar abscess, tonsillar hypertrophy causing obstruction or deglutition, repeated attacks of purulent otitis media, suspected hearing loss due to serous otitis media, or if the patient is a diptheria carrier or needs a biopsy. A tonsillectomy is not advised if the patient has any of the following contraindications: blood dyscrasias (leukemia, purpuras, aplastic anemia, hemophelia), uncontrolled systemic disease (diabetes, heart disease, seizure disorder), cleft palate, frank or submucosal, acute infections (tonsillitis, respiratory infections), or if the patient is less than 3 years old. prevent error. The surgeon injects the local anesthetic, administering a nerve block of local 1% lidocaine hydrochloride with 1:1OO,OOOepinephrine into the anterior and posterior pillars on both sides. Then the surgeon tests the tissue by pinching the surrounding tissue with an Allis forcep. The surgeon may ask the patient to hold an emesis basin to observe his or her condition and level of consciousness. If, at any time, the patient feels faint or becomes pale, the procedure should be stopped. The nurse lowers the patient’s head between knees or helps him or her stretch out with feet elevated, if possible. The nurse assesses the patient throughout the 783
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
A small amount of blood is expected, but any bright red bleeding should be reported immediately. procedure for drug reactions and behavioral and physiological changes. The nurse must be familiar with the drugs used and be able to recognize normal and abnormal reactions to drugs.
Procedure
T
he surgeon grasps one tonsil, usually with an Allis forcep, and separates and dissects the tissue around the anterior and posterior surfaces and the superior and lateral walls. The surgeon applies a tonsil snare over the clamp and removes the tonsil. By using the snare, minimal injury occurs to the surrounding tissue; it is considered a rapid and effective technique.6 The surgeon uses suction throughout the procedure and may use an absorbable suture, if necessary. Bleeding is controlled by placing a cotton roll or pack into the fossa. The procedure is repeated to remove the other tonsil. At the end of procedure, the cotton packing is removed, and the tonsils are labeled and sent to the pathology department. All hospitals have their own procedures, though. During the procedure, the nurse documents patient care: allergies, effect of premedication,level of consciousness before and during surgery, vital signs every 15 minutes, time when local anesthetic is administered, time when the procedure begins and ends, and an intraoperativeelectrocardiogram strip (if monitored). Drugs used, including IV fluids, are also documented type, time administered, amount, and effect.
Postoperative Care
T
he patient is placed on a bed in a prone position with the head to one side or in a semisitting position until fully recovered. To check the presence of cotton packing or to check for bleeding, the nurse uses a flashlight and tongue blade to look into the throat. The nurse 784
checks vital signs every 15 minutes for one hour, and every two hours for 12 hours. The nurse observes the postoperative patient for respiratory distress and signs of hemorrhage, aspiration, and shock. Signs of hemorrhage include: bright red drainage, frequent swallowing, hypotension, and tachycardia. A small amount of blood is expected, but any bright red bleeding should be reported immediately. A “rattle” during the patient’s respiration indicates that he or she has swallowed blood; blood can be swallowed without any external sign of bleeding, and may later cause vomiting. Suction equipment and additional packing should be available. The nurse watches for signs of airway obstruction: restlessness, choking, or respiratory changes. To prevent dislodging blood clots, the nurse tells the patient to avoid coughing or sneezing for eight to 10 hours, and to avoid gargling until healing begins (a gentle rinse with water every one to two hours is recommended). When necessary, an ice collar is used to help control pain, control bleeding, and constrict blood vessels. The patient may have analgesics that do not contain aspirin. If the patient is not nauseous and the gag reflex has returned, he or she can eat ice chips and have small amounts of water. Large amounts of water may cause nausea and vomiting. Later, when the patient can eat and drink freely, large swallows are less painf~l.~ The patient is discharged within 12 to 24 hours. The nurse gives all instructions verbally and in writing. The patient is told to: observe for bleeding, especially between day five and day 10 when tissue sloughs, report any bright red drainage to the physician, follow physician’s orders regarding medications or treatments, avoid smoking, avoid lifting heavy objects for two weeks, follow a cool-liquid diet for 24 hours, then
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
a soft-and-liquid bland diet, and return to a normal diet between seven and 10 days, and return to normal activity after one to two WeekS.8 For the first few days, the patient will experience a sore throat, earache,low-grade fever, or halitosis; this is normal.
