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CAPITOL MEDICAL CENTER COLLEGES, INC.
COLLEGE OF NURSING#4 STO. DOMINGO AVENUE QUEZON CITY
CASE PRESENTATION ABOUT
OTITIS MEDIA
I. Introduction
BACKGROUND OF THE STUDY
Otitis media with effusion (OME), also called serous or secretory
otitis media(SOM), is simply a collection of fluid that occurs within the middle ear space as a result of the negative pressure produced by altered Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle ear fluid can become very thick and glue-like (thus the name glue ear), which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care increased the duration of OME in the first two years of life
OBJECTIVE
General Objective: This case study aims to identify and determine the health
problem and needs of the patient who underwent for Otitis Media. This is all intends to help patient to promote health and medical understanding of such condition through application of the nurse skills
Specific Objective:
1. To assess and diagnose the condition of the patient
2. To give an effective nursing care plan to the patient
3. To help the patient improve from the illness
4. To give an optimum nursing care related skills to the patient
THEORETICAL FRAMEWORK
“Dorothea Elizabeth Orem”
“Self care” model of nursing.
In maintaining and promoting life processes. Regulating physiological modes of functioning in health and disease, promoting human growth and development and regulating position and movement in space.
The Orem model is based upon the philosophy that “All patient wish to care for themselves”.
Orem’s theory s specifically focuses on the nurse’s approach towards person’s who are limited in their ability to take care of themselves.
According to Orem, “individuals take actions to meet others human health needs”Nurses should ultimately provide a therapeutic human health service.
They can recover more quickly and holistically if they are allowed to perform their own self cares to the best of their ability. It is a particularly used in rehabilitation and primary care settings where the patient is encouraged to be as independent.
II.
1. NURSING HEALTH HISTORY Patient’s Profile Name : Mr. “B”
Address : Quezon City
Age : 10
Sex : Male
Civil Status : Single
Religion : Roman Catholic
Medical Diagnosis : Otitis Media
Chief Complaint : fluid secretions and bleeding
Name of Physician : Dr. Rosalina A. Bautista
Date & Time of Admission : March 8 2011
History of Present Illness
Patient complained of pain in ear and mild loss of hearing 2 weeks prior to consultation child’s parent ignored the signs and symptoms due to that the child have common colds and coughs. 1 week PTC patient was admitted to our institution because of dengue fever. He was still complaining of ear pain and parent saw secretions in ear, when the child’s parent cleaned his ear blood showed and physicians diagnosed otitis media. Patient was given medications.
Past Medical History
The patient was diagnosed with dengue fever and had common colds
Family Medical History
The patient mother’s side has a story of hypertension whereas the father side has none of any hereditary complications
Social History
The patient grew up with his parents and was taught with Pilipino values and belief, the patient normally goes to school and likes to play with his schoolmates, and his mother picks him up from after school hours. He likes to watch cartoons. And goes outside of their house to play with his friends
Environmental HistoryPatient lives in a subdivision away from the main road and have proper security
•Immunization History
Patient has a complete immunization record
2. PHYSICAL ASSESSMENT
Body Part Normal Findings Actual Findings Analysis/Interpretation
Skin
-Varies from light to deep brown; from ruddy pink to light pink; from yellow to overtones to olive-Generally uniform except in areas exposed to sun-no edema-freckles, some birthmarks some flat and raised nevi; no abrasions or other lesions-moisture in skin folds and the axillae (varies w/ environmental temp. & activity)
The skin color is light brown and uniform expect in exposed areas no edemas, some birthmarks were found. No skin lesions
Normal
Hair
-Evenly distributed hair-Thick hair-Silky reslient hair-No infection / infestation
Evenly Distributed hairThick hair
Normal
Nails
-Convex, curvature, angles of nail plate about 160degrees-Smooth texture-Highly vascular & pink in light-skinned clients, may have brown/black pigmentation in longitudinal streaks-Intact epidermis-Prompt return of pink/usual color (generally < 4sec)
Convex smooth texture highly vascular intact epidermis returns to usual color almost immediately
Normal
Skull & Face
-Rounded (normocephalic and symmetric)-Symmetric or slightly asymmetric facial features;-Phalpebral fissures equal in size; symmetric nasolabial folds
Normocephalic asymmetric facial features
Normal
Ears
-Color same as facial skin-Symmetrical-Auricle aligned with outer cantus of eye, about 10 degrees from vertical-Mobile, firm, and not tender; pinna recoils after it is folded.
