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Tonsillitis Nursing Guide

Content revised by: Claire Hartman, RN, BSN, BFA, IBCLC

Overview: Tonsillitis

This content is intended as a Quick Reference for tonsillitis and will cover an overview as well as nursing considerations utilizing the nursing process.

 

Etiology and Epidemiology

Tonsillitis is inflammation of the tonsils, a common upper respiratory tract infection. It is usually caused by bacterial or viral infection. Tonsillitis occurs most frequently in young people aged five to fifteen (Anderson & Paterek, 2021). Risk factors for developing tonsillitis are young age and frequent exposure to germs (such as at daycare, school, or crowded living conditions). The tonsils are a first line of defense in the immune system. The decline in tonsil immune function after puberty is thought to be another reason tonsillitis is seen less frequently in adults.

Tonsillitis may also be referred to as “pharyngitis” or simply as “sore throat.” The most common viral causes of tonsillitis are (Anderson & Paterek, 2021):

  • Rhinovirus (common cold)
  • Respiratory syncytial virus (RSV)
  • Adenovirus
  • Coronavirus

The most common bacterial causes of tonsillitis are (Anderson & Paterek, 2021):

  • Group A beta-hemolytic Streptococcus (GABHS)
  • Staphylococcus aureus (staph)
  • Streptococcus pneumoniae (strep throat)
  • Haemophilus influenza (flu)

Tonsillitis accounts for 2% of outpatient visits per year in the U.S. GABHS is present in 5% to 15% of affected adults and 15% to 30% of children ages 5 to 15. Children under 5 typically have viral etiologies (Anderson & Paterek, 2021).

Tonsillitis Diagnosis

Tonsillitis is diagnosed by completing a review of the presenting signs and symptoms, performing rapid antigen testing, and/or obtaining a throat culture. A Centor Score may be used to assess the severity of symptoms and decide the next steps of treatment (Windfuhr, et al., 2016). Centor scoring involves assigning one point for each of the following four signs:

  • Exudate or swelling on tonsils
  • Tender/swollen anterior cervical lymph nodes
  • Temperature > 38°C (100.4°F)
  • Cough

Centor scoring recommends the following interventions, based on the total number of points scored:

  • 0-1: Further testing is suggested, and antibiotics are not required
  • 2-3: Rapid strep testing and a throat culture are indicated
  • 4: Rapid strep testing/ throat culture and empiric antibiotics are required

GABHS testing is specific (88% to 100%) but not sensitive (61% to 95%), making false negatives possible (Anderson & Paterek, 2021).

The differential diagnosis for tonsillitis includes:

  • Pharyngitis
  • Retropharyngeal abscess
  • Epiglottitis
  • Ludwig angina
  • Dental abscess
  • Kawasaki disease
  • Primary HIV
  • Coxsackie virus
  • Epstein-Barr virus
  • Oral candidiasis

Five or more episodes of tonsillitis in a year is considered chronic or recurrent tonsillitis. This frequency is arbitrary but warrants further clinical investigation (Anderson & Paterek, 2021). For instance, recurrent tonsillitis may be caused by primary immunodeficiency or chronic underlying infection.

Possible complications of tonsillitis include:

  • Abnormal speech
  • Chronic upper airway obstruction
  • Dehydration
  • Nephritis
  • Otitis media
  • Peritonsillar abscess
  • Rheumatic fever
  • Sleep disturbances/sleep apnea

Management

Tonsillitis is usually self-limiting. Because most cases are of viral origin, supportive care is often adequate, including:

  • Analgesia: NSAIDs like ibuprofen (Advil® or Motrin®) and/or acetaminophen (Tylenol®)
  • Antipyretics: Acetaminophen (Tylenol®)
  • Hydration

Individuals thought to have bacterial etiology from Centor scoring, antigen testing, and/or throat culture may receive antibiotics. First-line antibiotic therapy is usually penicillin, unless the person has a penicillin allergy.

The following antibiotics are typically used to treat tonsillitis:

  • Penicillin: A 10-day oral course (Amoxil®, Bactocil®, Pipracil ®)
  • Benzathine penicillin G: A one-time IM injection (Bicillin C-R®)
  • Azithromycin: A 5-day oral course (Zithromax®, Zmax®)
  • Cephalosporin: A 10-day oral course (Ancef®, Keflex®, Rocephin®)
  • Clindamycin: A 10-day oral course (Cleocin®, Clindesse®)

Tonsillectomy

Surgical removal of the tonsils (tonsillectomy) may yield short-term benefits, such as decreased school absences, fewer episodes of acute infection, and less pain. While these may contribute to increased quality of life, there are limited long-term benefits associated with tonsillectomies (Anderson & Paterek, 2021). However, in instances of chronic infection and/or airway obstruction, tonsillectomy may be recommended, depending on the severity and frequency of tonsillitis. New guidelines state that tonsillectomy may be recommended if the following criteria are present (Mitchell, et al., 2019):

