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.
Monitor V/S Q4H and record
Pls refer
ACITVITY # 1 ( DAY 1 )
1. NCP - EAR PAIN
2. CHARTING - IMPAIRED VERBAL COMMUNICATION

2nd DAY NURSING ASSESSMENT:

8am > Received awake cuddled by mother, not in any form of respiratory distress, hides her face when tried to
communicate with, refuse and cries when tried to take vital sign but consolated by mother.mother states “ hindi ko
alam etong nararamdaman niya at konte kinakain nya”.
Vital signs were as follows: Temp: 38.2 C RR: 37 bpm
CR: 131bpm Spo2: 98 %

Doctor’s order: DAT

Continue meds
Multivitamin 125mg/ 5ml, 4ml OD
Monitor V/S Q4H and record
Refer accordingly

ACTIVITY # 2 ( DAY 2 )
1. NCP - KNOWLEDGE DEFICIT
2. CHARTING - FEVER
I. NURSING CARE PLAN

CUES EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

OF THE PROBLEM INTERVENTION
Subj: STG: after 5 hours of  Assess parent’s current Goal fully met
Deficient nursing intervention knowledge on the condition, the STG: after 5
knowledge is a the patient parents will risks of exposing the infant/child hours of
state in which be able to know and to passive smoking, feeding nursing
Obj: cognitive understand the disease activities with the infant, and intervention
Refuse and information or process and treatment exposure to illness. the patient
cries when psychomotor regimen Rationale: Provides baseline parents is
tried to take skills required for As manifested by information about the parent’s able to know
vital sign health recovery, Verbalization of awareness. and
but maintenance, or understanding about understand
consolated health promotion the disease of her the disease
by mother. are lacking. daughter.  Evaluate desire/readiness of process and
patient to learn. treatment
Mother Rationale: Determine amount or level of regimen
states “ information to provide at any given As manifested
hindi ko moment. by
alam etong Verbalization
nararamda LTG: after 3 days of of
man niya at nursing intervention  Explain possible causes of OM: understandin
konte the patient parents will exposure to illness of others, g about the
kinakain gain knowledge about irritation from environmental disease of her
nya”. prevention of Otitis smoke, or formula entering the daughter.
Media. Eustachian tube when the infant
Vital signs As manifested by is fed in a supine position.
were as initiation of lifestyle Rationale: Provides information about
follows: changes and participate health promotion.
Temp: 38.2 in treatment regimen. Goal partially
C met
RR: 37 bpm  Provide privacy for discussion, LTG: after 3
promote trust, remain days of
CR: 131bpm nonjudgmental, and support nursing
Spo2: 98 % parents. intervention
Rationale: Shows respect for the the patient
parents and opens communication. parents gain
knowledge
Nsg.dx about
Knowledge  Teach parents (and child if age- prevention of
deficit appropriate) about OM using an Otitis Media.
regarding ear model for demonstration. As manifested
condition, Ask parents to verbalize their by initiation
and understanding of teaching. of lifestyle
treatment Rationale: Provides information by changes and
 related to auditory and visual means and assesses participate in
absence of understanding. treatment
information regimen.

 Provide praise for decisions that

will promote wellness for the
child and lifestyle.
Rationale: Positive reinforcement
supports the decision to improve family.

 Refer parents to specialized

class such as caregiving,
smoking cessation, or parenting
skills as needed.
Rationale: Encourages follow-up and
gaining additional knowledge and skills.

 Assist parents to plan measures

to decrease the chances of
recurrent OM such as
completing the course of
antibiotic, avoiding exposure to
persons with infection,
maintaining a smoke-free
environment, and feeding the
infant in a sitting position.
Rationale: Allow parents to make good
parenting decisions for their child to
help prevent OM.

II. CHARTING:
 F> Hyperthermia related to bacterial infection as manifested by body temperature of 38.2 secondary to acute
otitis media

D> Received awake cuddled by mother, not in any form of respiratory distress, hides her face when tried to
communicate with, refuse and cries when tried to take vital sign but consolated by mother. Mother states “ hindi ko
alam etong nararamdaman niya at konte kinakain nya”.
Vital signs were as follows: Temp: 38.2 C RR: 37 bpm
CR: 131bpm Spo2: 98 %

A> Identified the triggering factors. Monitored the patient’s HR, BP, and especially the tympanic or rectal
temperature. Determined the patient’s age and weight. .
Monitored fluid intake and urine output. Reviewed serum electrolytes, especially serum sodium. Adjusted and
monitored environmental factors like room temperature and bed linens as indicated. Eliminated excess
clothing and covers. Gave antipyretic medications as prescribed. Encouraged ample fluid intake by mouth.
Provided additional cooling mechanisms commensurate with the significance of temperature elevation and
related manifestations:
• Noninvasive: cooling mattress, cold packs applied to major blood vessels
• Evaporative cooling: cool with a tepid bath; do not use alcohol
• Invasive: gastric lavage, peritoneal lavage, cardiopulmonary bypass in an emergency
Modified cooling measures based on the patient’s physical response. Started intravenous normal saline
solutions or as indicated. Educated patient and family members about the signs and symptoms of
hyperthermia and help in identifying factors related to occurrence of fever; discussed importance of increased
fluid intake to avoid dehydration.

R> The patient’s body temperature decreases from 38.2 C to 36.5 C.

Prepared by: Froilan T. Adaci
Clinical Instructor
Adjust and monitor environmental factors like room temperature and bed linens as indicated.

Eliminate excess clothing and covers.

Give antipyretic medications as prescribed.

Ready oxygen therapy for extreme cases.

Provide chlorpromazine (Thorazine) and diazepam (Valium) when excessive shivering occurs.

Encourage ample fluid intake by mouth.

Provide additional cooling mechanisms commensurate with the significance of temperature elevation
and related manifestations:
 Noninvasive: cooling mattress, cold packs applied to major blood vessels

 Evaporative cooling: cool with a tepid bath; do not use alcohol

 Invasive: gastric lavage, peritoneal lavage, cardiopulmonary bypass in an emergency

Modify cooling measures based on the patient’s physical response.

Start intravenous normal saline solutions or as indicated.

Educate patient and family members about the signs and symptoms of hyperthermia and help in
identifying factors related to occurrence of fever; discuss importance of increased fluid intake to avoid
dehydration.