CAPITOL MEDICAL CENTER COLLEGES, INC.

COLLEGE OF NURSING
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#4 Sto. Domingo Avenue Quezon City

CASE PRESENTATION ABOUT Otitis Media

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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 6/2/12

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:
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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. Orems theory s specifically focuses on the nurses approach towards persons who are limited in their ability to take care of themselves.
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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 6/2/12

II.

1. NURSING HEALTH HISTORY

Patients
Name Address Age Sex Civil Status Religion Medical Diagnosis Chief Complaint
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Profile
: Mr. B : Quezon City : 10 : Male : Single : Roman Catholic : Otitis Media : fluid secretions and bleeding : Dr. Rosalina A. Bautista

Name of Physician

 History

of Present Illness

Patient complained of pain in ear and mild loss of hearing 2 weeks prior to consultation childs 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 childs parent cleaned his ear blood showed and physicians diagnosed otitis media. Patient was given medications.

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 Past

Medical History

The patient was diagnosed with dengue fever and had common colds

Family

Medical History

The patient mothers side has a story of hypertension whereas the father side has none of any hereditary complications

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 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

History

Patient lives in a subdivision away from the main road and have proper security

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Immunization History
has a complete immunization

Patient

record

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2. PHYSICAL ASSESSMENT
Body Part

Normal Findings Actual Findings

Analysis/Interpretation

Skin

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-Varies from light to The skin color is light Normal deep brown; from brown and uniform ruddy pink to light expect in exposed pink; from yellow to areas no edemas, overtones to olive some birthmarks were -Generally uniform found. No skin lesions 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)

Hair

-Evenly distributed Evenly Distributed hair hair -Thick hair Thick hair -Silky reslient hair -No infection / infestation

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 Normal texture highly vascular intact epidermis returns to usual color almost immediately

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Skull & Face

-Rounded Normocephalic (normocephalic and asymmetric facial symmetric) features -Symmetric or slightly asymmetric facial features; -Phalpebral fissures equal in size; symmetric nasolabial folds

Normal

Ears
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-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, Secretion of thick grayish tan color; orand glue-like sticky, wet cerumen cerumen and blood in various shades offrom the ears due to brown Allergic reactions

Secretion of thick and glue-like cerumen and blood from allergic reaction

External

-Hair evenly distributed. -Eyebrows symmetrically align; equal movement. -Equally distributed; curled slightly Eyes 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

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Hearing Acuity

Able to hear whisper spoken 2 feet away.

Cannot hear whisper Indication of spoken in 2 feet away complication due to the illness it blocks hearing abilities

Ears

-Transparent, shiny, Transparent, and smooth; details of Details of iris are the iris are visible visible -Black in color; equal in Black in color size; normally 3 to 7 Symmetrical to the mm in diameter; round, other 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

Normal

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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 Uniform pink color, texture Soft moist Smooth -Symmetry of contour texture -Ability to purse lips -Smooth, moist soft glistering and elastic texture -Uniform pink color

Normal

Teeth & Gums

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-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 Light pink, Position in midline of the soft the midline of the soft palate palate -Light pink -Smooth, soft palate. 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

Neck

Normal

Breast
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- Color of the skin same with the abdomen

Color of the skin same Normal with the abdomen

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
-Respirations should be unlabored and regular in all ages -Respirations should be 2 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.

Unblemished skin, uniform color No evidence of enlargement of liver or spleen.

Normal

unlabored and regular Normal respirations within range of normal breaths per min

Thorax & Lungs

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Heart

-Normal Heart rates Two heart sound is - The two heart audible sound re audible in all areas but loudest and apical area.

Normal

No discharges and no No discharges and no Normal swelling swelling

Genitalia
-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 Normal temperature changers Scrotum appears asymmetric

Scrotum

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Inguinal

-No swelling or bulges

No swelling or bulges

Normal

Upper Extremities

-Skin color varies, Muscles appear equal Normal skin is smooth, fine warm and with good hair evenly distributed muscle tone. - Muscles appear equal, warm and with good muscle tone.

Lower Extremities

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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 function Patient Is alert but requires several repetition and increased tones to be heard Sensory 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

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Functioning
1. Health Perception

3. GORDONS PATTERN OF FUNCTIONING Patterns of Normal Before During

Functions

Analysis / Complication Complication Interpretation

Patient visits physician for consultations and check ups

Regular exercise, No regular check- Patient have check-ups, ups but have a checkups and maintenance visit regular exercise maintains for screening pattern exercise. examination.

2. Activity & Exercise

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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, Patients activities easily, was not altered rhythmically and during his illness purposely in the environment.

3. Nutrition & Metabolism

Eats 3 meals a Eats 3 meals a day, needs protein day, eats junk rich food and foods and breakfast to sweets, likes to sustain the drink water, prolonged drinks physical and carbonated mental effort. Reduced sodium beverages consumption. Drink at least 8 or more servings of liquids.

