Practice Essentials

Otitis media (OM) is any inflammation of the middle ear (see the images below), without
reference to etiology or pathogenesis. It is very common in children.

Acute otitis media with purulent

effusion behind a bulging tympanic membrane.

View Media Gallery

 Chronic otitis media with a
retraction pocket of the pars flaccida.

View Media Gallery

There are several subtypes of OM, as follows:

Acute OM (AOM)

OM with effusion (OME)

Chronic suppurative OM

Adhesive OM

Signs and symptoms

AOM implies rapid onset of disease associated with one or more of the following
symptoms:

Otalgia

Otorrhea

Headache

Fever

Irritability

Loss of appetite
 Vomiting

Diarrhea

OME often follows an episode of AOM. Symptoms that may be indicative of OME
include the following:

Hearing loss

Tinnitus

Vertigo

Otalgia

Chronic suppurative otitis media is a persistent ear infection that results in tearing or
perforation of the eardrum.

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the
middle ear space and stuck.

See Clinical Presentation for more detail.

Diagnosis

OME does not benefit from antibiotic treatment. Therefore, it is critical for clinicians to
be able to distinguish normal middle ear status from OME or AOM. Doing so will avoid
unnecessary use of antibiotics, which leads to increased adverse effects of medication
and facilitates the development of antimicrobial resistance.

Examination

Pneumatic otoscopy remains the standard examination technique for patients with
suspected OM. In addition to a carefully documented examination of the external ear
and tympanic membrane (TM), examining the entire head and neck region of patients
with suspected OM is important.

Every examination should include an evaluation and description of the following four TM
characteristics:

Color A normal TM is a translucent pale gray; an opaque yellow or blue TM is

consistent with middle ear effusion (MEE)

Position In AOM, the TM is usually bulging; in OME, the TM is typically

retracted or in the neutral position
 Mobility Impaired mobility is the most consistent finding in patients with OME

Perforation Single perforations are most common

Adjunctive screening techniques for OM include tympanometry, which measures

changes in acoustic impedance of the TM/middle ear system with air pressure changes
in the external auditory canal, and acoustic reflectometry, which measures reflected
sound from the TM; the louder the reflected sound, the greater the likelihood of an MEE.

See Workup for more detail.

Management

Most cases of AOM improve spontaneously. Cases that require treatment may be
managed with antibiotics and analgesics or with observation alone.

Guidelines from American Academy of Pediatrics

In February 2013, the American Academy of Pediatrics (AAP) and the American
Academy of Family Physicians (AAFP) released updated guidelines for the diagnosis
and management of AOM, including recurrent AOM, in children aged 6 months through
12 years. The recommendations offer more rigorous diagnostic criteria to reduce
unnecessary antibiotic use.

According to the guidelines, management of AOM should include an assessment of

pain. Analgesics, particularly acetaminophen and ibuprofen, should be used to treat
pain whether antibiotic therapy is or is not prescribed.

Recommendations for prescribing antibiotics include the following:

Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at

least 6 months with severe signs or symptoms (moderate or severe otalgia,
otalgia for 48 hours or longer, or temperature 39C or higher) and for nonsevere,
bilateral AOM in children aged 6 to 23 months

On the basis of joint decision-making with the parents, unilateral, nonsevere

AOM in children aged 6-23 months or nonsevere AOM in older children may be
managed either with antibiotics or with close follow-up and withholding antibiotics
unless the child worsens or does not improve within 48-72 hours of symptom
onset

Amoxicillin is the antibiotic of choice unless the child received it within 30 days,
has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases,
clinicians should prescribe an antibiotic with additional beta-lactamase coverage
In February 2016, the American Academy of OtolaryngologyHead and Neck Surgery
Foundation, the AAP, and the AAFP issued updated guidelines for the assessment and
management of OME

Background

Otitis media (OM) is the second most common disease of childhood, after upper
respiratory infection (URI). OM is also the most common cause for childhood visits to a
physician's office. Annually, an estimated 16 million office visits are attributed to OM; this
does not include visits to the emergency department.

OM is any inflammation of the middle ear, without reference to etiology or pathogenesis.

