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 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.
& 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
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

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 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
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
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
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 color
No evidence of
enlargement of
liver or spleen.
Normal



Thorax &
Lungs
-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.
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
equal
warm 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





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. GORDON’S PATTERN OF FUNCTIONING
Patterns of
Functioning
Normal
Functions
Before
Complication
During
Complication
Analysis /
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:

Drug study
Generic Name Brand
Name
Dosage Mechanism Indications Contraindicati
ons
Adverse
Reactions
Nsg
responsibiliti
es
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 Contraindicati
ons
Adverse
Reactions
Nsg
responsibiliti
es
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 includin
g
persistentAller
gic Rhinitis &
Chronic
idiopathic
uticaria
End-stage renal
disease,
patients
undergoing
dialysis.
Dry
mouth,
headache,
fatigue,
somnolen
ce,
asthenia.
Monitor VS

Observe
dizziness and
excessive
sedation
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