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P. P. is a 4-year-old boy who presents to the pediatrician’s office with pain in his right ear.
Subjective Data Mom states that her son woke up in the middle of the night crying two nights ago. She gave the child ibuprofen, and he went back to sleep. Last night he woke up in pain, and he was inconsolable. She felt he should be seen by the physician. Attends preschool program Lives with mother Father estranged Objective Data TM appears inflamed – it is red and may be bulging and immobile T 100. 3 Last ibuprofen 3 hours ago 1. What other assessments should be included for this patient? Inspection of the ear with ophthalmoscope. 2. What questions are appropriate for a patient presenting with earache? -When did the pain occur? -On a scale of 1-10 how severe is the pain? 3. What risk factors are associated with earaches for this age group? -This age group of adolescents are more at risk for ear infections, because of the size and shape of the Eustachian tube, and the immune system is not strong yet. 4. From the readings, what is the difference between otitis media and otitis external? -Otitis media is a middle ear infection that effects the ear drum.
Otitis external is inflammation, irritation or infection of the outer ear canal. 5. From the readings, what is the most probable cause of earache in this patient? -The most probable cause in this patient is acute otitis media. 6. What are three appropriate nursing diagnoses? -Inspect the ear –Take Medications to reduce the pain. -Check up in about two weeks if the pain does not die down. 7. What interventions should be included in the nursing care plan? -The nurse should prescribe antibiotics to help with the infection and schedule a check-up appointment to make sure the infection is gone or is improving.