AWA: Academic Writing at Auckland

History and Assessment of Client:

BK is a 23 month old New Zealand European male who has presented to his primary care practice with his mother and older sister. He lives at home with his mother, father and four year old sister AK. He has no chronic illnesses and is not on any medication other than paracetamol when feeling unwell. His mother reports he had a normal occipital presentation and vaginal birth with no abnormal postnatal findings. Mid 2009, when 9 months old, he was admitted to Middlemore hospital for three days with bronchiloitis. Both himself and his older sister also had Varicella in November 2009. He has had an ear infection once before, however his mother cannot recall when, and was managed independently at home. There are no congenital or child onset diseases which run in the family, including asthma. Other than Varicella, the mother describes BK's older sister as a well child, with only the usual childhood colds.

When BK presented with his mother and sister, he had been unwell for 6 days. The nursing assessment revealed the following:

Airway: no stridor, noisy breathing or nasal flaring present. However his nose was congested with a yellow green mucus. BK does not drool and has never used a dummy.

Breathing: His respiratory rate was 56 and was therefore tachypnoeic. Minor substernal recessions were noted on inspection. Auscultation revealed no wheezing and good air entry bilaterally. Mother reports he has had a productive cough for 6 days but has not noted the colour of the sputum as it is tainted with milk. Oxygen saturations were normal (98%).

Circulation: BK appeared warm and well perfused peripherally. His pulse was 126 beats per minute and regular. Both peripheral and central capillary refill were under two seconds. A blood pressure was not clinically indicated therefore not done to reduce client anxiety.

Disability/Level of consciousness: BK was an alert and interactive child during the half hour consultation.

Ear nose and throat: on inspection with an ottoscope the left ear drum was erythemous with swelling. The right ear drum had a slight erythema with no swelling. His throat was difficult to assess however there were some signs of infection sighted (redness and swelling). His mother reports for the past day he had been placing his hands over his ears when crying.

General: Mother reports BK has been irritable and lethargic for past three days and this is what had prompted her to seek treatment.

Temperature and fevers: Temperature was 37.9 when measure tympanically. However he had some paracetamol prior to arriving at the clinic, therefore it is likely to be higher. His mother reports he had appeared hot and flushed over night with flushed red cheeks.

Other: BK had not eaten solid foods for the past three days. Whilst still drinking milk and water his intake had dropped significantly (approximately 400mls per day over the last two days). This was causing distress for his mother. His sleeping had increased. There was no vomiting or diarrhoea. However the mother stated that BK has had diarrhoea from antibiotics in the past. One small resolving bruise on left knee but no unusual injuries.

Psychosocial: BK himself was pleasant and interactive, as previously stated, during the consultation. His mother however was anxious in regards to his lethargy and decreased input and output. She was appropriately interactive with both her children and there were no concerns of family violence.

Diagnostics: No diagnostic tests were done other than the nursing and medical assessment. The gold standard diagnostic is incision and drainage of the fluid, however assessment using an ottoscope has been found to be as accurate if the practitioner is experienced (Wetmore, 2007). The diagnosis was a unilateral acute ottitis media (AOM) secondary to an upper respiratory tract infection. There is also a risk of the AOM becoming bilateral due to the early signs of infection in the other ear.

Pathophysiology of Acute Ottitis Media:

Otitis Media is an inflammation of the inner ear (Bluestone & Klein, 2001) and is the most common presentation in children to primary care (Copstead & Banasik, 2005). The eustachian tubes connect the middle ear and the nasopharynx and are controlled by the tensor veli palatine muscle (Bluestone & Klein, 2001). The three primary functions of the eustachian tubes are ventilation of the middle ear, drainage and immunological protection through its villi (Bluestone & Klein, 2001). In a child the eustachian tubes are shorter, more horizontal (10 degrees) and less rigid; hence otitis media is primarily a paediatric health concern (Copstead & Banasik, 2005). The incidence of acute otitis media peaks between the ages of one and three years old (Wetmore, 2007). BK's age increases the likelihood the primary diagnosis of acute otitis media is correct.