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 Patient has Patient still has urination is from 1-2 normal bowel normal bowel times a day. elimination. movements. Average daily urine Usually output is 1200-1500 eliminates during ml. An average defecation is from the morning 1-2 times a day. No discomforts on urinating and defecating.

Patients elimination pattern was not altered because of his illness

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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 Sleep and rest a normal was not altered sleeping pattern by the illness even with complication

6. Cognition & Perception

Alert, oriented in Patient was alert Patients alertness Patients time, place, when name is was altered and perception was person, called, answers usually needs to altered due to understand verbalquestions be called more that hearing was and written properly and can than once to affected and words. understand verbalrespond can greatly reduced and written words understand its perception written words but verbal words must be repeated

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7. Self Perception & Self Control

Establishing priority of needs, recognizing both self and others.

Patients priority Patients priority Patients control and needs are was focused on was altered due focused to his his hearing to that there is nutrition, abilities, his pain in his ear studies hearing senses and usually entertainment, were weakened focuses his and usually therefore attention to it likes to play. turning his when pain Patient can priority to his occurs recognize his hearing. Patient parents relatives still recognize and friends his parents relatives and friends

8. Roles & Relationship

Family roles, Patient Patient Patients role work roles, maintains his maintains his was not altered student roles roles as a child roles as a child and social roles. and as a student and as a student

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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

Patients stress tolerance increased due to pain from the illness

10. Sexuality & Sexual activity is Reproductive common. Establishes own lifestyle and values

N/A

N/A

N/A

11. Values & Beliefs

New found N/A appreciation for the past; increased respect for inner voice.

N/A

N/A

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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.

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 Tympanometry-

uses sound tones and air pressure, is a diagnostic test a doctor might use if the diagnosis still isnt 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.

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III. CLINICAL/ DIAGNOSTIC PROCEDURES

ANATOMY AND PHYSIOLOGY Anatomy of an Ear

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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.

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 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.

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 inner

ear, consisting of:

cochlea (contains the nerves for hearing) vestibule (contains receptors for balance) semicircular canals (contain receptors for

balance

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Pathophysiology:

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Medical and surgical management

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Drug study
Generic Name Brand Name Dosage Mechanism Indications Contraindications Adverse Reactions Nsg responsibilities Clarithromycin Clariget 125 mg/ 5ml macrolide antibiotic Treatment of BID used to treat upper & lower pharyngitis, tonsillitis, resp tract acute maxillary infections, sinusitis, acute acute Otits bacterial Media & skin & exacerbation of soft tissue chronic bronchitis, infections. 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 Concomitant Nausea, therapy w/ dyspepsia, terfenadine in abdominal patients w/ pain, preexisting cardiac vomiting & abnormalities or diarrhea. electrolyte Headache, disturbances. taste Pregnancy & perversion, lactation 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

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Generic Name

Brand Name Dosage

Mechanism

Indications

Contraindications Adverse Reactions

Nsg responsibilities

Levocetirizine dihydrocloride

Xyzal

10ml HS

The active Symptomatic End-stage renal component of Xyzal, treatment of disease, patients Levocetirizine seasonal undergoing dihydrochloride, is & perennial dialysis. the R enantiomer of allergic cetirizine rhinitis including hydrochloride, a persistentAllergic racemic compound Rhinitis & Chronic with antihistaminic idiopathic uticaria properties. It is an orally active and selective H1-receptor antagonist. Histamines act on H1 receptors, causing the symptoms commonly seen in allergic reactions.

Dry mouth, headache, fatigue, somnolence, asthenia.

Monitor VS Observe dizziness and excessive sedation

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Nursing care plan

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Assessment Subjective:

Diagnosis

Planning

Intervention

Rationale 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

Evaluation 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

Altered Olfactory Short Term Goal: After Identify patient reception related to 2 hours of nursing with condition that Nahihirapan po ako bacterial infection as intervention the the px can affect sensing, makarinig. Mahina manifested by will be able to interpreting and po ang pang rinig ko Change in Usual recognize and communicating as verbalized by the response, irritability, compensate for stimuli patient restlessness, and sensory impairment Encourage use of disorientation Long Term Goal: listening devices After 4 hours of Objective: nursing intervention Interpret stimuli the patient will be able feedback - Change in Usual to use resources response Discuss Drug effectively and regimen, noting -irritability appropriately possible toxic side -restlessness -disorientation effects of both prescription and OTC drugs

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Assessment Subjective:

Diagnosis

Planning

Intervention

Rationale 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

Evaluation 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

Knowledge deficit Short Term Goal: After Verify patients level related to lack of 30 mins of nursing of knowledge about ano po ba tong sakit education on illness intervention the the px specific topic ko? Gusto ko po as manisfested by will be able to verify malaman as Assist patient to interest to learn accuracy of verbalized by the identify learning information patient goals Long Term Goal: After 1 hour of nursing Ascertain preffered intervention the patientmethods of learning Objective: will be able to verbalize - interest to learn understanding of information gained

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