Evidence Based Case Study – Leo

EvidenceBased Case Study – Leo

EvidenceBased Case Study – Leo

Thepaper is an evidence-based case about Leo, a two-year-old, with aprovisional diagnosis of his condition indicating Acute Otitis Media(AOM). Acute Otitis Media (AOM), according to Hathorn et al. (2014),is a painful kind of infection around the ear area. The infectionoccurs when the middle ear, which is the area just behind theeardrum, becomes inflamed and is infected eventually. There arecertain behaviors, especially in children, who shout AOM.

Forexample, these behaviors could be intense crying in infantsaccompanied fits of fussiness, wincing in pain, while clutching theear, and experiencing pain in the ear area in children. The paper,therefore, is a case study that would focus on Acute Otitis Mediaprovisionally diagnosed in a two-year-old, Leo. The paper willintroduce and assess the condition by looking at the holistic, bio,psycho, and informative overview of the child`s needs, management ofthe condition, rational and interventions of AOM that the family andthe child (Leo) may need, which include necessary equipment andresources when discharged.

Evidence-basedCase Scenario

Leois a two-year-old child brought by her mother to the After-Hoursgeneral practice clinic. At the clinic, Leo`s mother reports to thephysician that her child cried inconsolably for close to six yearsand did not want to eat or drink. Leo, she reports, is peripherallywarm and his skin appears pale. Leo also cries and rubs his earuncontrollably, which is also noticeably irritable, and he could notsettle keep calm even when he is comforted by the mother.

Thephysician`s assessment records data characterized by axillarytemperature (39.7 degrees Celsius), the heartbeat of 160 beats perminute, a respiratory rate of 35 breaths per minute and systolic BP81. Leo, according to his mother, experience profuse nasalsecretions, dry mouth with lips pink and with tacky mucous membranes.At once instance, the physician noted a bilateral inflamed tympanicmembrane in the child bulging on the right. Leo`s assessment alsoindicated gastrointestinal normal bowel sounds, soft abdomen with notenderness. The mother reported the child`s disinterest to eat, whichreflect on not having a normal diet.

However,Leo`s bowels open once a day, which in turn reflects on his normalappearance, but with diminishing urine output. His mother reports tothe physician immediately she arrives at the clinic that Leo had notpassed urine for close to 6 hours. The doctor was able to ascertainhis height and weight to be at the 50th percentile. Reflecting onLeo`s social history, he lives with his 17-year-old mother who inturn lives with her mother and her 5-year-old sister. The physiciangives Leo a provisional diagnosis of having Acute Otitis Media (AOM).

Leo`sHolistic Description of Needs

Accordingto Stephenson (2013), Acute Otitis Media`s (AOM) history varies withage however, there are constant symptoms, Leo`s case for example,which manifest during the prone years of between one and five years.The only indication of the condition in the neonate stages includesirritability and difficulties in feeding, which is the case with Leo.Leo`s physical assessment indicates irritability as a result ofincreased temperature levels of 39.7 degrees Celsius. Leo`s holisticassessment applies the pneumatic otoscopy, which according toBrumback (2013), refers to the “standard of care required followingthe provisional diagnosis of AOM (Acute Otitis Media) that is yet tobe ascertained.”

Biologically,Leo`s assessment requires the physician to check the details of theassessment. The details indicate that the tympanic membrane oftendemonstrates inflammation signs. The signs begin with the Mucosareddening with reduced tympanic mobility (Seshia, 2015). Leo`ssituation reveals the tympanic membrane bulging from the posteriorquadrant while the physical detail shows the superficial layerexhibiting a scalded appearance. Leo, in this case, does not haveperforations on the bulging middle ear, which is expected consideringan increase in his temperatures.

Havingundertaken Leo`s physical assessment, the absence of physicalperforations best explains Leo`s experiences with pain and fever.Again, with the redness and welling, which is provisionally presumedto be the middle ear infection of Acute Otitis Media occurred almostimmediately, according to his mother`s statement. The rationalebehind this is that Leo`s condition is because of the mucus and fluidtrapped inside the middle ear, which in turn results in ear pain,fever, and pain. Leo`s physical assessment details included profusenasal secretions, which were accompanied by the mucosal swelling,which according to Savolainen-Kopra et al. (2013) act as &quotaball valve.&quot

Leo`spsychological assessment details were taken, and were characterizedby his irritability, rubbing his ear incessantly, and cryinguncontrollably despite being comforted by his mother is based on hisage and the susceptibility of contracting the condition. Thefrequency with which is characterized by the child`s psychologicalbehavior and actions would be because of the condition. Leo,considering he is a two-year-old with a small body, has smallerEustachian tubes, horizontally placed, and shorter. As such, theEustachian tube would fail to drain fluid efficiently, which in turnaccumulate resulting in pain, pale skin, dry mouth, and pink lips.His situation, therefore, results in the child being withdrawn fromthe rest of the children affecting her social life.