Complications
T
he 1986 study reported by the American Association of Otolaryngology-Head and Neck Surgery noted that recurrent vomiting, usually caused by swallowing of blood, is the most common complication of tonsillectomy and adenoidectomy, and that hemorrhage is the most serious complication? Vomiting can lead to dehydration, requiring special nursing care to administer liquids and medications during 0 hospitalization. Noh I . J A McCurday, Jr, “The tonsillectomyadenoidectomy dilemma,” American Fmih Physician 16 (September 1977) 137-141; J C Snow, Manual of A n e s t M , semnd ed (Boston: Little, Brown and Co, 1982) 375-376. 2. C A Raymond, ”study questions safety, economic benefits of outpatient tonsil/adenoid surgery,” Journal of American Medical Associarion 256 (July 18, 1986) 31 1-312. 3. T R BuU, Color A h of Ear, Nose, Throat Diagnosis (Chicago: Year Book Medical Publishers, 1974) 174-176. 4. W Saunders et al, Nursing Care in Eye, Eor, Nose, and Thoat Disorders (St Louis: C V Mosby Co, 1979) 243-248. 5. Ibd 6. Bull, Color A t h of f i r , Nose, Throat Diagnosis, 174-176; Saunders et al, Nursing Care in Eye, Ear, Nose, and Throat Disorders 224. 7. B Bates, A Guide to Physial Examination, third ed (Philadelphia: J B Lippincott, 1983). 8. D F Saxton, “Nursing care of adults and children with problems of the respiratory system,” in The AaWon-Wesley Manual of Nursing h a k e (Menlo Park, Calif: Addison-Wesley Publishing Co, 1983) 240. 9. Raymond, “Study questions safety, economic benefits of outpatient tonsil/adenoid surgery.” Suggestedraoding Brunner, L S; Suddarth, D S. Textbook of
Medical-
Surgical Nursing, fifth ed. Philadelphia: J B Lippincott, 1984,429. Hood, G H.TotalPatientCare:Foundationandhatice sixth ed. St Louis: C V Mosby, 1984,294. Paparella, M M Shumrick, D A. Otohtyngologv, second ed. Meyerhoff, W L; %id, A B, eds. Philadelphia: W B Saunders Co, 1980,2285.
Sterility of Preloaded Insulin Syringes Studied The increased use of preloaded insulin syringes led to a study to determine their sterility after storage at room and refrigeration temperatures for up to 28 days. The findings were reported in the August issue of the American Journal of Infection Control. According to the researchers, syringes preloaded with either neutral protamine Hagedorn (NPH) insulin or regular purified pork insulin can remain sterile for up to 28 days. Of 1,536 syringes, only seven (0.46%)were found to contain bacteria. The organisms were primarily saprophyticstaphylococci,streptococci, or Cotynebacterium. Six syringes stored at rmm temperatures (mean 24.4 “C [76 OF]) had bacterial growth, while only one syringe stored at refrigeration temperature (mean 4.4 “C [40O F ] ) had a positive bacterial culture. Although the incidence of bacteria present at room temperature was low, the researchers recommend storage at refrigeration temperatures after sterile preparation to further reduce the risk of bacterial contamination. The researchers concluded, however, that their study had two limitations to applying this data to clinical practice. First, the insulin contained in these syringes was not used in actual patient care. Additionally, even though only a few contaminated syringes were found, the impact of the contamination on a patient’s therapy is not known. Other research has shown that insulin in polypropylene syringes remains chemically stable for up to 14 days; therefore, the researchers in this study recommend additional investigation on the clinical efficacy of insulin stored for more than 14 days.