It can be classified into many variants on the basis of etiology, duration,
symptomatology, and physical findings.

Acute OM (AOM) implies rapid onset of disease associated with one or more of the
following symptoms:

Otalgia

Fever

Otorrhea

Recent onset of anorexia

Irritability

Vomiting

Diarrhea

These symptoms are accompanied by abnormal otoscopic findings of the tympanic

membrane (TM), which may include the following:

Opacity

Bulging

Erythema

Middle ear effusion (MEE)

 Decreased mobility with pneumatic otoscopy

AOM is a recurrent disease. More than one third of children experience six or more
episodes of AOM by age 7 years.

OM with effusion (OME), formerly termed serous OM or secretory OM, is MEE of any
duration that lacks the associated signs and symptoms of infection (eg, fever, otalgia,
and irritability). OME usually follows an episode of AOM.

Chronic suppurative OM is a chronic inflammation of the middle ear that persists for at
least 6 weeks and is associated with otorrhea through a perforated TM, an indwelling
tympanostomy tube (TT; see the image below), or a surgical myringotomy.

Various tympanostomy tube styles

and sizes.

Pathophysiology

The most important factor in middle ear disease is eustachian tube (ET) dysfunction
(ETD), in which the mucosa at the pharyngeal end of the ET is part of the mucociliary
system of the middle ear. Interference with this mucosa by edema, tumor, or negative
intratympanic pressure facilitates direct extension of infectious processes from the
nasopharynx to the middle ear, causing OM. Esophageal contents regurgitated into the
nasopharynx and middle ear through the ET can create a direct mechanical disturbance
of the middle ear mucosa and cause middle ear inflammation.

In children, developmental alterations of the ET, an immature immune system, and

frequent infections of the upper respiratory mucosa all play major roles in AOM
development. Studies have demonstrated how viral infection of the upper respiratory
epithelium leads to increased ETD and increased bacterial colonization and adherence
in the nasopharynx. [1]

Certain viral infections cause abnormal host immune and inflammatory responses in the
ET mucosa and subsequent microbial invasion of the middle ear. The host immune and
inflammatory response to bacterial invasion of the middle ear produces fluid in the
middle ear and the signs and symptoms of AOM.
Although interactions between the common pathogenic bacteria in AOM and certain
viruses are not fully understood, strong evidence indicates that these interactions often
lead to more severe disease, lowered response to antimicrobial therapy, and OME
development following AOM.

Etiology

A multitude of host, infectious, allergic, and environmental factors contribute to the

development of OM.

Host factors
Immune system

The immature immune systems of infants or the impaired immune systems of patients
with congenital immune deficiencies, HIV infection, or diabetes may be involved in the
development of OM. [2] OM is an infectious disease that prospers in an environment of
decreased immune defenses. The interplay between pathogens and host immune
defense plays a role in disease progression.

Patel et al found higher interleukin (IL)6 levels in patients with OM who also had
influenza and adenoviral infections, whereas IL-1 levels were higher in patients who
developed OM following URI. [3] In another study, Skovbjerg et al found that middle ear
effusions with culturable pathogenic bacteria were associated with higher levels of IL-1
, IL-8, and IL-10 than sterile effusions. [4]

Familial (genetic) predisposition

Although familial clustering of OM has been demonstrated in studies that examined

genetic associations of OM, separating genetic factors from environmental influences
has been difficult. No specific genes have been linked to OM susceptibility. As with most
disease processes, effects of environmental exposures on genetic expression probably
play an important role in OM pathogenesis.

Mucins

The role of mucins in OME has been described. Mucins are responsible for gel-like
properties of mucus secretions. The middle ear mucin gene expression is unique
compared with the nasopharynx. Abnormalities of this gene expression, especially
upregulation of MUC5B in the ear, may have a predominant role in OME.

Anatomic abnormality
Children with anatomic abnormalities of the palate and associated musculature,
especially the tensor veli palantini, exhibit marked ETD and have higher risk for OM.
Specific anomalies that correlate with high prevalence of OM include cleft palate,
Crouzon syndrome or Apert syndrome, Down syndrome, and Treacher Collins
syndrome.

