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II. HEALTH HISTORY
A. PROFILE OF THE PATIENT
Name:
Age: Address: ?
Sex: Female
Birthday: ?
Placed of Birth: ?
Civil Status: Single
Religion: R. Catholic
Occupation: Housekeeper
Nationality: Filipino
Date Admission:June 30 2009
Time: 7:30 pm
Attending Physician: ?, MD
Admitting Diagnosis: Chronic Otitis Media, bilateral, brain abscess facial nerve
palsy,
S/P Mastoidectomy Right
Fathers name: ?
Mothers name: ?
Height: 52
Weight: 38 kgs
Blood pressure: 100/70 mmHg
Pulse rate: 82 bpm
Respiratory Rate: 18 cpm
Temperature: 37.2 C.
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B. FAMILY and PERSONAL HEALTH HISTORY
? had undergone surgery in the past, went do German doctors for ear problem on
both sides. She also has asthma. Her father is not known to have a genetic diease and
so with her mother. She doesnt seem to have food and drug allergies. She had been
taking mefenamic acid for the management of pain she experience whenever her ears
ar again infected. She doesnt smoke but drink liquor occasionaly
C. HISTORY OF THE PRESENT ILLNESS
8 years PTA patient had undergone Mastoidectomy on her Left side. 3 years PTA
patient had asthma but did not seek for medical assistant, instead, stayed at home and
went on self medication. 6 months PTA patient was admitted at the german Hospital for
her recurring Otitis media.
D. CHIEF COMPLAINT
The patient was admitted due to the Chief Complaint pain on both ears. Also,
patient is suffering from hearing loss and also from facial never palsy which is the factor
for making her depressed
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Anatomy and Physiology
Ear
The ear is divided into 3 main regions: the external ear, which collects sound
waves and channels them inward; the middle ear, which convey sound
vibration to the oval window; and the internal ear, which houses the
receptors for hearing and equilibrium
External ( Outer) ear
The external or outer ear consist of the auricle, external auditory canal, and
eardrum. The auricle (pinna) is a flap of elastic cartilage shape like the flared
and of a trumpet and covered by skin. The rim of the auricle is the helix; the
inferior portion of the lobule. Ligaments and muscles attach the auricle to
the head. The external auditory canal (audit=hearing) is a curved tube about
2.5 cm long that lies in the temporal bone and leads from the auricle to the
eardrum. The eardrum or tympanic membrane (tympan= a drum) is a thin,
semitransparent partition between the external auditory canal and middle
ear. The eardrum is covered by epidermis and lined by simple cuboidal
epithelium. Between the epithelial layers is connective tissue composed of
collagen, elastic fibers, and fibroblasts. Near the exterior, the external
auditory canal contains a few hairs and specialized sebaceous glands called
ceruminous glands that secret earwax or cerumen. The combination of hairs
and cerumen prevent dust and foreign objectives from entering the ear.
Cerumen usually dries up and falls out of the ear canal. Some people,
however, produce a large amount of cerumen, which can become impacted
and can muffle incoming sounds.
Middle ear
The middle is a small, air-filled cavity in the temporal bone that is lined by
epithelium. It is separated from the external ear by the eardrum and from
the internal ear by a thin bony partition that contains 2 small membrane-
covered opening: the oval window and the round window. Extending across
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the middle ear and attached to it by ligament are the 3 smallest bone in the
body, the auditory ossicles, which are connected by synovial joints. The
bones, named for their shapes, are the malleus, incus, and stapes-commonly
called the hammer, anvil and stirrup, respectively. The handle of the
malleus attaches to the internal surface of the eardrum. The head of the
malleus articulates with the body of the incus. The incus, the middle bone in
the series, articulates with the head of the stapes. The base or footplate of
the stapes fits into the oval window. Directly below the oval window is
another opening, the round window, which is enclosed by a membrane,
called the secondary tympanic membrane. Besides the ligaments, 2 tiny
skeletal muscles also attach to the ossicles. The tensor tympanimuscle,
which is innervated by the mandibular branch of the trigeminal nerve or
cranial nerve number 5, limits movement and increases tension on the
eardrum to prevent damage to the inner ear from loud noises.
