Name of Patient:________________ Age/Sex: 6 y.

o/M Room&Bed#: ______________

Chief Complaint: _________________________ Diagnosis: Otitis media
Physician: ______________________________________
Date/ Time Cues Need Nursing Diagnosis Patient Nursing Implementation Evaluation
Outcome Intervention
Aug.31, Objective: C Acute pain related to inflammation of After 1 hour Assess 1. Aug.31, 2021
2021 O the middle ear as evidenced by of nursing frequency of 8:00 a.m
7:00 a.m  (+) Right G restlessness, irritability and a pain intervention pain using the
tympanic N scale of 8/10 on wong-baker faces the patient pain rating Goal was
membrane I pain rating scale. will scale. met.
is full with T experience
reddish/ I Rationale: relief from Rationale: After an hour
orange V Otitis media is an inflammatory pain as To assess the of care, the
in E condition of the middle ear with no evidenced by level of pain. patient
appearance known cause or pathophysiology. Fluid comfortable experience
A accumulates behind the eardrum when sleeping, no Monitor and 2. relief from
 (+) N the tube connecting the middle ear to pulling of ear record vital sign pain as
Opaque D the pharynx (eustachian tube) is and a evidenced by
with pus obstructed. In most cases, bacteria will decrease Rationale: comfortably
draining at P grow in the fluid, causing pain and pain scale of A normal sleeping, not
the right E infection. 2/10 on response to irritated, no
ear noted R wong-baker pain is an pulling of ear
C faces rating increase in and a
 Pain scale I scale. respiratory rate, decrease
of 8/10 P Reference: heart rate, and pain scale of
based on T blood pressure; 2/10 on
Wong- U Belleza M. (2021). Otitis fever may wong-baker
Baker A Media.Retrieved from: cause faces rating
Faces L https://nurseslabs.com/otitis-media/ discomfort. scale.
Pain
Rating Johnson, S. (2018). Middle Ear Instruct mother 3.
Scale Infection (Otitis Media).Retrieved to give liquid or
from: soft foods.
https://www.healthline.com/health/wh
y-does-my-ear-feel- Rationale:
clogged#_noHeaderPrefixedContent Chewing may
cause
additional pain
as it can affect
the eustachian
tube.

Administer pain
medication 4.
such as
Ibuprofen and
acetaminophen
as ordered.

Rationale:
Analgesic such
as Ibuprofen
and
acetaminophen
shown to be
effective to
alter the pain.

Have the child

to lie on the
unaffected area
and put pillows 5.
behind the
head.

Rationale:
Elevation
encourages
drainage and
relieves fluid
pressure.

Applying heat 6.
or cold
application.

Rationale:
Cold reduces
pain,
inflammation,
and muscular
stiffness thus
Heat causes
vasodilation,
which relieves
discomfort.

Provide a quiet
environment 7.
and adequate
rest.

Rationale:
For
management of
 pain.

CLUSTERED DATA
GORDON’S Health Nutrition/ Eliminati Activity/ Sleep/Rest Cognitive/Perceptual Self- Roles/ Sexualit Coping/ Values/
FUNCTIONAL Perception/ Metabolic on Exercise Pattern Pattern Perception/ Relations y/ Stress Beliefs
HEALTH Health Pattern Pattern Pattern Self- hip Reprodu Toleranc Pattern
PATTERN Managemen Manageme Pattern ctive e
t Pattern nt Pattern Pattern Pattern
CUES  Runny  Difficulty  Pulls the right
Nose of ear
sleeping
 Congest  Irritable
ion
 (+) Right
 Mild tympanic
Cough membrane full
with
reddish/orange
in appearance
 (+) Opaque with
pus draining at
the ear noted
 Pain scale of
8/10 based on
Wong-Baker
Faces Pain
Rating Scale
Reference:
Harmes, k. et al. (2013). Otitis Media: Diagnosis and Treatment. Retrieved from: https://www.aafp.org/afp/2013/1001/p435.html
Wayne, G. (2021). Acute Pain Nursing Care Plan. Retrieved from: https://nurseslabs.com/acute-pain/
Doenges, M. et al. Nurses’ Pocket Guide. Diagnoses, Prioritized, Interventions, and Rationales (2013) p.1147
and Rationales
Belleza, M. (2021). Otitis Media.Retrieved from: https://nurseslabs.com/otitis-media/
Johnson, S. (2018). Middle Ear Infection (Otitis Media).Retrieved from: https://www.healthline.com/health/why-does-my-ear-feel-
clogged#_noHeaderPrefixedContent