OTITIS MEDIA

OTITIS MEDIA IN CHILDREN AGED 0-17

OTITIS MEDIA IN CHILDREN AGED 0-17

1. Define otitis media
2. Etiology, pathophysiology, and general clinical manifestation of symptoms of otitis media based on research articles (3 minimum).
3. How might age or overall health status alter the normal clinical manifestation of otitis media?
4. Describe patient’s social and medical history and clinical assessment from the perspective of the previously cited literature.
5. Diagnostic work-up and findings, which includes the rationale for each diagnostic test and expected findings.
6. Age-appropriate modifications of treatments based on clinical guidelines
7. Age appropriate medications modifications
8. Assistive therapies
9. Specific limitations of activities in your plan.
10. Potential complications of care.
11. Possible side effects of medication based on literature that includes follow-up instructions.
12. Patient education materials and community resources.
13. Describe how to engage patient and family in the care plan using teach back method?
14. As medical professional, describe how otitis media relates to underlying health issues
15. Analyze how the principles of Watson’s theory of human caring are integrated into the plan of care and patient education.

ANSWERS

OTITIS MEDIA IN CHILDREN AGED 0-17

1. Define Otitis Media
   According to Nitsche and Carreno (2015), otitis media is a medical term used to refer to a sequence of conditions that exclude serious otitis media, and is a recurrent childhood disorder. It is a generic term that is used to define all distinct conditions that involve the manifestation of inflammation and infection of the middle ear (Venekamp, 2015). Specifically, it’s the inflammation of the mucosal lining that affects the sequelae or the middle ear cleft. Klein & Pelton (2013) defines it as the swelling of the middle ear that predominantly affects children in the 0-17 age bracket. Otitis media occurs predominantly during winter and especially the effusion type even though it seldom occurs at any other time. The disease manifests in different forms including Acute Otitis Externa (AOE), which refers to the ordinary swelling of the epithelium (Venekamp, 2015). The inflammation may sometimes extend to the external ear canal, causing swelling to the pinna. Williamson (2011) defines AOE as a common ontologic condition caused by bacterial infections, and occurs largely in mixed hot and humid conditions. Some publications define Otitis media as a common swelling of the middle ear cleft due to a bacterial infection, even though it can occur without an infection. The type of otitis media that is characterized by bacterial infection is referred to as acute otitis media (AOM), which can degenerate into a severe condition known as Otitis media with effusion (OME). When otitis media (OM) becomes persistent, it is usually known as chronic otitis media. It is common among children aged 0-17 and is usually characterized by obstinate pain, hearing loss and pressure (Klein & Pelton, 2013). The chronic type of otitis media can cause a dysfunction and delay in the language learning process particularly for children. The chronic condition can also cause permanent damage to the tympanic membrane and other middle ear organs with a possibility of resulting to permanent hearing loss. According to other sources, the pathogenesis of acute otitis media (AOM) is bacterial infection that occurs among children aged 0-17 and is the primary reason for administering antibiotics to children in this age bracket. This type of otitis media is caused by the dysfunction of the Eustachian tube as a result of an infection in the upper respiratory tract that extends to the middle ear thereby attacking the pathogenic bacteria that are found in the nasopharyngeal mucosa (Leung, A. K., & Wong, 2017). It’s this microbial that invoke the local cells that respond by causing swelling.