Basedon the physical assessment details, Leo`s provisional diagnosis ofAcute Otitis Media correlates with the influence the AOM diagnosisbased on his social costs, personality, and language development inthe environment he is raised in. For instance, Leo lives with her 17years old mother who, in turn, lives with her parents and her5-years-old sister. Having been diagnosed with Acute Otitis Media,according to the physical details, the chances are that the boy couldhave difficulties in his development, for example, in speech,socializing, limited response, and reading.

Thesedetails indicate that his psycho-social development is interferedwith, and is characterized by a persistent disturbance in maintainingattention. Increase in respiratory rate (35 breaths per minute) leadsto increased anxiety. Simonen-Tikka et al. (2013) noted thatincreased anxiety limits the child`s interaction with his peers and,in turn, affect the quality of life negatively. Acute Otitis Mediaimpacts on one of the parameters (quality of life), correlates withthe problems of social development.

KeyProblems, Justification, Planning, Implementation, and Evaluation ofCare

Afterthe assessment, Leo provisionally diagnosed with Acute Otitis Media.After further assessment, two key problems were noted, which includepain and dehydration.

Leois still young. For purposes of physical assessment, it is importantto put into consideration his age, level of development,communication, as well as cognitive skills According to Geurten etal. (2016), mild pains require pharmacological interventions. AOMdiagnosis for a young child like Leo will require the prescription ofparacetamol and ibuprofen to be given orally for every 6 to 8 hoursmaximum. For Non-pharmacological interventions, it will require theinvolvement of a parent, for example, breastfeeding, rocking thechild, and reading him a book to minimize pain and reduce stress(Piovani et al., 2013). Also, when the pain starts to take effect, itshould be followed up by another review to guarantee Leo issatisfactory, a positive outcome is achieved. Reduction in pain willensure he breastfeeds. Leo mother will also be directed to manage thepain and record the result in the next two or three days.

Thesecond key problem is dehydration. Following the assessment, theproblem is emphasized based on the fact that it is one of the maincauses of deaths in young children (Cherpillod, 2011). An infant isrecorded to have approximately 67 % of the total body weight.Additionally, young children like Leo have a high vulnerability tochanges in their overall body fluids considering the total bodyfluids have greater surface area, a higher rate of metabolism, andless-functional kidneys compared to adults. According to Van (2013),the total amount of body fluids involves two sections, which includeintracellular and extracellular sections. Since cell membranes areregularly absorbent body fluids, especially water, dehydration willimpact on both the sections equally, which in turn increases thetonicity of the serum. Serum tonicity means that mental status andthirsts activate the changes.

Incontinuing with Leo`s assessment, the records revealed a dry mouth,dry skin, tenting of skin turgor, sticky mucous membrane, and sunkenanterior membrane. And when these changes are compared to that of ahealthy child, all these changes shows the level of dehydration (Neset al., 2015). Again, Leo`s excessive nasal secretion coupled with abulged inflammation

Ofthe right tympanic membrane shows symptoms of viral respiratoryinfection that is ongoing, and that the presence of acute pain shouldbe controlled.

Theneurological assessment followed next, and it did not reveal anypossible extreme abnormalities. However, Leo`s uncontrollable cry andheight of irritability are part of behavioral responses of a youngchild going through discomforts that are associated with the acutepain (Schaaf &amp Lane, 2015). Additionally, at the time ofErikson`s stage of psychosocial development, there is preciselanguage. When the child is in distress, the only way such a youngchild can express his discomfort is through crying. More so, youngchildren rely on their parents and caregivers for assistanceregarding physical and visual contact.

Rationaleand Interventions, Management, and Identified Nursing Diagnosis

Leo`sprovisional diagnosis indicates Acute Otitis Media. However, thecompletion of nursing health assessment prioritized two key problems,pain, and dehydration. Acute pain, being the first to be selected,required a decision to be made. Such decision is based on the factthat continuous pain has adverse psychological and physical effectsthat cause more problems (Tully, 2012). In this case, if at all thisacute pain is managed Leo`s food and fluid intake could increase.

Khanbabaei&amp Kadivar (2012) noted that acute pain occurs suddenly and lastsfor a short while. Acute pain is felt almost immediately following aninjury. Medical procedures are recommended and are linked withinflammation. For example, Leo`s case is characterized by inflamedtympanic membrane situated in the right ear. Here, when there isstimulation of nociceptors, what followed is the initiation of anerve impulse and is carried via spinal cord by neuronal pathway.