Physiologic dysfunction

Abnormalities in the physiologic function of the ET mucosa, including ciliary dysfunction

and edema, increase the risk of bacterial invasion of the middle ear and the resultant
OME. Children with cochlear implants have a high incidence of OM, especially chronic
OM and cholesteatoma formation. One study described a relationship between
laryngopharyngeal reflux and chronic OM (COM); the authors concluded that reflux
work-up should be performed as part of COM investigations, and, if reflux is confirmed,
reflux treatment should be initiated in addition to treatment of primary disease. [5]

Other host factors

Vitamin A deficiency is associated with pediatric upper respiratory infections and AOM.

Obesity has been linked to an increased incidence of OM, although the causal factor is
unknown. Speculations include alteration of intrinsic cytokine profile, increased
gastroesophageal reflux with alterations of the oral flora, and/or fat accumulation; all of
these have been linked with an increased incidence of OM. Conversely, OM may
increase the risk of obesity by altering the taste buds. [6]

Infectious factors
Bacterial pathogens

The most common bacterial pathogen in AOM is Streptococcus pneumoniae, followed

by nontypeable Haemophilus influenzae and Moraxella (Branhamella) catarrhalis.
These three organisms are responsible for more than 95% of all AOM cases with a
bacterial etiology. [7]

In infants younger than 6 weeks, gram-negative bacilli (eg, Escherichia coli, Klebsiella
species, and Pseudomonas aeruginosa) play a much larger role in AOM, causing 20%
of cases. S pneumoniae and H influenzae are also the most common pathogens in this
age group. Some studies also found Staphylococcus aureus as a pathogen in this age
group, but subsequent studies suggested that the flora in these young infants may be
that of usual AOM in children older than 6 weeks.
Many experts had proposed that the MEE associated with OME was sterile because
cultures of middle ear fluid obtained by tympanocentesis often did not grow bacteria.
This view is changing as newer studies show 30-50% incidence of positive results in
middle ear bacterial cultures in patients with chronic MEE. These cultures grow a wide
range of aerobic and anaerobic bacteria, of which S pneumoniae, H influenzae, M
catarrhalis, and group A streptococci are the most common.

M catarrhalisinduced AOM differs from AOM caused by other bacterial pathogens in

several ways. It is characterized by higher a proportion of mixed infections, younger age
at the time of diagnosis, lower risk of spontaneous perforation of the tympanic
membrane, and an absence of mastoiditis. [8]

Further evidence for the presence of bacteria in the MEE of patients with OME was
provided by studies using polymerase chain reaction (PCR) assay to detect bacterial
DNA in MEE samples that were determined to be sterile with standard bacterial culture
techniques. In one such study using PCR assay, 77.3% of the MEE samples had
positive results for one or more common AOM pathogens (eg, S pneumoniae, H
influenzae, M catarrhalis).

In chronic suppurative OM, the most frequently isolated organisms include P

aeruginosa, S aureus, Corynebacterium species, and Klebsiella pneumoniae. An
unanswered question is whether these pathogens invade the middle ear from the
nasopharynx via the ET (as do the bacteria responsible for AOM) or whether they enter
through the perforated TM or a TT from the EAC.

The role of Helicobacter pylori in children with OME has been increasingly recognized. [9]
Evidence that this agent might be responsible for OME comes from its isolation from
middle ear and tonsillar and adenoidal tissue in patients with OME.

Alloiococcus otitidis is a species of gram-positive bacterium that has been discovered

as a pathogen associated with OME. [10, 11] This organism is the most frequent bacterium
in AOM, as well as in OME. It has also been detected in patients who had been treated
with antibiotics, such as beta-lactams or erythromycin, suggesting that these agents
may not be sufficiently effective to eliminate this organism. Further investigation is
needed to reveal the clinical role of the organism in OM.

Viral pathogens

Because acute viral URI is a prominent risk factor for AOM development, most
investigators have suspected a role for respiratory viruses in AOM pathogenesis.
Many studies have substantiated this suspicion by showing how certain respiratory
viruses can cause inflammatory changes to the respiratory mucosa that lead to ETD,
increased bacterial colonization and adherence, and, eventually, AOM. Studies have
also shown that viruses can alter the host-immune response to AOM, thereby
contributing to prolonged middle ear fluid production and development of chronic OME.