2. Etiology, pathophysiology, and general clinical manifestation of symptoms of otitis media based on research articles (3 minimum). The first and most common host factor is the maturation of the host’s immune system. OM is prevalent in children and infants due to their pre-mature immune system (Venekamp et. 2014). It’s also common in adults who have impaired immune systems such as people living with HI (PLHIV). Its rate of progression is highest in children aged 0-17 due to their developing immunity. In fact, OM proliferation is highest especially when pathogens get an impaired immune system. Another host factor is the genetic predisposition of the host, with different studies showing interplay between genetic and environmental pathogenesis (Nitsche & Carreño, 2015). It’s probable that the interaction between these two can be the cause otitis media. Mucins have also been linked to the development to the development of Otitis media externa (OME). These mucins, especially from the middle ear have unique genetic characteristics that differentiate them from the nasopharynx (Klein & Pelton, 2013). Thus it’s probable that the resulting abnormalities from the mucin-mediated genetic reaction, and particularly the increase of MUC5B in the middle ear could have a significant role in the pathogenesis of Otitis Media External (OME) (Venekamp et. 2014). Other etiological factors that are associated with the host include the anatomic abnormality that largely affects children who have an abnormal palate. The anatomic abnormality that is linked to the development of Otitis media is the cleft palate and other syndromes. OM is also caused by physiologic dysfunction, and especially the ET mucosa as well as the dysfunction of the ciliary that increase chances of a bacterial infection in the middle ear cleft, and hence development of otitis media externa (OME). Moreover, children aged 0-17 years who have cochlear implants are at high risk of developing chronic OM (Williamson, 2011).
   Other host factors include vitamin A deficiency and obesity even though the exact causal factors for obesity remain speculative. Infectious factors include the bacterial pathogens, and especially the streptococcus pneumonia and other respiratory infections. This pathogen as well as Haemophilus influenza and Moraxella have been linked to over 95% of acute otitis media (AOM) incidences caused by bacterial infections (Leung & Wong, 2017). Viral pathogens are another common cause of acute otitis, and especially the respiratory viruses that have been associated with its pathogenesis. In fact, respiratory viruses such as syncytial virus and adenovirus are predominantly linked to acute OM especially in 0-17 aged children. For instance, the human parechovirus 1 has been associated with the development of OM in pediatric patients (Venekamp et. 2014). Other etiological factors include allergies even though their definite role in the development of OM remains unknown. In children under 5 years, the immune system is still immature and hence respiratory related allergies cannot be linked to the prevalence and persistence of acute otitis media in this age group. Lastly, environmental factors could have a role in the development of OM (Nitsche & Carreño, 2015). This encompasses the methods used to feed infants, passive exposure to smoke; children group daycare attendance as well as socio-economic status. Studies have shown that exclusive breastfeeding particularly for the first 6 months helps boosts the immunity of infants, thus lessening their chances of developing OM. Still, a link has been established between passive smoke and inflammation of the middle ear. Moreover, congested and overcrowded daycares increase chances of children contracting upper respiratory infections and OM (Nitsche & Carreño, 2015). Lastly, the social economic status of parents has been associated with increased risks and chances of contracting an OM infection.
3. How might age or overall health status alter the normal clinical manifestation of otitis media?
   Age is the single most critical factor that increases the risks of bacterial and viral attacks that could cause different types of otitis media such as otitis media externa (OME), chronic otitis media (COM) and acute otitis media (AOM) (Klein & Pelton, 2013). This is because the age factor is directly linked to the maturation of the immune system. In fact, the risks of OM decreases with increase in age thus indicating that children aged between 0-17 are the most at risk. Their pre-mature immune system is incapable of protecting infants and children within this age group against OM pathogens. Studies have shown high risks in children who lacked exclusive breastfeeding for the first 3-6 months, and low risk in children who were exclusively breastfed. Therefore, the disease prevalence level is higher in under-5 year olds as compared to children aged 10-17 years. This can be attributed to the fact that the former has a premature immune system while the later has a slightly matured immunity. The overall body health status can also help decrease the manifestation of OM (Nitsche & Carreño, 2015). Thus a balanced diet that is rich in vitamin A can help reduce respiratory infections in pediatric patients, hence providing protection against acute otitis media (AOM). Although the link between obesity and a high OM incidence is still speculative, exercises and a fat-free diet can help decrease the risks of developing OM (Klein & Pelton, 2013). Still, HIV positive children have a high risk of contracting OM due to a highly weakened immune system. Thus the overall parental health status has a direct impact on their children’s risk levels. Parents should therefore lead healthy lifestyles; avoid smoking and irresponsible sexual behavior that could endanger that could put their children at risk of contracting otitis media.
4. Describe patient’s social and medical history and clinical assessment from the perspective of the previously cited literature.