The stapedious muscle, which is innervated by the facial nerve (cranial nerve
VII), is the smallest of all skeletal muscle. By dampening large vibrations if
the stapes due to loud noises, it protect s the oval window but it also
decrease the sensitivity of hearing. For this reasons, paralysis of the
stapedious muscle is associated with the hyperacusia (abnormally sensitive
hearing). Because it takes a fraction of a second for the tensor tympanic and
stapedious muscles to contract, they can protect the inner from prolonged
loud noises, but not from brief ones such as a gun shot. The anterior wall of
the middle ear contains an opening that leads directly into the auditory
(pharyngotympanic) tube, commonly known as the Eustachian tube. The
auditory tubes, which consist of both bone and hyaline cartilage, connect the
middle ear with the nasopharynx (upper portion of the throat). It is normally
closed at its medial (pharyngeal) end. During swallowing and yawning, it
opens, allowing air to enter or leave the middle ear until the pressure in the
middle equals the atmospheric pressure. When the pressures are balanced,
the eardrum vibrates freely as sound waves strike it. If the pressure is not
equalized, intense pain, hearing impairment, ringing in the ears, and vertigo
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could develop. The auditory also is route whereby pathogens may travel from
the nose and throat to the middle ear.
Internal (inner) ear
The internal ear is also called the labyrinth because of its complicate d series
of canals. Structurally, it consists of 2 main divisions; an outer bony labyrinth
that encloses an inner membranous labyrinth. The only labyrinth is a series
of cavities in the temporal bone divided into 3 areas: 1. the semi circular
canals, 2. the vestibule, both if which contain receptors for equilibrium, and
3. The choclea, which contains receptors for hearing. The bony labyrinth is
lined with periosteum and contains perilymph. This fluid, which is chemically
similar to cerebrospinal fluids, sorrounds the membranous labyrinth, a series
of sacs and tubes inside the bony labyrinth and having the same general
form. The membranous labyrinth is lined by epithelium and contains
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endolymph. The level of potassium ions in endolymph is unusually high for
an extracellular fluid, and potassium ions play a role in the generation of
auditory signals. The vestibule is the oval central portion of the bony
labyrinth. The membranous labyrinth in the vitibule consists if 2 sacs called
the utricle (little bag) and the saccule (little sac), which are connected by a
small duct. Projecting superiorly and posteriorly from the vestibule is the 3
bony semicircular canals, each of which lies at approximately right angles to
the other 2. Based on their positions, they are named the anterior, posterior,
and lateral semi circular canals. The anterior and posterior semi circular
canals are vertically oriented; the lateral one is horizontally oriented. At one
end of each canal is a swollen enlargement called the ampulla (saclike duct).
The portions of the membranous labyrinth that lie inside the bony semi
circular canals are called the semi circular ducts. These structures
communicate with the utricle of the vestibule. The vestibular branch of the
vestibulochoclear nerve (cranial nerve VIII) consists of ampullary, utricular,
and saccular nervers. These nerves contain both first order sensory neurons
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and motor neurons that synapse with receptors for equilibrium. The first
order sensory neurons carry sensory information from the receptors, and the
motor neurons carry feedback signals to the receptors, apparently to modify
their sensitivity. Cell bodies Of the sensory neurons are located in the
vestibular ganglia. Anterior to the vestibule is the choclea (snail shape) a
bony spiral canal that resembles a snails shell and makes almost 3 turns
around a central bony core called the modiolus.
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Sections through the choclea reveal that it is divided into 3 channels.
