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. Orems theory s specifically focuses on the nurses approach towards persons 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 Patients 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 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.

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

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

Immunization History

Patient has a complete immunization record

2. PHYSICAL ASSESSMENT
Body Part Normal Findings Actual Findings
Analysis/Interpretati on

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.

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 hair Thick 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 -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.

Normocephalic asymmetric facial features

Normal

Color is same with facial skin, symmetrical, mobile firm and not tender pinna recoils

Normal

Ears

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 to Allergic 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 Indication of spoken in 2 feet away 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

Transparent, Details of iris are visible Black in color Symmetrical 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 Uniform pink color, texture Soft moist Smooth -Symmetry of texture contour -Ability to purse lips -Smooth, moist soft glistering and elastic texture

Normal

-Uniform pink color

Teeth & Gums

-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
-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 respirations within range of normal breaths per min

Normal

Thorax & Lungs

Heart

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

No discharges and no swelling

No discharges and no swelling

Normal

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 temperature changers Scrotum appears asymmetric Normal

Scrotum

Inguinal

-No swelling or bulges -Skin color varies, skin is smooth, fine hair evenly distributed - Muscles appear equal, warm and with good muscle tone.

No swelling or bulges Muscles appear equal warm and with good muscle tone.

Normal

Normal

Upper Extremities

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

Muscles is symmetrical, length symmetrical. Muscles appear equal, warm and with good muscle tone.

Normal

Neurologi c

-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

3. GORDONS PATTERN OF FUNCTIONING

Patterns of Functioning
1. Health Perception Normal Functions Regular exercise, check-ups, maintenance visit for screening examination. Moves freely, easily, rhythmically and purposely in the environment. Participates in exercise programs for at least 2-3 times a week. Before Complication No regular check-ups but have a regular exercise pattern During Complication Patient have checkups and maintains exercise. Analysis / Interpretation Patient visits physician for consultations and check ups

2. Activity & Exercise

Moves freely, easily, rhythmically and purposely in the environment.

Moves freely, easily, rhythmically and purposely in the environment.

Patients 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.

Patients 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.

Patients priority and needs are focused to his nutrition, studies entertainment, and usually likes to play. Patient can recognize his parents relatives and friends

Patients 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 maintains his roles as a child and as a student

Patients 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

Patients 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 N/A

Patient plays alone and gets irritated from pain

Patients stress tolerance increased due to pain from the illness

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

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 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.

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:

Drug study
Generic Name Brand Name Dosage Mechanism Indications Contraindicati ons Adverse Reactions Nsg responsibiliti es 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 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.

Generic Name

Brand Name

Dosage

Mechanism

Indications

Contraindicati ons

Adverse Reactions

Nsg responsibiliti es Monitor VS Observe dizziness and excessive sedation

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 H1receptor antagonist. Histamines act on H1 receptors, causing the symptoms commonly seen in allergic reactions.

Symptomatic treatment of seasonal & perennial allergic rhinitis includin g persistentAller gic Rhinitis & Chronic idiopathic uticaria

End-stage renal disease, patients undergoing dialysis.

Dry mouth, headache, fatigue, somnolen ce, asthenia.

Assessment Subjective: Nahihirapan po ako makarinig. Mahina po ang pang rinig ko as verbalized by the patient

Diagnosis Altered Olfactory reception related to bacterial infection as manifested by Change in Usual response, irritability, restlessness, and disorientation

Planning 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

Intervention 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

Rationale

Evaluation

Objective: - Change in Usual response -irritability

To assess After 2 hours of nursing contributing factors intervention the the px will affecting sensory be able to recognize and perception compensate for sensory impairment To assist managing auditory impairment After 4 hours of nursing intervention the patient To assist patient to was able to use resources sperate reality from effectively and fantasy or altered appropriately perception Prompt recognition of side effects allows for timely intervention

-restlessness
-disorientation

Assessment Subjective: ano po ba tong sakit ko? Gusto ko po malaman as verbalized by the patient

Diagnosis Knowledge deficit related to lack of education on illness as manisfested by interest to learn

Planning 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

Intervention Verify patients level of knowledge about specific topic Assist patient to identify learning goals

Rationale Provides opportunity to assure accuracy and completeness of knowledge base for future learning

Evaluation After 2 hours of nursing intervention the the px will be able to recognize and compensate for sensory impairment

Objective: - interest to learn

After 4 hours of nursing Helps focus content intervention the patient to be learned was able to use resources Ascertain preffered effectively and methods of Identifies best appropriately learning 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