   4.1 Pediatric Patients Social History
   The social history would include their exposure to environmental risk factors such as daycare attendance, which would predispose them to great risks of contracting upper respiratory infections that are linked to AOM, COM and OME (Venekamp et. 2014). It is a critical component of the patient’s history and includes persistent exposure to passive cigarette smoke, exposure to harsh winter season and supine bottle nursing in infants. Children who come from a family with tobacco smokers will be highly susceptible as compared to those from non-smoking families (Klein & Pelton, 2013).
   4.2 Pediatric Medical History
   Pediatric patients who have a history of persistent head-neck and other normal symptoms could be suffering from acute otitis media (AOM). The most common head-neck symptoms include Otalgia, which involves the frequent pulling of the affected ear and it quite often happens when the child is lying down (Nitsche & Carreño, 2015). The second symptom is Otorrhea that refers to persistent discharge from the middle ear that occurs through a pierced tympanic membrane. The patient would have a history of incessant headaches. Besides, the Patient will have previously manifested upper respiratory infection (URI) that may include a persistent cough and sinus congestion (Leung & Wong, 2017). Pediatric patients will also have a history of mild fever of less than 40°C, although severe fever could signal a different medical complication. Irritability may occur specifically in infants and toddlers. Children aged 0-17 are also likely to have a history of an unspecified lethargy even though this is not specific to OM. Children are also likely to exhibit a history of gastrointestinal tract infections that will encompass diarrhea, aneroxia and vomiting (Venekamp et. 2014). Pediatric patients with otitis media externa (OME) or otitis media with effusion are likely to have a unique history that includes hearing loss, tinnitus, vertigo and otalgia, even though tinnitus, vertigo seldom happen except in cases of acute otitis media (AOM).
   4.3 Clinical Assessment
   Clinical assessment may vary based on the patient’s age and underlying health issues, even though the most predominant symptoms may include ear pain, fever, corzal symptoms and malaise (SCPG, 2012). Children who have a swelling in the middle ear will feel pain, be highly irritable and often lack appetite for food. On clinical assessment, the patient’s tympanic membrane will appear erythematous, and swollen. Besides, a small yellow colored fluid may discharge from the patient’s auditory canal. Further clinical examination may also reveal conductive hearing loss with a possibility of degenerating into cervical lymphadenopathy (SCPG, 2012). Otitis media may also present through sudden extreme ear pain and discharge thereafter as this may suggest a raptured tympanic membrane. The functioning of the facial nerve also needs to be tested due to its link to the middle ear. The existence of intracranial complications could suggest an upper respiratory infection (URI). Clinical diagnosis may also include MRI and CT imaging that will help confirm the existence of a middle ear inflammation. Lastly, Ear discharge should be checked through culture and blood culture, which should suggest OM if found to be pyrexial (SCPG, 2012).
   5 Diagnostic work-up and findings, which includes the rationale for each diagnostic test and expected findings.

Otitis media can be diagnosed using different medical techniques. First and foremost, it can be diagnosed sing Computed tomography (CT) that is used to establish the occurrence of a complication (Media, 2014). However, for intracranial complications, the use of magnetic resonance imaging is recommended. Tympanometry is another diagnostic technique that is used in the diagnosis of middle ear effusion that largely associated with acute otitis media (AOM). The use of a pneumatic otoscopy may be necessary, even though rarely used. A comprehensive sepsis workup is recommended in 3 months old infants who present AOM symptoms (SCPG, 2012). CT is the most preferred imaging technique for suspicious cases notably because it can detect multiple complications such as mastoiditis, meningitis and epidural abscess among others. A contrast enhanced CT scans may be used to reveal the ossicular disease as well as cholesteatoma (Media, 2014). MRI is most preferred due to its effectiveness in revealing fluid concentrations in the middle ear, even though it should come after CT scanning. Tympanocentesis is still used in the diagnosis of acute otitis media as it helps reveal the collection of fluid in the middle ear (Thomas et al., 2014). This is then followed by fluid culture used to detect the presence of OM pathogens. Although it improves diagnostic accuracy, tympanocentesis is seldom used in the diagnosis of AOM and OME due to its unavailability and high cost (Media, 2014). The rationale for its usage is that it eliminates the need for surgical operations particularly in patients who present recurrent otitis media. Other diagnostic techniques include tympanometry and reflectometry whereas the former is used in the diagnosis of OME; the latter is used to diagnose otitis media with effusion (Media, 2014).