Suggestedevidence-based guidelines for successful management of pain involvespain assessment, interview with nurses, physical assessment, and painintensity measurement tool

(Yawmanet al., 2014). Guidelines will be able to monitor pain and evaluatemeasurement suitable to such an age. Tools used in health care tomeasure the intensity of acute pain in young children are Children`sand Infant`s Postoperative Pain Scale (CHIPPS) and Face, Legs,Activity, Cry, Consolability (FLACC) pain score. The two are dividedinto three, while the scores are regarded as comfortable and relaxedmild, moderate, and severe pain (Silove et al., 2013). Therefore,Leo`s pain will be documented using the FLACC pain score, and in themeantime taking into account his behavioral data, it was noted thatthe child was experiencing mild pain.

Leo`smother informed the nurse that was in charge of her son`s lack ofinterest in breast milk. She compares that her son normally feeds forclose to five times daily, which takes approximately ten to fifteenminutes each. Leo`s bowels according to her mother are openapproximately once daily and would appear to be normal. However, Leodid not experience wet nappies as was usual for such a young child,and thus his urine output was drastically reduced. Of satisfactorywas his weight and height. Nevertheless, Leo`s overall weight shouldbe monitored since fluid loss can result in drastic loss of weight(Corsello et al., 2013). The above data refers to the inadequacy thatcharacterizes the intake of fluid and continual further assessment.

Thesecond problem, dehydration, was measured based on the recordedtemperature. Leo`s temperature as a result of dehydration indicated aminimum of 175 heartbeats per minute, 46 breaths, and high bloodpressure. According to Corsello et al. (2013), vital signs in youngchildren are only acceptable when the temperature is below 39.6 to36. 7 degrees Celsius, 120-150 beats per minute, 30 to 50 breaths perminute, and 96160 mmHg blood pressure, and oxygen saturation notexceeding 95Yo room air. In comparison a normal range indicatingvital signs shows that Leo`s temperature is more than is normal,increased heart rate, and decreased blood pressure.

Changesin Leo`s temperature indicate high chances of viral infection. Theviral infection is characterized by changes in heart rate possibilityof experiencing low blood pressure and acute pain, which is likely tobe associated with having a pale skin as was noted during theadmission. Dehydration can be unnoticeable because of fever, sincefever will result in increased

Insensibleloss of fluids (Hau et al., 2014).While the extracellular fluid maydirectly be translated into the outward environment, and since Leohas a bigger surface area, this means that that there is higherquantity of the extracellular volume. Therefore, any condition orsickness in which the fluids intake is not possible, result in adefinite imbalances (Mittal et al., 2014).

Duringthe assessment of Leo`s physical condition, all recorded dataindicate moderate dehydration signs. For example, irritability,fever, decreased output of urine, tacky mucus membrane, increasedheart rate, decreased skin turgor, and a sunken anterior fontanel,which reflect to severe symptoms of dehydration, which are morethreatening to life (Marchisio et al., 2010).

Therefore,for proper handling of moderate dehydration should be solved by usingoral rehydration solution (ORS). The ORS should be at approximately100ml/kg over a period of four to five hours. The ORS should be madeto replace gradually sodium, glucose, potassium, and chloride tocounter balancing of electrolyte levels. For beginners, the smallamounts of the solution (ORS) should be given the infant with a smallspoon or a syringe. This is later followed by gradual increase in theamount the infant is supposed to drink (Hau et al., 2014). Throughoutthe treatment period, the infant should undergo evaluation for theongoing loss of fluid as expected, and that the fluid level should bemaintained at home. The mother of the infant should also beencouraged to provide the kid with water constantly followed byfrequent breastfeeding.


Theevidence-based case study is about a two-year-old child, Leo, isdiagnosed with what could be the Acute Otitis Media. The assessmentrecords, among others, include data such as the temperatures of 39.7degrees Celsius, increased respiratory rate, profuse nasalsecretions, and inflammation of the tympanic membrane. The paper isbased on the case scenario involving Leo a two-year-old childassessment description applies pneumatic otoscopy best practice. Thebest practice technique is determined by the justification of theassessment following the diagnosis of the problem.

Thepaper identifies two problems, acute pain and pain, whosejustification is based on inflammation of tympanic membrane, reducedurine output, irritability, and respiratory tract infection. Again,family and child-centered care considerations are targeted atidentifying the best practice, screening, and taking drastic measuresto ensure the symptoms remain as symptoms. The paper identified theseconsiderations as measures proposed to handle all cases surroundingthe problem.


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