The viruses most commonly associated with AOM are respiratory syncytial virus (RSV),
influenza viruses, parainfluenza viruses, rhinovirus, and adenovirus. Human
parechovirus 1 (HPeV1) infection is associated with OM and cough in pediatric patients.
[12]
OM developed in 50% of 3-month follow-up periods that yielded evidence of HPeV1
infection but in only 14% of the HPeV1-negative periods; in recurring OM, the middle
ear fluid samples were positive for HPeV in 15% of episodes.

Factors related to allergies

The relation between allergies and OM remains unclear. In children younger than 4
years, the immune system is still developing, and allergies are unlikely to play a role in
recurrent AOM in this age group. Although much evidence suggests that allergies
contribute to the pathogenesis of OM in older children, extensive evidence refutes the
role of allergies in the etiology of middle ear disease.

The following is a brief list of evidence for and against the etiologic role of allergy in OM:

Many patients with OM have concomitant allergic respiratory disease (eg, allergic
rhinitis, asthma)

Many patients with OM have positive results to skin testing or radioallergosorbent

testing (RAST)

Although mast cells are found in the middle ear mucosa, most studies fail to
show significant levels of immunoglobulin E (IgE) or eosinophils in the MEE of
patients with OM

OM is most common in the winter and early spring, yet most major allergens (eg,
tree and grass pollens) peak in the late spring and early fall

Most patients with concomitant OM and allergy show no marked improvement in

middle ear disease with aggressive allergy management, despite marked
improvements to nasal and other allergy-related symptoms

Environmental factors
Infant feeding methods
Many studies report that breastfeeding protects infants against OM. The best of these
studies indicates that this benefit is evident only in children who are breastfed
exclusively for the first 3-6 months of life. Breastfeeding of this duration reduces the
incidence of OM by 13%. The protective effects of breastfeeding for the first 3-6 months
persist for 4-12 months after breastfeeding ceases, possibly because delaying onset of
the first OM episode reduces recurrence of OM in these children.

Passive smoke exposure

Many studies have shown a direct relation between passive smoke exposure and risk of
middle ear disease. [13] A systematic review of 45 publications dealing with OM and
parental smoking showed pooled odds ratios of 1.48 (95% confidence interval [CI] of
1.08-2.04) for recurrent OM, 1.38 (95% CI of 1.23-1.55) for MEE, and 1.3 (95% CI of
1.3-1.6) for AOM. [14]

Group daycare attendance

Daycare centers create close contact among many children, which increases the risks
of respiratory infection, nasopharyngeal colonization with pathogenic microbes, and
OM.

Many researchers have used meta-analysis to confirm that exposure to other young
children (including siblings) in group daycare settings is a major risk factor for OM. [15] A
meta-analysis reported that care outside the home conferred a 2.5-fold risk for OM.
Other critical reviews of studies on OM and group childcare show heightened odds
ratios of 1.6-4.0:1 for center care versus home care.

Children who attend daycare centers frequently acquire antibacterial-resistant

organisms in their nasopharynx, leading to AOM that may be refractory to antibacterial
treatment. American Academy of Pediatrics and American Academy of Family
Physicians' guidelines recommend high-dose amoxicillin-clavulanate as the antibiotic of
choice in the treatment of AOM in children who attend daycare.

Socioeconomic status

Socioeconomic status encompasses many independent factors that affect both the risk
of OM and the likelihood that OM will be diagnosed. [16]

In general, lower socioeconomic status confers higher risk for environmental exposure
to parental smoking, bottle-feeding, crowded group daycare, crowded living conditions,
and viruses and bacterial pathogens. Compared with children from middle-income and
high-income families, children from lower socioeconomic groups use health care
resources less frequently, which decreases the likelihood that OM cases will be
diagnosed.

Epidemiology

United States statistics

OM, the most common specifically treated childhood disease, accounts for
approximately 20 million annual physician visits. Various epidemiologic studies report
the prevalence rate of AOM to be 17-20% within the first 2 years of life, and 90% of
children have at least one documented MEE by age 2 years. OM is a recurrent disease.
One third of children experience six or more episodes of AOM by age 7 years.