6 Age-appropriate modifications of treatments based on clinical guidelines
Age appropriate modifications are necessary especially for clinical based guidelines for children aged 0-17 years. The pediatric treatment for acute otitis media (AOM) encompasses dealing with symptoms and OM recurrence. Studies indicate that a vast majority of children who present AOM symptoms have rapid symptomatic reduction within 7-14 days of treatment (Qureishi, 2014). Thus antibiotics should not form the first line of medication. Still, antibiotic therapy in some pediatric patients could drastically cut down on treatment costs. Symptomatic treatment should be administered within the first two days of OM diagnosis. Prescribed treatment should include acetaminophen (15mg/kg in 4-6 hrs.) and ibuprofen (10mg/kg, 6hrs) (Thomas et al., 2014). Antipyrine should be administered to specifically deal with analgesia symptoms. Besides, antihistamines can be administered to pediatric patients who present allergies. Another form of treatment is the use of oral decongestants as they are recommended in reducing the effects of AOM. However, corticosteroids are not recommended for AOM patients. Lastly, antibiotics should be administered for patients diagnosed with AOM, and especially for children aged less than 2 years, and who have tested positive for AOM and Otorrhea. Still, antibiotics can be administered in children less than 6 months when the diagnosis is 100% definite (Qureishi, 2014). However, for healthy children aged 0.5-2 years, who present mild OM, antibiotics should also be administered when the diagnosis is definite.
7 Age appropriate medications modifications
Otitis media medication is predominantly based on antibiotics that are recommended for all pediatric patients aged below 6 months, and in those aged between 0.5-2 years when the diagnosis is definite (Thomas et al., 2014). They can also be administered to all children who present severe infections regardless of their age. Nevertheless, the dosage must be as prescribed by the physician as it must be age appropriate. Still, the most recommended first line of medication drug is amoxicillin, which should be taken as a high dose (80-90mg/kg/day). However, other alternative medications such as macrolide antibiotics and cephalosporins should only be administered when the patient presents rare sensitivity to penicillin and those with recurrent and highly resistant infections (Thomas et al., 2014). Clindamycin can also be used as an alternative medication for children aged 0.5-2 years. The OM medication should be taken in accordance with the physician’s directions. Some pediatric patients may exhibit resistance and non-resistance to medication and thus they should be re-evaluated for appropriate modifications in their medication. Other recommended medications include cortisporins Otic. This should be administered 4 drops 3-4 times every day, and Ofloxacin (Floxin Otic) which should be administered 5 drops for children aged 0-12 years, and 10 drops for pediatric patients above 12 years old (Thomas et al., 2014).