  • Frequently recurring tonsillitis, designated as at least:
    • 7 episodes of tonsillitis in the past year
    • 5 episodes of tonsillitis per year in the past 2 years
    • 3 episodes of tonsillitis per year for 3 years
  • Documentation in the medical record of tonsillitis episodes must include at least one of the following:
    • Temperature ≥ 38.3°C (101°F)
    • Cervical adenopathy
    • Tonsillar exudate
    • Positive test for GABHS

Post-operatively, children may have the following symptoms related to tonsillectomy (Finestone et al., 2019):

  • Throat pain (pain may last up to 2 weeks)
    • Throat pain is often more pronounced in the morning
  • Vomiting or nausea
  • Dehydration
  • Bleeding in the mouth
  • Fever: temperature ≥ 38.3°C (101°F)

Tonsillitis Nursing Care Plan and Considerations

Assessment

Signs and symptoms of tonsillitis include:

  • Swelling and erythema at the site
  • White, gray, or yellow patches or coating on tonsils
  • Sore throat
  • Pain or difficulty swallowing
  • Pyrexia
  • Fatigue/malaise
  • Enlarged cervical lymph nodes
  • Vocal changes (scratchy or throaty voice)
  • Halitosis (bad breath)
  • Stomachache
  • Nausea
  • Neck pain/stiff neck
  • Headache
  • Ear pain (referred)
  • Rhinorrhea

Children may present with:

  • Drooling (from painful or difficult swallowing)
  • Refusal to eat
  • Unusual fussiness

Tonsillitis Nursing Diagnosis/Risk For

  • Impaired swallowing, related to pain and swelling of tonsils, as evidenced by:
    • Drooling in young children
    • Refusal to eat in young children
    • Verbalization of impaired swallowing
  • Risk for deficient fluid volume, related to pyrexia and pain/difficulty swallowing, as evidenced by:
    • Decreased urinary output
    • Verbalization of reduced fluid intake
    • Headache secondary to dehydration
  • Acute pain, related to inflammation of tonsils as evidenced by:
    • Verbalization of sore throat, headache, or neck pain
    • Difficulty swallowing
    • Tender lymph nodes
    • Fussiness in children
    • Refusal to eat
    • Swelling and erythema of tonsils
  • Hyperthermia, related to fever secondary to infection, as evidenced by:
    • Fever: Temperature of > 38°C (100.4°F)
    • Symptoms of fever, such as flushing, being hot to the touch, and sweating or chills
  • Ineffective airway clearance related to swelling and inflammation of the throat, as evidenced by:
    • Coughing
    • Drooling in children
    • Difficulty and pain swallowing
    • Inflamed submandibular lymph nodes
  • Fatigue secondary to infection, as evidenced by:
    • Verbalization of fatigue or disrupted sleep patterns
    • Malaise
    • Increased napping and/or fussiness in children

Interventions

  • Obtain labs as ordered
  • Administer medications as prescribed
  • Encourage fluid intake
  • Assess pain level
  • Monitor vital signs, especially temperature
  • Provide a restful, humidified environment
  • Educate about home care and medication regimen
  • Monitor intake and output
  • Offer ice or popsicles to reduce throat pain
  • Encourage warm saline gargles and throat lozenges for pain
  • Advise bedrest while febrile
  • Provide information about possible adverse effects of antibiotics, if prescribed:
    • Nausea
    • Yeast infection
    • Rash
    • Headache
    • Bacterial resistance with overuse

Expected Outcomes

  • Demonstrates reduced difficulty with swallowing
  • Verbalizes or demonstrates reduced pain
  • Demonstrates decreased fatigue
  • Demonstrates adequate fluid volume intake
  • Verbalizes understanding medication regimen
  • Verbalizes self/home care recommendations
  • Verbalizes/demonstrates normal sleep pattern
  • Demonstrates temperature within normal limits
  • Verbalizes or demonstrates adequate food intake

Patient/Caregiver Education

  • Maintain adequate fluid intake
  • Continue antipyretics and analgesics, as directed
  • Complete the full course of antibiotics, as prescribed
  • Wash hands frequently
  • Do not return to school/work until 24 hours after antibiotics have begun
  • Do not share personal items (cups, spoons, straws, etc.)
  • Contact the provider if condition worsens or symptoms do not improve after 1-2 days of antibiotic therapy
  • Avoid salty or irritating foods
  • Avoid ill people

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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2024

Content Contributor

The content was revised by Claire Hartman, RN, BSN, BFA, IBCLC.

Claire Hartman, RN, BSN, BFA, IBCLC is a SME nurse writer for Relias in Acute Care. She has nursing experience in functional medicine, neonatal intensive care, and obstetrics, with a focus in high-risk obstetrics and perinatal hospice care. She is an Internationally Board Certified Lactation Consultant and has taught neonatal resuscitation, breastfeeding support, and routine gynecological care to providers in varied medical settings and has led community support groups for bereaved families experiencing perinatal loss. For over ten years, Ms. Hartman has worked in birth, with nursing experience in both a large public teaching hospital and a small, private birth center. In addition to obstetrics, she is enthusiastic about frontiers in functional medicine, and the burgeoning field of trauma-informed care. She holds degrees in both nursing and fine arts from the University of North Carolina at Chapel Hill.

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