Color is same with facial skin, symmetrical, mobile firm and not tender pinna recoils
Normal
Outer Ears
-Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown
Secretion of thick and glue-like cerumen and blood from the ears due toAllergic reactions
Secretion of thick and glue-like cerumen and blood from allergic reaction
External Eyes
-Hair evenly distributed.-Eyebrows symmetrically align; equal movement.-Equally distributed; curled slightly outward. Skin intact; no discharge or discoloration.-Shiny, smooth, & pink/red-no edema/tenderness over lacrimal gland
Equally distributed; curled slightly outward. Skin intact; no discharge or discoloration.
Normal
Hearing Acuity
Able to hear whisper spoken 2 feet away.
Cannot hear whisper spoken in 2 feet away
Indication of complication due to the illness it blocks hearing abilities
Ears
-Transparent, shiny, and smooth; details of the iris are visible-Black in color; equal in size; normally 3 to 7 mm in diameter; round, smooth border, iris flat and round-Pupil constricts when looking near objects-When looking straight ahead, client can see objects in the periphery.-Both eyes coordinates, move in union, with parallel alignment
Transparent,Details of iris are visibleBlack in colorSymmetrical to the other
Normal
Nose
-Symmetric & straight-No discharge / flaring. -Uniform color-Mucosa pink-Clear watery discharge.
Uniform in color, no discharge
Normal
Lips & Buccal Mucosa
-Uniform pink color-Soft moist, smooth texture-Symmetry of contour-Ability to purse lips-Smooth, moist soft glistering and elastic texture
Uniform pink color, Soft moist Smooth texture
Normal
Teeth & Gums
-Uniform pink color-Soft moist, smooth texture-Symmetry of contour-Ability to purse lips-Smooth, moist soft glistering and elastic texture
Uniform pink color, Soft moist Smooth texture
Normal
Tongue
-Central position-Pink color-Moves freely
Moves freely Pink color
Normal
Palates & Uvula
-Position in the midline of the soft palate-Light pink-Smooth, soft palate.
Light pink, Position in the midline of the soft palate
Normal
Neck
Proportional to the size of the body and head, symmetrical and position.
Proportional to the size of the body and head, symmetrical and position.
Normal
Breast
- Color of the skin same with the abdomen
Color of the skin same with the abdomen
Normal
Abdomen
-Unblemished skin, uniform color-Sliver white striae (stretch marks) / surgical scars-Flat rounded (convex), scaphoid (concave)-No evidence of enlargement of liver or spleen
Unblemished skin, uniform colorNo evidence of enlargement of liver or spleen.
Normal
Thorax & Lungs
-Respirations should be unlabored and regular in all ages-Respirations should be2 yrs to 10 yrs: 20-28 breaths per min.10 yrs to 18 yrs: 12-20 breaths per min.-Hyperresonance is the normal ton elicited in young children because of thinness of the chest wall.
unlabored and regular respirations within range of normal breaths per min
Normal
Heart
-Normal Heart rates - The two heart sound re audible in all areas but loudest and apical area.
Two heart sound is audible
Normal
Genitalia
No discharges and no swelling
No discharges and no swelling
Normal
Scrotum
-Scrotal skin is darker on color than that of the rest of the body and is loose. Size varies with temperature changers. Scrotum appears asymmetric
Size varies with temperature changers Scrotum appears asymmetric
Normal
Inguinal -No swelling or bulges
No swelling or bulges
Normal
Upper Extremities
-Skin color varies, skin is smooth, fine hair evenly distributed- Muscles appear equal, warm and with good muscle tone.
Muscles appear equalwarm and with good muscle tone.
Normal
Lower Extremities
Skin color varies, skin is smooth, fine hair evenly distributed, and absence of varicose veins, muscles is symmetrical, length symmetrical.Muscles appear equal, warm and with good muscle tone.
Muscles is symmetrical, length symmetrical.Muscles appear equal, warm and with good muscle tone.
Normal
Neurologic
-Cerebral function:The client should be alert and active, respond appropriately, and relate well to the parent and the nurse.-Sensory function:Sensitivity to touch and discrimination should be present.