8 Assistive therapies Homeopathic remedies
The homeopathic remedy for acute otitis media is belladonna. It should be used when the pains are spontaneous and severe. It is the recommended remedy for otalgia when particularly the symptoms exceed the usefulness of pulsatilla (Bell & Boyer, 2013). Secondly, Aconite IX is best for excruciating pains, as it’s stronger than Chamomilla, and is still superior to pulsatilla. However, it should be used when there is redness and throbbing in the middle ear and high sensitivity (Bell & Boyer, 2013). Belladonna should be used as a remedy for abrupt change in temperature that worsens at night, even though it should be immediately used after the infection as it has short usefulness as compared to ferrum phosphoricum. Another remedy is pulsatilla which is best for otitis externa, which works best when there is hotness, redness, swelling and throbbing pains that worsen at night (Bell & Boyer, 2013). It’s best recommended for acute swelling of the middle ear and itchiness in the inner ear. The presence of yellow or green discharge and a feeling of extreme deafness evidence it. For general ear infections, Ferrum Phosphoricum is best, and works best as a remedy for congestion and swelling that is prevalent among anaemic pediatric patients (Bell & Boyer, 2013). It also works well as a remedy for acute otalgia that resembles pulsatilla even though without deafness, and is characterized by high sound sensitivity, pulsating pains. Still, Kali muriaticum is the best remedy for tubal catarrh and related conditions that affect the middle ear, and so is Chamomilla, which is an important remedy for infantile Otalgia where the pains are severe and can worsen due to warmth and is characterized by restlessness (Bell & Boyer, 2013). Still, ear pain that comes due to a sudden change in weather conditions. Capsicum is a good remedy for otitis media that is largely characterized by a ruptured tympanic membrane (TM), severe soreness of mastoid and is best for chronic suppurations of the middle ear. Mercurius is the best remedy for suppurative middle ear characterized by inflammation of parotid glands, and scrofulous ear conditions (Bell & Boyer, 2013). Silicea is the best remedy for suppurative middle ear especially when the tympanic membrane is perforated and should be used as a remedy for persistent itching in the Eutachian tube. Other homeopathic remedies include hepar sulpha, causticum and sulphur, which should only be used as, directed by the physician (Bell & Boyer, 2013).
Home remedies
Home remedies include placing a warm piece of cloth close to the infected ear. Alternatively, a heating pad may also be used instead of a warm cloth. The patient can use cold compresses to reduce inflammation and pain (Bell & Boyer, 2013). This can be achieved by placing a cold ice bag closer to the affected ear for a few minutes. The constant use of colloidal silver to clean the ears can be a good home remedy as it has natural antibiotic properties. Additionally, a patient should lie on the side while placing the ear on a dry washcloth as this position causes the collected fluid to naturally drain out of the affected ear (Bell & Boyer, 2013).
Natural remedies with study findings
The first natural remedy is “Eustachian tube rehabilitation” (ETR). This alternative OM treatment method was developed in France (D’Alatri et al., 2012). It is a natural treatment method that aids in the opening of ET based on diverse natural methods such as enhanced nasal hygiene and breathing, muscle strengthening and exercises and autosufflation (D’Alatri et al., 2012). It’s an effective remedy for OME especially in children given that their Eustachian tubes are underdeveloped. As part of this therapy, studies have also shown that regular chewing gum can be helpful as it activates jaw movements as well as paratubal muscles and tubal openings and hence can be effective in the management of otitis media with effusion (D’Alatri et al., 2012). ETR can significantly improve middle ear ventilation, thus eliminating the need for tympanostomy. Nevertheless, the efficacy of ETR over other conventional OM remedies is yet to be established. The second natural remedy is acupuncture or needle puncturing. This treatment method was borrowed from the traditional Chinese medicine and entails needle insertion into certain body points. Acupuncture causes the body to generate energy force, chi (qi) (D’Alatri et al., 2012). Thus this technique enhance chi, which restores the body into a healthy state. For OM treatment, one of the four locations on the auricle are punctured and especially the external canal which is associated with ear energy. Though not substantiated, acupuncture can help drain the collected fluid in the middle ear due to its immunomodulatory characteristics. Another natural remedy is Chiropratic, which treats the mechanical syndromes associated with the skeletal system, and the spine in particular (D’Alatri et al., 2012). This method is based on the understanding that the musculoskeletal system problems impact the entire body health through the central nervous system, and entails manipulation of the spine and body joints that restores the body to a healthy state (D’Alatri et al., 2012). Another remedy is candling which involves the use of a candle, which is said to help in blood purification which cleans and drains collected fluid from the middle ear by generating a negative pressure (D’Alatri et al., 2012). However, further investigation is required to validate these claims. The other remedy is the use of probiotics, which are microorganisms that are used to improve human health through modulation of the microbial community thereby improving the patient’s body health (D’Alatri et al., 2012). These can be achieved through inhibition of pathogens and secretion of bacteriocins. The last natural remedy involves the use of vitamin D supplements which acts as immunomodulators of the host’s immune system, especially the 25-hydroxyvitamin D. It does this by shifting the status of T-helper cells, thus making them Th2, which inhibits the generation of pro-inflammatory cytokines that cause middle ear inflammation (D’Alatri et al., 2012).