International statistics
Incidence and prevalence in other industrialized nations are similar to US rates. In less
developed nations, OM is extremely common and remains a major contributor to
childhood mortality resulting from late-presenting intracranial complications.
International studies show increased prevalence of AOM and chronic OM (COM) among
Micronesian and Australian aboriginal children.

Age-related demographics
Peak prevalence of OM in both sexes occurs in children aged 6-18 months. Some
studies show bimodal prevalence peaks; a second, lower peak occurs at age 4-5 years
and corresponds with school entry. Although OM can occur at any age, 80-90% of
cases occur in children younger than 6 years. Children who are diagnosed with AOM
during the first year of life are much more likely to develop recurrent OM and chronic
OME than children in whom the first middle ear infection occurs after age 1 year.

Sex-related demographics
Several studies have now shown equal AOM prevalence in males and females; many
previous studies had shown increased incidence in boys.

Race-related demographics
For some time, the prevalence of OM in the United States was reported to be higher in
black and Hispanic children than in white children. However, a study that controlled for
socioeconomic and other confounding factors showed equal incidence in blacks and
whites. Hispanic children and Alaskan Inuit and other American Indian children have
higher prevalence of AOM than white and black children in the United States.
Prognosis

US mortality is extremely low in this era of antimicrobial therapy (< 1 death per 100,000
cases). In developing nations with limited access to primary medical care and modern
antibiotics, mortality figures are similar to those reported in the United States before
antibiotic therapy. A study that examined the causes of death in Los Angeles County
Hospital from 1928-1933, years before the advent of sulfa, showed that 1 in 40 deaths
was caused by intracranial complications of OM.

Morbidity from this disease remains significant, despite frequent use of systemic
antibiotics to treat the illness and its complications. Intratemporal and intracranial
complications of OM are the two major types.

Intratemporal complications include the following:

Hearing loss (conductive and sensorineural)

TM perforation (acute and chronic)

Chronic suppurative OM (with or without cholesteatoma)

Cholesteatoma

Tympanosclerosis

Mastoiditis

Petrositis

Labyrinthitis

Facial paralysis

Cholesterol granuloma

Infectious eczematoid dermatitis

Intracranial complications include the following [17] :

Meningitis

Subdural empyema
 Brain abscess

Extradural abscess

Lateral sinus thrombosis

Otitic hydrocephalus

The prognosis for almost all patients with OM is excellent [18] ; the exceptions are
patients in whom OM involves intratemporal and intracranial complications (< 1%).

Data on cognitive and educational outcomes of OM in the literature are limited. [19] The
impact of OM on child development depends on numerous factors. OM in infants
younger than 12 months predisposes to long-term speech and language problems. OM
has also been reported to negatively affect preexisting cognitive or language problems.
Careful follow-up and early referral are key to management.

Patient Education

Patient education topics should include the following:

Avoiding risk factors

Appropriate use of antibiotics

Understanding the implications of antibiotic-resistant bacteria in OM

Education for health care providers should focus on the following topics:

Antibiotic-resistant bacteria and the need to avoid overprescribing antibiotics

Importance of pneumatic otoscope examination to distinguish AOM from OME

Treatment differences between AOM and OME

Nursing Diagnosis for Acute Otitis Media and Nursing Interventions for Acute
Otitis Media

Nursing Assessment for Acute Otitis Media

Assess the presence of pain behaviors: verbal and non-verbal.

Assess the increase in temperature (an indication of the infection process).

 Assess the presence of enlarged lymph nodes in the neck area.

Assess nutritional status and adequacy of fluid intake of calories.

Assess the possibility of deafness.

Nursing Diagnosis for Acute Otitis Media

1. Acute Pain related to inflammation of the middle ear tissue.

2. Disturbed Sensory Perception: auditory conductive disorder related to the sound

of the organ.

Nursing Interventions for Acute Otitis Media

1. Acute Pain related to inflammation of the middle ear tissue.

Purpose: The reduction in pain.

Intervention:

Assess the level of intensity of the client and client's coping mechanisms.