The pathophysiology of acute otitis media tends to begin with an upper respiratory tract infection [URTI]. BK exhibits symptoms of an URTI, such as nasal congestion. That BK is not experiencing a lower respiratory tract infection is supported by the assessment finding no wheezes, crackles or decreased air entry in either of his lungs. URT infections are viral (Arrol & Goodyear-Smith, 2000) and in this age group are usually a rhinovirus (Van Benten et al., 2003). The immune response to the URTI results in congestion of the upper respiratory tract and the opening of the Eustachian tube (Copstead & Banasik, 2005).This is the likely cause of the nasal secretions and productive cough BK is experiencing. Congestion prevents the eustachian tube fulfilling its role as a pressure regulator and a drainage tract for middle ear secretions (Copstead & Banasik, 2005). This, combined with building pressure in the nasopharynx, results in the middle ear developing a negative pressure which effectively aspirates the pathogens from the nasopharynx (Bluestone & Klein, 2001). The aspirate cannot escape via the eustachian tube due to blockage and pressure differentials. Nor can it escape from the ear canal as the middle ear is isolated from the external ear by the tympanic membrane (Bluestone & Klein, 2001). The pathogen proliferates in this environment. Lymphatic fluid secondary to the immune response collects in the chamber of the middle ear and is referred to as effusion. This causes the tympanic membrane to appear oedematous, inflamed and the usual landmarks obscured(Wetmore, 2007) as BK's left tympanic membrane appeared. Acute otitis media may occur with or without effusion present (Wetmore, 2007). Redness of the tympanic membrane is not diagnostic of infection as this may be cause by the infant crying (Wetmore, 2007). Therefore whilst there is a risk pathogens may be aspirated into BK's right ear drum, the erythema noted is not indicative of early infection as BK was crying at the beginning of the consultation.

The inability to regulate pressure effectively is further exacerbated by an infant's under developed tensor veli palatine muscle. When infection occurs it is unable to contract effectively to open the lumen of the eustachian tubes. Pressure rises and the child experiences otalgia or ear ache (Bluestone & Klein, 2001). This is most often noted as the child tugging at the ear (Copstead & Banasik, 2005) however in BK's case his mother noticed BK placing his hands over his ears when grizzling.

Whilst it was not assessed for in BK's case as it is difficult for a 23 month old to respond appropriately to a hearing test, it is common for acute otitis media to result in temporary conductive hearing loss. This occurs because the congestion of the middle ear stops the conduction of sound waves into the round window membrane (Bluestone & Klein, 2001).

The most common pathogens causing otitis media according to the literature are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis (Bluestone & Klein, 2001; Copstead & Banasik, 2005; Wetmore, 2007).These are colonisers of the nasopharynx, which adhere to the epithelial cells and do not usually cause acute infections in the upper respiratory tract (Bluestone & Klein, 2001). BK is up to date with his immunisations and therefore has had four doses of pneumococcal vaccination and three of Haemophilus influenza type b (Ministry of Health [MOH], 2006). This means the chances of BK's AOM being viral is slightly increased. However other strands of H. influenzae tend to be implicated in AOM rather than type b (MOH, 2006). When the middle ear fluid is aspirated in a case of otitis media a mixture of bacteria and the virus causing the URTI can be found. However, generally, it is the bacteria primarily causing the otitis media not the virus isolated.

One of the key indicators of infection is pyrexia. BK's fever is less than 39 degrees Celsius(37.9) and therefore his AOM is defined as non-severe (Bluestone & Klein, 2001). However as paracetamol also acts on the thermoregulatory centre of the hypothalamus it is difficult to gauge an accurate measure. This is one reason the GP prescribed antibiotics; as the guidelines state under two year olds with severe disease should be treated (Thomas & Taylor, 2008). There are two mechanisms for infection to lead to an increased temperature. The first is when the antigens present on the bacterial surface trigger an endogenous cytokine response which amplifies the signal to the thermoregulatory centre in the hypothalamus (Dinarello, 2004). The less well understood mechanism is the exogenous pathway where the antigens act directly on receptors called toll like receptors. These TLR act communicate directly with the thermoregulatory centre (Dinarello, 2004).