9 Specific limitations of activities in your plan.
There are no specific known physical limitations since most studies indicate that a child who has undergone tympanostomy can still assume schooling the day after discharge. However, there are certain conditions that the ear shouldn’t be exposed to. For instance, any activity that might cause water to enter into the ears such as swimming, bathing and showering should be avoided given that water exposure can cause re-infection in the tympanostony tubes immediately after surgery (Pashley & Scholl, 2014). Furthermore, the patient should avoid highly noisy places due to high noise sensitivity that occurs immediately after tympanostomy. Three days after tympanostomy, the child should avoid all activities that can strain and exert undue pressure to the affected ear as this may affect the healing process (Pashley& Scholl, 2014). The child should avoid sports and games that might cause accidental falls or injuries to the affected ear. To protect the ears from water exposure, the child should wear ear protections or completely avoid water play, bathing or showering for three days after tympanostony (Pashley& Scholl, 2014). The affected ear should be protected from exposure to excessive noise and water until the next follow-up visit.
10 Potential complications of care.
The advent of antibiotics significantly reduced the number of OM treatment related complications. Nevertheless, complications still occur in both children and adults. The complications vary from one type of OM, medication and individual response to the medication. Although recent studies have suggested a decline in complications when antibiotics and placebo are concurrently used as treatment in children aged 0-17 years, some patients may still experience mild to severe complications either resulting from post-medication or severe manifestation of otitis media (Qureishi, 2014). Possible complications during nursing care can be divided into two namely extracranial and intracranial complications. Extracranial complications include facial palsy, mastoiditis and petrositis. Facial palsy is an extracranial complication that is common in AOM pediatric patients. It is a facial palsy that includes frontalis, which could lead to visual impairment (Qureishi, 2014). On the other hand, mastoiditis is an extracranial complication that results from prolonged infection of the middle ear that creates an abscess within the mastoid and the temporal bone. Nevertheless, mastoiditis complication seldom happens due to the prevalence of middle ear infection type. Still, pediatric patients who present mastoiditis are irritable; this could cause inflammation behind the ear cleft (Qureishi, 2014). The good news is that mastoid abscess seldom spreads internally. Petrositis is a type of extracranial complication that involves the spread of infection from the middle ear to the petrous temporal bone area (Qureishi, 2014). It presents with sepsis and other symptoms similar to those of mastoiditis. Eventually, the patient may develop the Grandenigo’s Syndrome. On the other hand, intracranial complications can be divided into three namely meningitis, sigmoid sinus thrombosis and brain abscess. Meningitis often presents with symptoms such as sepsis, vomiting and headache among others. Notably, patients experience pain on the meningeal area, while sigmoid sinus thrombosis manifests with symptoms such as sepsis, meningitis and unstable pyrexia (Qureishi, 2014). In severe cases, a palpable cord can form within the neck as a result of an internal clot. The spread of the clot can cause protosis as well other unspecified intracranial complications. The last intracranial complication is brain abscess, which is predominantly associated with sepsis alongside other mild to severe neurological symptoms (Qureishi, 2014).
11 Possible side effects of medication based on literature that includes follow-up instructions.
11.1 Possible side effects of medication based on literature

Although the advent of antibiotics significantly reduced post-medication effects; different types can have varying effects on the pediatric patient. For example, Amoxicillin/Augmentin is largely associated with gastrointestinal side effects that can include diarrhea. Pediatric patients using clavulanate will also exhibit lack of appetite, which further predisposes their gastrointestinal tracts to the effects of medication owing to their empty stomachs. Still, amoxicillin suspension has a bad taste as compared to other antibiotics. Trimethoprim has been found to cause side effects such as hypersensitivity of sulfonamides in pediatric patients. Seldom, the patient may experience allergy-like reactions that could encompass hemolytic anemia as well as crystalluria. However, the prevalent side effects of sulfamethoxazole includes nausea, body rash and in rare cases, vomiting. Patients who use Cefpodoxime proxetil may report gastrointestinal side effects, while in rare cases, skin rash. On the other hand, Cefdinir is associated with diarrhea and nausea. In addition, women may experience vaginal moniliasis. Patients may also report red stool, and where incorrect prescription is followed, patients may develop antibiotic resistance.