-Cerebral functionPatient Is alert but requires several repetition and increased tones to be heardSensory Function: Patient is sensitive when touch
Cerebral functions have been altered due to that hearing is weakened because of the illness but sensory functions are normal
3. GORDON’S PATTERN OF FUNCTIONINGPatterns of
FunctioningNormal
FunctionsBefore
ComplicationDuring
ComplicationAnalysis /
Interpretation
1. Health Perception
Regular exercise, check-ups, maintenance visit for screening examination.
No regular check-ups but have a regular exercise pattern
Patient have checkups and maintains exercise.
Patient visits physician for consultations and check ups
2. Activity & Exercise
Moves freely, easily, rhythmically and purposely in the environment. Participates in exercise programs for at least 2-3 times a week.
Moves freely, easily, rhythmically and purposely in the environment.
Moves freely, easily, rhythmically and purposely in the environment.
Patient’s activities was not altered during his illness
3. Nutrition & Metabolism
Eats 3 meals a day, needs protein rich food and breakfast to sustain the prolonged physical and mental effort. Reduced sodium consumption. Drink at least 8 or more servings of liquids.
Eats 3 meals a day, eats junk foods and sweets, likes to drink water, drinks carbonated beverages
Eats 3 times a day, still eats junk foods and sweets and drinks water
Even though patient was eating junk foods. His nutrition was not altered because of his illness
4.Elimination General range of urination is from 1-2 times a day. Average daily urine output is 1200-1500 ml. An average defecation is from 1-2 times a day. No discomforts on urinating and defecating.
Patient has normal bowel elimination. Usually eliminates during the morning
Patient still has normal bowel movements.
Patient’s elimination pattern was not altered because of his illness
5. Sleep & Rest
Most healthy adult needs 7 to 9 hours of undisturbed sleep because they tend to have sleeping disorders.
Have a normal sleeping pattern. Usually around 8-10 hours
Patient still have a normal sleeping pattern even with complication
Sleep and rest was not altered by the illness
6. Cognition & Perception
Alert, oriented in time, place, person, understand verbal and written words.
Patient was alert when name is called, answers questions properly and can understand verbal and written words
Patients alertness was altered and usually needs to be called more than once to respond can understand written words but verbal words must be repeated
Patients perception was altered due to that hearing was affected and greatly reduced its perception
7. Self Perception & Self Control
Establishing priority of needs, recognizing both self and others.
Patient’s priority and needs are focused to his nutrition, studies entertainment, and usually likes to play. Patient can recognize his parents relatives and friends
Patient’s priority was focused on his hearing abilities, his hearing senses were weakened therefore turning his priority to his hearing. Patient still recognize his parents relatives and friends
Patient’s control was altered due to that there is pain in his ear and usually focuses his attention to it when pain occurs
8. Roles & Relationship
Family roles, work roles, student roles and social roles.
Patient maintains his roles as a child and as a student
Patient maintains his roles as a child and as a student
Patient’s role was not altered
9. Coping & Stress Tolerance
Maintaining social status and standard of living. Can express thoughts and anger without any hesitation.
Patient usually maintain stress by playing hand held gadgets or plays with his friends
Patient plays alone and gets irritated from pain
Patient’s stress tolerance increased due to pain from the illness
10. Sexuality & Reproductive
Sexual activity is common. Establishes own lifestyle and values
N/A N/A N/A
11. Values & Beliefs
New found appreciation for the past; increased respect for inner voice.
N/A N/A N/A
Laboratory / Diagnostic Examinations
Physical Examination Pneumatic otoscope- blows a puff of air
into the ear canal, to check for fluid behind the eardrum. A normal eardrum will move back and forth more easily than an eardrum with fluid behind it.
Tympanometry- uses sound tones and air pressure, is a diagnostic test a doctor might use if the diagnosis still isn’t clear. A tympanometer is a small, soft plug that contains a tiny microphone and speaker as well as a device that varies air pressure in the ear. It measures how flexible the eardrum is at different pressures.
III. CLINICAL/ DIAGNOSTIC PROCEDURES
ANATOMY AND PHYSIOLOGY
Anatomy of an Ear
The ear is the organ of hearing. The parts of the ear include:
External or Outer Ear, consisting of:Pinna or Auricle - the outside part of the ear.External auditory canal or tube - the tube that
connects the outer ear to the inside or middle ear.
Tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear from the middle ear.