If acute otitis media does not resolve spontaneously or with treatment complications may occur. These are more common in children who have recurrent AOM (defined as more than 11 episodes (orange)) and therefore BK is at low risk. AOM can result in rupturing of the tympanic membrane secondary to pressure. This leads to ottohreoa and the infection travelling to the external ear (Bluestone & Klein, 2001). Infection may also spread to cause acute mastoiditis, osteomyelitis of the skull, facial paralysis, otitic hydrocephalus and meningitis (Bluestone & Klein, 2001; Copstead & Banasik, 2005). Multiple episodes of acute otitis media are common in children and are more likely if there is some minor malformation in the eustachian tubes (Bluestone & Klein, 2001). If this occurs there is the risk the sclerosis of the tympanic membrane will occur (Bluestone & Klein, 2001). This impairs the movement of the tympanic membrane and results in permanent conductive hearing loss. Conductive hearing loss can also occur secondary to the mucus membranes of the inner ear becoming fibrosed (Bluestone & Klein, 2001).

The other symptoms BK experienced such as irritability and difficulty eating and sleeping are documented symptoms of acute otitis media in children his age(Copstead & Banasik, 2005). However they are non-specific symptoms seen in almost all childhood illnesses and therefore do not have a clear pathophysiological pathway.

Nursing Care Plan:

Nursing Diagnosis one: Otalgia and general discomfort related to AOM as exhibited by BK's grizzliness and covering of ears

Goal: BK's pain will be reduced to a level where no ear grabbing is seen within two hours of paracetamol administration and will remain at this level the remainder of his unwellness.

Interventions: Assess mothers knowledge of the signs of pain in her toddler and assist her in identifying other common signs. o Rationale: In this age group pain assessment can be done by observing behaviour such as grizzling, tugging on ears, and clinginess (Pickup & Aitkenhead, 2006). Regular six hourly paracetamol. The prescription given was for parapeid 120mg/5mLs. Therefore BK requires 8mLs of paracetamol every 6 hours.

Rationale: the optimal does of paracetamol is 15mg/kg (World Health Organisation [WHO], 2010). A maximum of four doses should be given a day (WHO, 2010). Therefore spacing the paracetamol from 4 hourly to 6 hourly ensures analgesia is spread across the day.

Rationale: Paracetamol inhibits prostaglandin synthesis in the hypothalamus therefore lowering temperature (Mohammed, 2006). Reducing BK's temperature is likely to reduce his discomfort and irritability. Ensure mother has syringe for administering paracetamol o Rationale: Paracetamol is toxic to the liver (WHO, 2010). Appropriate dosing of paracetamol is essential in paediatrics (Pickup & Aitkenhead, 2006) and oral syringes are an appropriate way to ensure this. Educate mother to reassess pain levels after one hour of paracetamol administration. 

Rationale: The time of absorption of oral paracetamol (Pickup & Aitkenhead, 2006). Provide non-pharamacological pain management techniques for BK's mother to assist in his pain control such as application of hot or cold packs to outer ear and loose and minimal clothing. 

Rationale: Heat and cold application have been shown to provide comfort for children with AOM (Wilson, 2009) 

Rationale: Minimal and loose fitting clothing is a cooling technique but can promote comfort in children who are febrile and in pain (Mohammed, 2006). Assure mother she should return to the clinic if pain is not resolving in 48-72 hours or sooner if she is worried in any way

Rationale: It is important BK's mother feels she can call or access the clinic if she needs support at any time in managing his care.

Nurising Diagnosis Two: Risk for fluid imbalance (less than body requirements) related to BK's decreased oral intake, and potential for high dose antibiotic induced diarrhoea, as exhibited by drying of BK's lips and communication of mothers concerns.