11.2 Follow-up instructions:
Following tympanostomy, follow-up should be scheduled 4-6 weeks after the operation. The follow-up appointment should be scheduled prior to the surgery. The patient’s symptoms should improve 24-48 hours after the surgery. Therefore a follow-up is needed 24-48 hours to help the doctor examine the condition and make possible treatment modifications if necessary. A follow-up can be made through a telephone call especially if the condition worsens 24 hours after the operation. Studies have shown that the patient may experience fever and discomfort and hence antibiotics should help alleviate these symptoms. Follow-up for children aged 0-2 years should be scheduled 2-3 months following treatment of an ear related infection. This should be done specifically given that the fluid collection in the middle ear can cause delays in speech and may also adversely affect hearing if not timely treated.
12 Patient education materials and community resources.
Patient educational materials can be found on www.uptodate.com/patients, which offers a range of short articles on otitis media, related topics .These articles have been written specifically for patients. The site offers up-to-date educational materials that are categorized into basics and beyond basics (Uptodate.com, 2018). The basics level offers basic patient educational material designed to answer most commonly asked questions. This site is best for patients who need a general overview since its brief and well summarized. The basics category covers the following topics namely ear infections, outer ear infection, Eustachian tube problems, ear wax impaction, ruptured ear drum, ear tubes, secondhand smoke: risks to children, and tonsillectomy and adenoidectomy for pediatric patients (Uptodate.com, 2018). The beyond basics category provides longer articles that are more complex and detailed and well suited for patients seeking for advanced knowledge about otitis media. It also provides information on vaccines that are available for children aged 0-6 years (Uptodate.com, 2018). It also provides professional level information for healthcare providers, doctors and other healthcare professionals based on the current research findings. Other organizations such as the National Library of Medicine also provide valuable educational material on OM and can be accessed using the following URL (www.nlm.nih.gov/medlineplus/earinfections.html). Another organization that provides valuable patient targeted information is The Nemours Foundation. This website offers thoroughly researched and up-to-date educational resources on OM and can be accessed from the following URL (http://kidshealth.org/parent/infections/ear/otitis_media.html) (Uptodate.com, 2018). Patients can also access printed educational material from public health centers. Still, private hospitals and pediatric consultants can provide patient educational material on appointment. Other places where patient and community educational material can be accessed include community health centers (Uptodate.com, 2018). Up-to-date educational resources for healthcare providers and professionals include NCBI (https://www.ncbi.nlm.nih.gov/pmc/articles/), MEDLINE DATABASE, PubMed and other medical research databases.

13. Describe how to engage patient and family in the care plan using teach back method
    Parents of pediatric patients will be educated using the teach-back method. It’s important to engage parents since it would be impractical to educate infants and children aged 0-17 years. Secondly, parents are their primary caregivers especially for children aged 0-12 years. Still, most pediatric patients are underage and may not be able to comprehend the complex facts about otitis media. Moreover, it’s is important to engage parents considering that most of the risk factors associated with OM pathogenesis are within their control. For instance, parents can be educated to avoid congested or overcrowded daycare or ECD centers thereby decreasing chances of their children contracting upper respiratory infections that can spread to the middle ear and cause inflammation. Moreover, parents are responsible for the family diet hence educating them will enlighten them on the importance of providing their children with diets rich in vitamin A and zinc. Parents can also ensure that their children are not exposed to other high risk factors such as extreme winter conditions and passive tobacco smoke among others. Still, HIV positive parents pose a significant risk to their children hence education will help them understand safe practices that will protect their children from contracting the virus. Parents who have HIV positive children will also be educated on medication and healthcare practices that will protect and keep their children’s immunity strong.