Give analgesics as indicated.

Distract the patient by using relaxation techniques: distraction, guided

imagination, touching, etc..

2. Disturbed Sensory Perception: auditory conductive disorder related to the sound of

the organ.

Purpose: to improve communication

Intervention:

Reduce noise in the client environment.

Looking at the client when speaking.

Speaking clearly and firmly on the client without the need to shout.
 Provide good lighting when the client relies on the lips.

Using the signs of non-verbal (eg facial expressions, pointing, or body

movement) and other communications.

Instruct family or the people closest to the client on how techniques of effective
communication so that they can interact with clients.

If the client wants, the client can use hearing aids.

Nursing Diagnosis for Acute Pain

Definition: Unpleasant sensory and emotional experience arising from actual or

potential tissue damage or described in terms of such damage (International
Association for the Study of Pain); sudden or slow onset of any intensity from mild to
severe with an anticipated or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide
range of distressing factors may be experienced by the sufferer. Pain may be a
symptom of injury or illness. Pain may also arise from emotional, psychological, cultural,
or spiritual distress. Pain can be very difficult to explain, because it is unique to the
individual; pain should be accepted as described by the sufferer. Pain assessment can
be challenging, especially in elderly patients, where cognitive impairment and sensory-
perceptual deficits are more common.

Defining Characteristics

Patient reports pain

Guarding behavior, protecting body part

Self-focused

Narrowed focus (e.g., altered time perception, withdrawal from social or physical
contact)

Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other
people or activities, restlessness)

Facial mask of pain

 Alteration in muscle tone: listlessness or flaccidness; rigidity or tension

Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse

rate; pupillary dilation; change in respiratory rate; pallor; nausea)

Related Factors:

Postoperative pain

Cardiovascular pain

Musculoskeletal pain

Obstetrical pain

Pain resulting from medical problems

Pain resulting from diagnostic procedures or medical treatments

Pain resulting from trauma

Pain resulting from emotional, psychological, spiritual, or cultural distress

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Comfort Level

Medication Response

Pain Control

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Analgesic Administration

Conscious Sedation

Pain Management

Patient-Controlled Analgesia Assistance

 Expected Outcomes

Patient verbalizes adequate relief of pain or ability to cope with incompletely

relieved pain.

Anxiety is probably present at some level in every individuals life, but the degree and
the frequency with which it manifests differs broadly. Each individuals response to
anxiety is different. Some people are able to use the emotional edge that anxiety
provokes to stimulate creativity or problem-solving abilities; others can become
immobilized to a pathological degree. The feeling is generally categorized into four
levels for treatment purposes: mild, moderate, severe, and panic. The nurse can
encounter the anxious patient anywhere in the hospital or community. The presence of
the nurse may lend support to the anxious patient and provide some strategies for
traversing anxious moments or panic attacks.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

* Anxiety Control
* Coping

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

* Anxiety Reduction
* Presence
* Calming Technique
* Emotional Support

* Defining Characteristics: Physiological:

o Increase in blood pressure, pulse, and respirations
o Dizziness, light-headedness
o Perspiration
o Frequent urination
o Flushing
o Dyspnea
o Palpitations
o Dry mouth
o Headaches
o Nausea and/or diarrhea
o Restlessness
o Pacing
o Pupil dilation
o Insomnia, nightmares
o Trembling
o Feelings of helplessness and discomfort
* Behavioral:
o Expressions of helplessness
o Feelings of inadequacy
o Crying
o Difficulty concentrating
o Rumination
o Inability to problem-solve
o Preoccupation

* Related Factors: Threat or perceived threat to physical and emotional integrity

* Changes in role function
* Intrusive diagnostic and surgical tests and procedures
* Changes in environment and routines
* Threat or perceived threat to self-concept
* Threat to (or change in) socioeconomic status
* Situational and maturational crises
* Interpersonal conflicts

* Expected Outcomes Patient is able to recognize signs of anxiety.

* Patient demonstrates positive coping mechanisms.
* Patient may describe a reduction in the level of anxiety experienced.

Definition :

Impaired verbal communication is defined as decreased, delayed, or absent ability to

receive, process, transmit, and use a system of symbols.

