KRISTIAN KARL B.

KIW-IS

Course Code RLE 116/117

Course Title ENT SURGERY
Level Offering 3rd Year 2nd Semester AY 2021
Clinical area of assignment ENT WARD
Date of Exposure APRIL 19 - 21, 2021
No. of hours 24 hours
RELATED LEARNING EXPERIENCE
ENT WARD CASE STUDY

CONGRATULATIONS! For you are a few steps away of pursuing your dream of becoming a “nurse”.
Remember: ‘The Way to Get Started Is to Quit Talking and Begin Doing.” – Walt Disney
INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the information provided, before
answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom you think can help you
understand but remember a greater amount of output should come from you, as you are the LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand and do not know what to
do. Would be thankful and gladly help you on your learning needs. You can contact me through my number Messenger/ Mobile
number/ Email address at ______________________________________________

Modular: Remember that you are given 3 days to finish this task

IDENTIFICATION OF THE CASE:

The case of a 24 month old female child who had twice episode of acute otitis media. The mother accompany patient
for medical consultation and admitted for management.
History of present illness:
LJ a 24month old female had a 3 days rhinorrhea and a day of irritability. Temperature ( 38.7 c as per mom). right ear
tugging. The mother denies that LJ had any nausea, vomitting nor diarrhea. On otoscopic examination, health care
provider sees a bulging and erythematous right tympanic membrane.her left tympanic membrane was normal.
History of past illness:
Patient was born in full term via normal spontaneous delivery. She was hospitalized at 10 month of age due to
respiratory syncytial virus associated with bronchiolitis and was treated. Two episode of acute otitis media, With last
episode about 6 month earlier.
Family history:
No history of here do familial diseases, asthma, HPN, DM, CA.
Social and environmental history:
Patient lives with parent and her 5 year old brother who attend kindergarten. LJ attends daycare twice a day per week as
visitor.and stays at home with maternal grandmother 3 days per week.
Allergies:
NO known drug allergies
Immunization:
Vaccine completed
Home medication:
Vitamin D 5gtts 600 IU/day
Paracetamol 250mg/5ml, 5ml Q4H for fever/pain
NURSING ASSESSMENT:
patient was easily irritated but comforted by mother.patient always holding her right ear and appear not listening to
what the health care provider was asking .
Vital signs prior to operation: Temp:37.0 C RR: 35bpm Wt: 23.7 kg
CR: 139 bpm Spo2: 98% Ht: 82 cm
Chief Complaint: Increased irritabilty and Right ear pain.
Clinical diagnosis: Acute Otitis media

Doctor,s order: DAT

Amoxicillin 250mg/ 5ml, 4ml TID
Paracetamol 250/5ml, 4 ml q4H for fever/pain.
Pls refer
ACITVITY # 1 ( DAY 1 )
1. NCP - EAR PAIN
2. CHARTING - IMPAIRED VERBAL COMMUNICATION
I. NURSING CARE PLAN

CUES EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

OF THE PROBLEM INTERVENTION
Subj: STG: after 5 hours of  Reduce unnecessary Goal Fully
‘’Kinakausa Otitis Media nursing intervention environmental noise. met
p ko sya (OM) the patient will be able Rationale: The child may be confused STG: after 5
pero hindi to respond when and startled by sounds he or she cannot hours of
siya spoken to. hear properly. nursing
sumasagot” infection of the intervention
as middle ear (the As manifested by active the patient is
verbalized space behind the listening able to
by the eardrum) caused  Encourage parents to speak in a respond
mother by bacteria or loud and clear voice and look at when spoken
virus the child when talking. to.
Rationale: Assists the client to hear As manifested
Obj: Inflammatory what is being said. by active
obstruction of listening
V/S as the eustachian
follows: tube  Administer antibiotics as
Temp:37.0 prescribed.
C Rationale: When indicated for bacterial
RR: 35bpm accumulation of infection, a full 10-day course of an
Wt: 23.7 kg secretions in the antibiotic is given to resolve otitis media
middle ear and regain hearing.
CR: 139
bpm
Spo2: 98% negative pressure LTG: after 3 days of  Notify caregiver of changes in
Ht: 82 cm from lack of nursing intervention hearing ability or drainage from
it is noted ventilation the patient will be able the affected ear.
the patient to regain and improved Rationale: Complications of OM may Goal Partially
does not hearing thereby include perforation of the eardrum, met
respond to otitis media with communication will be mastoiditis, or conductive hearing loss. LTG: after 3
verbal effusion established days of
noise. nursing
 Learn patient needs and pay intervention
runs a fever, is attention to nonverbal cues. the patient is
irritable, and Rationale: The nurse should set aside to regain and
complains of a enough time to attend to all of the improved
severe earache details of patient care. Care measures hearing
may take longer to complete in the thereby
presence of a communication deficit. communicatio
Nsg.dx n will be
Impaired May or may not established
Verbal have a purulent  Provide an alternative means of
Communica discharge from communication for times when
tion related the affected ear. interpreters are not available
to auditory (e.g., a phone contact who can
impairment Auditory interpret the patient’s needs).
as evidence impairment Rationale: An alternative means of
by absence communication (e.g., flash cards, symbol
of speech to boards, electronic messaging) can help
verbal the patient express ideas and
responses communicate needs.
and
inattention Verbal
to noise. communication  Clarify your understanding of
will be impaired the patient’s communication
with the patient or an
interpreter.
Rationale: Feedback promotes effective
communication.