Together, the partitions that separate the channels are shaped like the letter
Y. the stem of the Y is bony shell that protrudes into the canal; the wing of
the Y are composed mainly of membranous labyrinth. The channel above the
bony partition is the scala vestibule, which ends at the oval window; the
channel below is the scala tympani, which ends at the round window. The
scala vestibule and scala tympani both contain perilymph and are completely
separated, except for an opening at eh apex of the cochlea, the helicotrema.
The cochlea adjoins the wall of the vestibule, into which the scala vestibule
opens. The perilymph in the vestibule is continuous with that of the scala
vestibule. The third channel is the cochlear duct or scala media. The
vestibular membrane separate the cochlear duct from the scala vestibule,
and the basilar membrane separates the cocholear from the scala tympani.
Resting on the basilar membrane is the spiral organ of corti. The spiral corti
is a coiled sheet of epithelial cells, including supporting cells and about 16
thousands hair cells, which are the receptors for hearing. There are 2 groups
of hair cells; the inner hair cells are arranged in a single row whereas the
outer hair called are arrange in 3 rows. At the apical tip of each hair cell is a
hair bundle, consisting of 30-100 streocilia that extends into the endolymph
of the cochlear duct. Despite their name, stereocilia are actually long hair
like microvili arrange in several rows of graded height. At their ends, inner
and outer cells synapse both with first-order sensory neurons and with motor
neurons from the cochlear branch of the vestibulucocholear. Cells bodies of
the sensory neurons are located in the spiral ganglion. Although outer hair
cells outnumber them by 3-1 the inner hair cells synapse 90-95% of the first
order sensory neurons in the cochlear nerve that relay auditory information
to the brain. By contrast 90% of the motor neurons in the cochlear nerve
synapse in the outer hair cells. Projecting over and in contact with hair cells
of the spiral organ is the tectorial membrane, a flexible gelatinous
membrane.
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Pathophysiology of Chronic Otitis Media
Definition: chronic inflammation of the middle ear with tissue damage
Precipitating factors Predisposing
Factors
Hemolytic streptococci Lifestyle
S. pnuemoniae Age
H. Influenzae
Invision of the middle ear
Immune system fights back and try to
Eliminate baterias
Inflammation of the middle ear
Pus accumulate in the middle
Necrosis of middle ear tissue
Damage of tympanic membrane
And ossicles
Infections extends to the mastoid cells
(mastoiditis)
Cholesteatoma form
Chronic Otitis media
Fever, pain
at infected
Hearingloss, pain atinfected ear
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Nursing Diagnosis:Disturbed auditory Sensory Perception related to surgicaldisturbance of middle ear structures
Objectives: at the end of 2days of intervention, patient will be able to identifyways to communicate and compensate for deficits
SubjectiveDili na gyud siya maka dungog sir as verbalized by significant other
ObjectiveDeafDoesnt look relax
Interventions RationalePosition client to see surroundings and activities.
Provide uninterrupted sleep and rest periods.
Provided common sign language during
communication
Provides sensory input for stimulation
Reduces sensory overload, enhances orientationand coping abilities
To facilitate learning for communicating
Evaluation: at the end of 2 days intervention, patient had not learned how tocommunicate and still in denial stage.
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Nursing Diagnosis: Low self esteem related to situational crises
Objectives: at the end of 2 days intervention, patient will be able to accept thesituation in her life and develop realistic plans in adapting new role in life
SubjectivePermi lagi na siya guol ug nawong sir, unya usahay pud maghilak na siya
ObjectivesLack of eye contactAnxiousWeak
Intervention RationaleEncourage SO to treat client as normally as
possible
Visited patient very often
Interact to patient as if no health problem exist
Involving client in family unit reduces feelings of
social isolation, helplessness, and uselessness
There are time that patient is alone,to provide company for the patient,so she may feel shes not alone
For patient to regain the confidenceshe once lost
Evaluation: at the end of 2days intervention, patient still in denial stage anddoesnt like to mingle with me or other people around