Goal: For BK's mother to learn to adequately monitor and maintain BK's hydration during the course of antibiotics and the resolution of the AOM (five days).

Interventions:

Conduct a hydration assessment of BK during the consultation. o Rationale: Provides baseline, and information regarding BK's dehydration status. Rationale: Can be used as an opportunity for teaching Mrs K the signs of dehydration. For example reduced skin turgor, dryness of the lips and mucus membranes, and sinking of the eyes. Encourage Mrs K to continue to keep a fluid diary of how much BK is drinking which she states she has started at home. Assist her to include output.

Rationale: According to the 4:2:1 method of estimating paediatric fluid requirements BK requires 45mLs of fluid an hour to maintain his fluid balance (Miller, 2010). The diary will assist Mrs K in deciding if his intake is adequate.

Rationale: This will give Mrs K confidence that she is managing BK's fluid intake appropriately.

Rationale: Due to its approximate osmolarity nappy contents can be weighed and one gram attributed to one millilitre of fluid output (Wilson, 2009).

Rationale: Mrs K was extremely stressed regarding BK's input and output. Whilst these tools may not be entirely necessary for BK, as his risk for dehydration is moderate, they allow Mrs K to feel in control of the situation.

Supply the family with saline drops to loosen nasal secretions 

Rationale: effective in clearing secretions and found to increase toddlers and infants desire to feed as minimises the exhaustion associated with feeding when congested (Pillitteri, 2010) Brainstorm with Mrs K alternative methods for hydrating BK. 

Rationale: Mrs K reported in the consult that his intake of food and fluids had decreased significantly. He had been less willing to take milk and has drunk only minimum water in the past two days. Plain flavoured ice blocks, or watered down juices, are a source of fluid which a feverish child may be more motivated to consume. Also regular sipping maybe more tolerable than larger "feeds". 

Ensure Mrs K is aware of the signs of a severely unwell child and feels confident returning or taking the child to secondary care. Utilise BK's plunked book whilst doing this so Mrs K can return to the written information when returning home. 

Rationale: As Mrs K is not a health professional but is managing her child's care at home, it is important she feels safe and well supported.

Rationale: The plunket signs of an unwell child are clear and evidence based, and as Mrs K already utilises her plunket book, is an appropriate source of written information.

Nursing Diagnosis Three: Need for health education related to safe management of AOM at home exhibited by mothers apparent anxiety and statements of lack of confidence.

Goal: BK will complete the five day script of amoxicillin with the possible side effects safely managed.

Intervention:

Give Mrs K a basic understanding of antibiotic resistance and the rationale for giving her child antibitotics.

Rationale: There are already several strains of pneumococcal bacteria that are resistant to antibiotics (Wilson, 2009). As up to 20% of AOM is viral the use of antibiotics are contested in its treatment (Bluestone & Klein, 2001). However the time frame of spontaneous resolution is 72 hours and as this has already passed antibiotics are appropriate (GPAC, 2010). These are further suggested due to BK's age, risk of bilateral infection and the relatively high temperature despite paracetamol administration (Thomas & Taylor, 2008).

Inform Mrs K of the potential side effects of high dose amoxicillin.

Rationale: Amoxicillin commonly causes diarrhoea and rashes, particularly in children (Mimms, 2008). Awareness of these side effects mean Mrs K is more likely to continue administering the medication to her child.

Rationale: Mrs K has already mentioned that BK tends to develop diarrhoea when taking penicillin based medications. Therefore informing Mrs K of the side effects establishes further the importance of fluid maintenance.

Rationale: It is important the primary health team are informed of these adverse effects or of any reactions BK has to the amoxicillin. He currently has no known drug allergies but also limited exposure.

Reinforce the health care team at the clinic is available for her to call or come in to see between the hours of 8am-6pm without an appointment. If she needs services outside these times inform her of the relevant after hours and secondary care.