 Avoid talking with others in

front of the patient as though
he or she comprehends nothing.
Rationale: Excluding the patient from an
interaction increases the patient’s sense
of frustration and feeling of
helplessness.

 Maintain eye contact with

patient when speaking. Stand
close, within patient’s line of
vision (generally midline).
Rationale: Patients may have defect in
field of vision or they may need to see
the nurses’ face or lips to enhance their
understanding of what is being
communicated.

 Give the patient ample time to

respond.
Rationale: It may be difficult for patients
to respond under pressure; they may
need extra time to organize responses,
find the correct word, or make
necessary language translations.

 Maintain a calm, unhurried

manner. Provide sufficient time
for patient to respond.
Rationale: Individuals with expressive
aphasia may talk more easily when they
are rested and relaxed and when they
are talking to one person at a time.
o
  Provide environmental stimuli
as needed.
Rationale: To maintain contact with
reality; or reduce stimuli to lessen
anxiety that may worsen problem.

 Try to phrase questions

requiring a “yes” and “no”
answers.
Rationale: Patients can be frustrated
when they cannot communicate in a
simple manner.

 Use short sentences, and ask

only one question at a time.
Rationale: This method allows the
patient to stay focused on one thought.

 Speak slowly.
Rationale: This approach provides the
patient with more channels through
which information can be
communicated.

 Provide concrete directions that

the patient is physically capable
of doing (e.g., “point to the
pain,” “open your mouth,” “turn
your head”).
Rationale: Simple, one-action directions
enhance comprehension for the patient
with language impairment.

 Provide practice sessions within

the day.
Rationale: Practice will increase the
patient’s communication.
II. CHARTING:

F: Acute Pain related to Inflammation and increased pressure in the middle ear as evidenced by irritable and
facial grimace secondary to Acute Otitis media

D: Received lying on bed with an ongoing IVF of PNSS 1 liter x KVO @ 700cc level
, V/S as follows: Temp:37.0 C RR: 35bpm Wt: 23.7 kg
CR: 139 bpm Spo2: 98% Ht: 82 cm
‘’Saumsakit ang kanyang kanang tenga’’ as verbalized by the mother, with facial grimace and irritable
Patient always holding her right ear and appear not listening to what the health care provider was asking.
.
A: Assessed the client’s current health status. Monitored and record vital signs closely. Assessed client’s
hearing ability. Encouraged and assisted the parent to hold and comfort the client. Administered pain
medication such as acetaminophen or ibuprofen as prescribed. Monitor child for relief of pain and any side
effects of medication. Provided information about the condition and answer any inquiries r to the mother.
Reassured parents and child that hearing loss is not permanent and will resolve with treatment.

R: The patient experienced relief from pain as manifested by absence of irritable and facial grimace.
® Deficientknowledge
isa   s t a t e   i n whichcogn
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healthrecovery,maintena
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articipateintreatmentregi
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1.
Establish rapport.® to
gain patient’s trust and
havea good nurse-
patient
relationship2. Evaluate 
desire/readiness
of patient to learn.®
determine amount or
level
of information to provi
de at anygiven
moment.3. Provide an 
atmosphere of respect
, openness, trust, andc
ollaboration.® importa
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cation to patients wit
hdifferent values and 
beliefsabout health and
illness.4. Assess moti
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learn® some patient a
re ready tolearn as so
on after they arediagn
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bydenying or delaying
the need
for instruction5. Assess
history of hepatitis
binfection® to trace the
source of infectionGoal
Met!08/19/10@7:00pm 
After 4 hours
of m y   n u r s i n g interven
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“Ah.
Kabalonako asa nam
akuha angh e a p   b   u
g unsaonpagkuha ana
na sakit.” Asverbalize
d by
83
KNOWLEDGE
DEFICIT
Prepared by: Froilan T. Adaci
Clinical Instructor