Impaired Verbal Communication Related To :

Physiologic conditions

Alteration of central nervous system

Impaired neurologic development or dysfunction

 Disturbance in attachment/bonding with the parent/caregiver

As Evidenced By :

Language delay or total absence of language

Immature grammatic structure; pronoun reversal; inability to name objects

Stereotyped or repetitive use of language (echolalia, idiosyncratic words,

inappropriate high-pitched squealing/giggling, repetitive phrases, sing-song
speech quality)

Lack of response to communication attempts by others

Outcome Criteria - Impaired Verbal Communication

Communicate in words/gestures that are understood by others

Long-Term Goals

Communicate to parent/caregiver and peers at least four basic needs (hunger,

thirst, fatigue, pain), verbally and/or through gestures and body language

Short-Term Goals

Communicate through eye contact, facial expressions, and other nonverbal

gestures within 1 month

Attempt to use language and begin to communicate with words within 5 to 6

months

Increase language skills needed for social and emotional reciprocal interactions
within 6 to 8 months

Use language or gestures to identify self, others, objects, feelings, needs, plans,
and desires within 12 months

Otitis media is inflammation in the middle ear. Otitis media is actually the most common
diagnosis in children under the age of 15 years.

Acute otitis media is an infection of the middle ear caused by the entry of pathogenic
bacteria in the middle ear (Smeltzer, 2001).
Causes

1. Eustachian tube dysfunction or obstruction is a major cause of otitis media

caused the ciliary body's defense disrupted mucosal eustachian tube, so that
prevention of invasion of germs into the middle ear may also be disrupted.

2. The upper respiratory tract infection, inflammation of the surrounding tissue (eg,
sinusitis, adenoid hypertrophy), or an allergic reaction (eg allergic rhinitis). In
children, the more frequent upper respiratory tract infection, the more likely the
occurrence of acute otitis media (AOM). In infants, AOM easy because
eustachiusnya tube short, wide, and is located some horizontal.

3. Bacteria. The bacteria are commonly found as causative microorganism is

Streptococcus peumoniae, Haemophylus influenza, Moraxella catarrhalis, and
other pyogenic bacteria, such as Streptococcus hemolyticus, Staphylococcus
aureus, E. coli, Pneumococcus vulgaris.

Signs and symptoms

Depending on the stage of the disease and the age of the client.

1. Hyperemia

Pain and filled in the ear because the eustachian tube that experienced
hyperemia and edema.

Fever.

Hearing is usually still normal.

2. Occlusion

Pain and fever intensified.

In children: high heat accompanied by vomiting, seizures, and meningismus.

Hearing begins to decline.

3. Suppuration

Exit discharge from the ear.

 Pain is reduced because the drainage is formed as a result of rupture of the
tympanic membrane.

Fever is reduced.

Hearing loss is increased due to the disruption of air conduction mechanism in

the middle ear.

4. Koalesen

Tenderness over the mastoid region, and will feel heavy at night.

5. Resolution

Hearing improved or returned to normal.

Nursing Diagnosis for Acute Otitis Media

1. Acute pain related to inflammation of the middle ear hearing.

2. Anxiety related to health status.

3. Impaired verbal communication related to the effects of hearing loss.

4. Disturbed sensory perception related to obstruction, infection of the middle ear or

auditory nerve damage.

5. Social isolation related to pain, foul-smelling otorrhoea.

6. Knowledge deficit related to cognitive limitations and lack of interest in learning.

Nursing Diagnosis for Acute Otitis Media and Chronic Otitis Media

1. Acute Pain / Chronic Pain related to the inflammatory process.

2. Impaired verbal communication related to the effects of hearing loss.

3. Disturbed Sensory perception: hearing related to obstruction, infection of the middle

ear or auditory nerve damage.

4. Risk for injury related to hearing loss, decreased visual acuity.

5. Anxiety related to surgical procedure, diagnosis, prognosis, anesthesia, pain, loss of
function, the possibility of a greater hearing loss after surgery.

6. Social isolation related to pain, foul-smelling otorrhoea.

7. Knowledge Deficit regarding treatment, and prevention of relapse of the disease

process.