Care Plan-Otitis
Care Plan-Otitis
Care Plan-Otitis
Family history
S.No Name Age/sex Relationship Education Occupation Health
with patient status
Family Tree
family tree
Socio-economic history
Mr.Vinod kumar belongs to middle class family his
father is only the earning member of his family that
consist of total 6 members.
Personal history
Personal hygiene
Oral hygiene once a day
Agent - Colgate
Bath - once a day
Agent –soap
Breakfast- yes
Lunch-yes
Dinner-yes
Sleep and rest
Mr. Vinod kumar takes rest far about 6-7 hours a
day during night.
Elimination
Bowel elimnation frequency: - once a day
Urine output frequency: - 3-time a day
Housing
Type - pakka
No of room - 4 rooms
Water supply - supply water
Electricity - available
Physical examination
Vital sign : -
Temperature- 99 degree f
Pulse - 80 beats/mins
Respiration -20 breaths/mins
Blood pressure – 130/80 mmhg
General appearance and behaviour
Gender – male
Body built – thin
Nourishment - wel nourished
Activity - decreased
Appearance - dull
Height - 5.8 inc
Weight - 65kg
Integumentary system
Skin – normal, no lesion found
Moisture – dry
Colour-fail
Tenture-normal
Tone- well toned
Eye
Colour- black
Eye ball-oval
Conjunctiva-normal
Pupil-reaction time is normal
Ear
External ears -discharg is come out
Hearing - impaited
Nose
External nares - no inflammation
Mouth
Lip-pink
Teeth-white
Gums-pink
Neck
Lymph node- no enlargement
Chest
Auscultion-s1 s2 sound heared
Polpation-normal
Abdomen
Inspection-no any lesion
Percussion- normal
Extermities: -
Movement of joints- normal movement
Ankles- normal
Genital
Discharge-no any discharged
Sexual transmitted disease – absent
Rectum
Discharge- no any discharge
Haeorrhoid-absent
Anatomy and
physiology
1 .auricle:-
Tympanic membrane:-
The tympanic membrane (eardrum),about 1 cm in diameter and very
thin is normally pearly gray and translucet t consist of three layers of
tissues:-
1. An outer layer
2. Inner mocosal layer
3. A fibrous middle layer
Ossicles:-
The middle ear contains the three smallest bones (the ossicles) of the
body:the malleus the incus and the stapes .the ossicle which are held in
pluceby joints muscles and ligaments, assist in the transmssion of
sound.
Membranous labyrinth
The mambranous labyrinth is composed of the utricle the sacule the
cochlear duct the semicircular canal and te organ of corti all of which
are surround by a fluid called endolymph.
Organo of carti
The organ of carti is housed in the cochlea, a snail shaped bony
tube about 3.5 cm long with two and a half spiral turns.
Membranes seperated the cochlear duct (scal media) form the
scala vestibili and the scala tympani form the basilar
mambrane.
Dissase
Condition
External otitis
Introduction:-
External otitis is the infection and inflammation of the external
ear. There are various causes that leads to otitis media.
Definition
External otitis refers to an inflammation of the external
audotory canal.
Etiology
Water in the ear canal (swimmers ear)
Traccma
Vitamin deficiency
Bacterical /fungal infections
(staphylococcus aureus and pseudomonas species aspergillus)
Dermatosis- psariasis ,eczema,seorrhcic
Dermatitis.
Clinical mainfestation
Cellulitis Pruritis
Lymhodenopathy
Pruritis
Feeling of fullness
Hearing Loss
Hearing Impairment
Feeling of fullness
Hearing Impairment
Dianostic Evaluation
Book picture Patient Picture
History collection History collected
Physical examination Physical Examination
CT-scan and MRI --
Radionuclide Scan Radionuclide scan
Madical Management
Book Picture Patient picture
Ear irrigation Ear irritation
Antibiotic therapy Antibiotic therapy
Analgesics Analgesic
Acidifying
Nursing Diagnosis
1) Acute pain related to ear infection as
evidenced by folial expression.
2) Disturbed sensory perception related to
obstruction infection of the external ear
as evidenced by verbalization.
3) Impaired verbal communication related
to the effects of hearing loss.
4) Social Isolation related to pain foul
smelling otorrhoea.
5) Knowledge deficit related to cognitive
limitations and lack of interest in
learning.
Day to day prognosis Note
1st day
General Condition
Temperature-99 degree
Respiration- 24 breath/min
Pulse-82 beat/min
Spo2-96%
Patient complain
I am having problem in sleeping at night.
Doctor advice
Take medication as per time.
NURSING MANAGEMENT
Give to the patient soft diet.
2nd day
General condition
Temprature - 98degree F
Respiration- 24breath/min
Blood presser-120/80mmHg
SPo2-96%
Patient complain
Weakness
Fullness felling
Hearing impairment
Doctor’s advice
Take rest properly
Nursing management
Give nutries died.
HEALTH EDUCATION
Personal hygienes
Adviced the patient to maintain personal hygiene like bathing,
hair care, brushing and not poring water in ear during bathing.
Change dress daily and clean body with the shop and antiseptic
solution.
NUTRITION
Encourage the patient to eat small amount of protein rich diet for
improve health.
Adviced the patient to maintain adequate amount (6 glass) fluid
intake.
Adviced the patient nat to scape any male.
Avoid sicy and oily food.
Exercise
Adviced the patient for passive and active exercise.
Adivice the patient to maintain the body movement.
Adviced the atient to walk daily for 30min if he is able to walk.
Medication and follow up
Adviced the patient to take medicine according to doctors
order.
Adviced the patient to take medicine in correct time,
Adviced the atiet do not scape medication in any how.
Adviced the patient come regularly for follow up check up
and proper explore if any side effect and sign and symptoms show
during medicine taking.
Summary
Mr.Vinod kumar come to hospital RIMS with the
complain of encessive ear ache and hearing impairment .
After investigation the disease was diagnosed as external
otitis by the physician .External otitis the infection and
inflammation of the external ear that causes ain and
hearing impairment which was similar to the Vinod
kumar complain.
Conclusion
This medical case study is an “External otitis”. While completing
this case study I practically come to know about the disease
condition as well as the management of external otitis and the
patient was very Co-operative.
Bibliography
1) Brunner and suddhartha : A textbook of
Medical surgical nursing publication,12th
Edition, Page No -189-182.
2) Sr.Nancy: Principle and Practice of Nursing 1 st
volume, age No:-174-175.
3) Javed Ansari : A textbook of medical surgical
Nursing – Page No- 22 – 24.