Rationale: It is important Mrs K feels secure in her decision to manage BK's care. The chances of severe adverse effects are relatively low but her confidence and feelings of support need to be enforced.

Evaluation of the care plan:

Short term:

Assess whether mother is able to verbalise the pharmacological and non- pharmacological techniques she will use to manage BK's pain independently at home near the conclusion of the consultation.

Evaluate if Mrs K is able to state the signs of fluid imbalance she is looking for and the amount of fluid she is trying to encourage BK to drink. BK's mother reports increased confidence in managing BK's illness independently at the conclusion of the consultation.

Long term:

Due to the nature of primary health care it will be BK's mother who primarily evaluates over the long term whether the goals have been met and his care is delivered adequately. We are somewhat restricted to evaluating the steps and tools we have provided her as part of the short term evaluation.

A novel means of assessing BK's care may be to call mid way (three days) through his antibiotic treatment to see how he is doing. Then we can evaluate if the antibiotic is effective (AOM symptoms resolving), if his mother remains confident in managing his care, and if his input and output are improving. This also allows the opportunity to assess whether BK needs to come in for follow up treatment or assessment in the clinic. This will also increase rapport with the family if they feel they are well supported through this relatively common childhood illness.

References

Arrol, B & Goodyear-Smith, F. (2000). General practitioner management of upper respiratory tract infections: When are antibiotics prescribed? New Zealand Medical Journal. 113(11), 493-496.

Bluestone, C.D. & Klein, J.O. (2001). Otitis Media in Infants and Children: Third Edition. PA, USA: W.B. Saunders Company.

Copstead, L.E. & Banasik, J.L. (2005). Alterations in special sensory function. In Pathophysiology. St. Louis, Missouri: Elsevier Saunders.

Dinarello, C. A. (2004). Review: Infection, fever, and exogenous and endogenous pyrogens: some concepts have changed. Journal of Endotoxin Research. 10(4), 201-222.

Guidelines and Protocols Advisory Committee [GPAC]. (2010). Otitis Media: Acute Otitis Media (AOM) & Otitis Media with Effusion (OME). Retreived August 30th, 2010, from http://www.bcguidelines.ca/gpac/pdf/otitis.pdf

Ministry of Health [MOH]. (2006). Immunisation Handbook 2006. Wellington: Ministry of Health.

Miller, I. (2010). How to Calculate Paediatric Fluid Rates. Retrieved August 30th, 2010 from http://www.impactednurse.com/?p=764

Mohammed, T.A. (2006). Temperature control. In E. Trigg & T.A. Mohammed (Eds.), Practices in Children's Nursing; Guidelines for Hospital and Community (2nd ed., pp. 391-395). 

Pickup, S. & Aitkenhead, S. (2006). Pain management. In E. Trigg & T.A. Mohammed (Eds.), Practices in Children's Nursing; Guidelines for Hospital and Community (2nd ed., pp. 391-395).

Pillitteri, A. (2010). Maternal and Child Health Nursing; Care of the Childbearing and Childrearing Family. WY, USA: Lippincott, Williams & Wilkins.

Thomas, M. & Taylor, S. (2008). Antibiotic choices for common infections. Best Practice Journal. 21, Pp 20-28.

Van Benten, I., Koopman, L., Niesters, B., Hop, W., Van Middelkoop, B., De Waal, L. et al. (2003). Predominance of rhinovirus in the nose of symptomatic and asymptomatic infants. Paediatric Allergy and Immunology.14(5), 363-370.

Wetmore, R.F. (2007). Paediatric Otolaryngology. PA, USA; Mosby Elsavier.

Wilson, D. (2009). The child with respiratory dysfunction. In M.J. Hockenberry & D. Wilson (Eds.) Wong's Essentials of Paediatric Nursing(8th ed, pp 754812). World Health Organisation [WHO]. (2010). WHO Model Formulary for Children. Geneva, Switzerland: World Health Organisation.