Middle ear (tympanic cavity), consisting of:Ossicles - three small bones that are connected
and transmit the sound waves to the inner ear. The bones are called:○ malleus○ incus○ stapes
Eustachian tube - a canal that links the middle ear with the throat area. The eustachian tube helps to equalize the pressure between the outer ear and the middle ear. Having the same pressure allows for the proper transfer of sound waves. The eustachian tube is lined with mucous, just like the inside of the nose and throat.
inner ear, consisting of:cochlea (contains the nerves for hearing)vestibule (contains receptors for balance)semicircular canals (contain receptors for
balance
PATHOPHYSIOLOGY:
MEDICAL AND SURGICAL
MANAGEMENT
Drug studyGeneric Name Brand
Name Dosage Mechanism Indications Contraindicati
ons Adverse Reactions
Nsg responsibilities
Clarithromycin Clariget 125 mg/ 5ml BID
macrolide antibiotic used to treat pharyngitis, tonsillitis, acute maxillary sinusitis, acute bacterial exacerbation of chronic bronchitis, pneumonia (especially atypical pneumonias associated with Chlamydia pneumoniae or TWAR), skin and skin structure infections, and, in HIV and AIDS patients to prevent, and to treat, disseminated Mycobacterium avium complex or MAC
Treatment of upper & lower resp tract infections, acute Otits Media & skin & soft tissue infections.
Concomitant therapy w/ terfenadine in patients w/ preexisting cardiac abnormalities or electrolyte disturbances. Pregnancy & lactation
Nausea, dyspepsia, abdominal pain, vomiting & diarrhea. Headache, taste perversion, transient elevation of liver enzymes.
Culture infection before therapy. Do not cut or crush, and ensure that patient does not chew ER tablets. Monitor patient for anticipated response. Administer without regard to meals; administer with food if GI effects occur
Generic Name Brand Name
Dosage Mechanism Indications Contraindications
Adverse Reactions
Nsg responsibilities
Levocetirizine dihydrocloride
Xyzal 10ml HS The active component of Xyzal, Levocetirizine dihydrochloride, is the R enantiomer of cetirizine hydrochloride, a racemic compound with antihistaminic properties. It is an orally active and selective H1-receptor antagonist. Histamines act on H1 receptors, causing the symptoms commonly seen in allergic reactions.
Symptomatic treatment of seasonal & perennial allergic rhinitis including persistentAllergic Rhinitis & Chronic idiopathic uticaria
End-stage renal disease, patients undergoing dialysis.
Dry mouth, headache, fatigue, somnolence, asthenia.
Monitor VS Observe dizziness and excessive sedation
NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“Nahihirapan po ako makarinig. Mahina po ang pang rinig ko” as verbalized by the patient
Objective:
- Change in Usual response
-irritability
-restlessness
-disorientation
Altered Olfactory reception related to bacterial infection as manifested by Change in Usual
response, irritability,
restlessness, and disorientation
Short Term Goal: After 2 hours of
nursing intervention the the px will be able to recognize
and compensate for sensory impairment
Long Term Goal: After 4 hours of
nursing intervention the patient will be
able to use resources effectively
and appropriately
Identify patient with condition that can affect sensing, interpreting and communicating stimuli
Encourage use of listening devices
Interpret stimuli feedback
Discuss Drug regimen, noting possible toxic side effects of both prescription and OTC drugs
To assess contributing factors affecting sensory perception
To assist managing auditory impairment
To assist patient to sperate reality from fantasy or altered perception
Prompt recognition of side effects allows for timely intervention
After 2 hours of nursing intervention the the px will be able to recognize and compensate for sensory
impairment
After 4 hours of nursing intervention the patient
was able to use resources effectively and
appropriately
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“ano po ba tong sakit ko? Gusto ko po malaman” as verbalized by the patient
Objective:
- interest to learn
Knowledge deficit related to lack of
education on illness as
manisfested by interest to learn
Short Term Goal: After 30 mins of
nursing intervention the the px will be
able to verify accuracy of information
Long Term Goal: After 1 hour of
nursing intervention the patient will be able to verbalize understanding of
information gained
Verify patient’s level of knowledge about specific topic
Assist patient to identify learning goals
Ascertain preffered methods of learning
Provides opportunity to assure accuracy and completeness of knowledge base for future learning
Helps focus content to be learned
Identifies best approaches to facilitate learning process
To assist patient to sperate reality from fantasy or altered perception
Prompt recognition of side effects allows for timely intervention
After 2 hours of nursing intervention the the px will be able to recognize and compensate for sensory
impairment
After 4 hours of nursing intervention the patient
was able to use resources effectively and appropriately