    Parents will be engaged through consultative educational forums organized in collaboration with schools and educational centers. This will ensure that both parents and teachers get educated about the disease. Parents will also be engaged through religious institutions and health centers. Besides group engagement, personalized engagements will be used to reach parents who already have OM patients. Educational material will also be published on an online platform, thus making it possible to engage parents through online forums. Moreover, educational material on OM will be published in form of handouts and handbills and distributed to parents. Technological tools such as social media platforms will be used for continuous education. Open forums will be created on Facebook and Whatsapp where educational content on OM will be regularly posted.
    13 As medical professional, describe how otitis media relates to underlying health issues
    There is interplay between Otitis media (OM) development, manifestation and progression, and other underlying health issues. This interplay is reminiscent in the disease’s prevalence among children aged 0-17 years due to a developing immune system. Its manifestation and presentation is rapid especially in HIV positive children. Similarly, OM will likely manifest in adults who have weakened immune systems. In patients with impaired immune systems, OM presents as an opportunistic infection. Besides, there is a direct relationship between the existence of an underlying upper respiratory infection (URI) and OM development in both pediatric and non-pediatric patients. An underlying URI infection increases the probability of developing OM.
    14 Analyze how the principles of Watson’s theory of human caring are integrated into the plan of care and patient education

The principles of Watson’s theory of patient care will be integrated into the patient education and plan of care for improved outcomes. In accordance with Watson’s 10 curative principles, pediatric patients will be handled with utmost kindness and respect. Infants and Children aged below 5 years will be given special attention. This will be realized through the use of soft and reassuring touch, smiling and use of friendly conversations. When diagnosing the affected ear, care will be taken to ensure careful and tender treatment. Infants and children aged 0-7years will be assessed and diagnosed while in the care of their parents. Parental separation will not be done as this would have adverse psychological effect on the patients and subsequently the curative outcomes (Ozkan & Watson, 2013). Transpersonal care will be upheld throughout the treatment process by ensuring that all pediatric patients are treated and handled in a dignified manner. This will be achieved by ensuring that the patients are handled in a dignified manner during diagnosis and surgery. Before surgery, the patients will be put on anaesthesia to relieve them of excess pain. Utmost care will be taken by ensuring absolute adherence to surgical tenets and procedures. Surgical tools will be sterilized and handled with care to ensure that the patient is not accidentally injured. Before the surgery, both the parent and the patient will be counseled for psychological preparedness while after the surgery, patients will counseled and reassured of quick recovery. Connection with the patients will be achieved through constant physical contact. For children aged 5-17 years, connection will be established through light conversations in which they will be reassured of their wellness. A heart centered care will be attained through show of genuine concern and show of empathy. Effort will be made to consistently show appreciation and acknowledge OM patients as unique individuals notwithstanding their health condition (Watson & Woodward, 2010). I shall strive to understand the patients both as humans and persons, thus I will interact with the patients on a personal level to get to understand their feelings and address any fears and concerns that they might have (Ozkan & Watson, 2013). For breastfeeding infants, parents will be permitted to breastfeed while diagnosis is ongoing if necessary. Still, parents will be encouraged to be free to attend to their children’s call of nature as part of the effort of ensuring that their rights as humans are not violated. Parents will be advised to ensure that their children are comfortable and that all their needs are well taken care of.

References
Bell, I. R., & Boyer, N. N. (2013). Homeopathic medications as clinical alternatives for symptomatic care of acute otitis media and upper respiratory infections in children. Global Advances in Health and Medicine : Improving Healthcare Outcomes Worldwide, 2(1), 32–43..
D’Alatri, L., Picciotti, P. M., Marchese, M. R., & Fiorita, a. (2012). Alternative treatment for otitis media with effusion: eustachian tube rehabilitation. Acta Otorhinolaryngologica Italica : Organo Ufficiale Della Società Italiana Di Otorinolaringologia e Chirurgia Cervico-Facciale, 32(1), 26–30. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3324963&tool=pmcentrez&r endertype=abstract (D’Alatri et al., 2012).
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