Introduction

Child rearing has been already a challenge since the early times. It has already
been a problem for every generation, but also an important matter in the family since
childhood experiences affects the quality of an individual when he goes into adulthood.
In order to discuss some hurdles of child rearing and why it is a challenge to every
generation, it is necessary to look at a case of a four-year-old boy psychologically,
physically and emotionally.
Definition of terminologies used in this research:
1. Grommets – an eyelet of firm material to strengthen or protect an opening
or to insulate or protect something passed through it. It is used in
severe otitis media to repair a part of the Eustachian tube.

2. Acute otitis media with effusion – onset of inflammation in the middle ear
with yellowish discharge over a short period of time (Kuo et. al., 2011)

3. Z-score – also referred to as standard deviation classification system used

for nutritional, growth and developmental assessment for children by
comparing to the reference population. Z-score is widely recognized as
the best system for analysis and presentation of anthropometric data
because of its advantages compared to the other methods (WHO, n.d.).

4. Childhood obesity - abnormal or excessive fat accumulation that may impair

health. In children, it is weight-for-height greater than 2-3 standard
deviations above the z-score (WHO, 2018)

5. Vaccines - biological preparation that improves immunity to an infection

(WHO, n.d.)

6. Passive immunity – Immunity acquired by transferring antibodies that were

produced by another person such as breastfeeding

7. Active immunity -Immunity acquired from the development of antibodies in

after being injected with vaccine or natural exposure to an organism

8. Infancy – first 12 months of life

9. Childhood – stage of human life cycle between infancy and puberty.

10. Adulthood – stage of a human life cycle which follows adolescence.

Usually begins at age 18 to 21
Background
Introduction – a nurse must first give her name and introduce himself/herself as the
one in charge for nursing care. This is to establish a rapport to the
patient and relatives. Introducing other members of the team is also
important. Lastly, the nurse should confirm who is he talking to and get
the patient’s general data.
Situation – after introducing himself, the nurse should tell why he is talking to the
patient especially if it’s an emergency. In this case, the patient is being
interviewed for the insertion of bilateral grommets.
Observations – the patient is has normal blood pressure for his age, heart rate,
respiratory rate and afebrile at 37.4 degrees Celsius. Patient was
previoulsy assessed with acute otitis media
Background – patient is a four-year-old male from a remote community who came
in for insertion of bilateral grommets due to recurrent acute otitis media
with effusion. Patient was stable, but anxious and unwilling to let go of
his mother. He also has an old dried exudate and remains of eardrops
surrounding the ears and dental caries was also observed in physical
examination
Agreed Plan/assessment – Patient’s case is urgent since there is an infectious
process in his ears. Patient must have bilateral grommets together with
antibiotics. Aside from the infection, patient’s airway is patent, breathing
is not labored, circulation is normal as indicated by blood pressure and
heart rate. No signs of disability and no history of any exposure.
Read back – Patient will undergo insertion of bilateral grommets due to repeated
occurrences of acute otitis media with effusion together with a complete
course of antibiotics and supportive therapy. A holistic management will
be given to the patient.
Management
At the time of admission, preoperatively, the team of health providers must have a
complete history of the patient and must have done a thorough physical examination. The
nurse must establish rapport not only to the patient since the patient but also with the
relatives in order to be trusted and give confidence in the procedure. This will also
strengthen their relationship with the medical team. The team must remember that they
are not treating the disease, they are treating the patient.
Assessment – the medical team discuss the case before talking directly to the
patient as preparation for the interview. To assess the patient, the nurse should start with
history by asking relevant questions. The nurse can ask about the history of the disease
by asking “When did it all started?” and “What are the associated symptoms?” these
questions could give information on the possible severity of the disease since the longer
the otitis media goes untreated, the worse could be the complications. Associated
symptoms such as fever, hearing loss, headache, cough, colds, should be noted in the
history if present or not. Most common acute otitis media risk factors are upper respiratory
tract infection, bacterial infection, and lack of breastfeeding (Chonmaitree et. al., 2016),
allergy/atopy, snoring, Second-hand smoke, low social economic status (Zhang et. al.,
2014). If risk factors are always present, the patient is likely to have recurrence. As a
nurse, identifying risk factors in the history taking is the most useful thing to do to help the
child. Assessment tool such as pain scale is necessary for this case, for these can help
in monitoring if treatment is effective and if the patient is comfortable to the management.
Asking question such as preferred food and drinks is necessary for nutritional assessment
and asking parents about being overprotective should be done. History of asthma should
also be asked since the patient is about to undergo surgery and has a probability of using
inhalational anesthesia. Patients with asthma could have problems in using inhalational
anesthesia and if present, the surgical team should be alerted. Family history and living
condition is also important since an infectious process is being discussed and low social
economic status predisposes the patient to numerous psychological and physical
diseases especially if the patient is living in poor sanitary conditions. The last part of
history taking is vaccination history. This will give information on what diseases is the
patient at risk and could be prevented. After the history, another important part of
assessment is a through physical examination should be done starting from head to toe.
An examiner’s physical examination begins at looking at the patient and note if the patient
is awake, alert, well-hydrated, well-looking, well-nourished, in distress and anxious. This
will help to determine what approach to make in the patient. Vital signs should again be
taken and recorded. Height and weight and anthropometrics should be measured to
assess the nutritional status and growth of the patient by plotting to the z-scores.
Examiner must also look at the hair or head for lice and investigate if the child is
normocephalic using head circumference measurement, for the ears, an otoscope is
needed to visualize the ear canal and tympanic membrane. This will confirm if the patient
has otitis media. Assessment of hearing should be done. A very accurate method is using
a tuning fork and performing Rinne’s and Weber’s test (Kong, et. al., 2017). The nose,
buccal mucosa and cervical lymph nodes should be investigated for dental caries,
discharge and hyperemia as these are evidence of upper respiratory tract infection.
Another must do in physical exam is Malampati scoring and thyromental distance
measurement, since the patient will undergo surgery. Cardiovascular, abdominal and
pulmonary physical examination is imperative to do for providing a holistic management
and incidental findings of heart disease, asthma and pneumonia are common in this age
group.
Nursing diagnosis – First, the patient was already diagnosed with acute otitis
media with effusion and dental caries. What is not stated in the case is the psychological
impact of being overprotective of the guardian with Kevin that may predispose him to
childhood anxiety and give rise to psychological disorders when he reaches adulthood
(Clarke et. al., 2013). According to Howard et. al. (2016), there is a positive correlation
between overprotection and anxiety. Another problem with the patient is diet, it was stated
that the patient is drinking a bottle containing cordial his hands. As told by Bowatte et. al.
(2015), sugar content in flavored bottle drinks sold in the UK are unacceptable high. This
will predispose the patient to childhood obesity, and children who drinks sugar-sweetened
beverages tend no to eat healthy and nutritious foods (Byrne et. al., 2017). At a weight of
13.9 kgs, Kevin’s z-score is at below -1, a borderline normal score but alarming. His height
is normal at 100cm.
Planning – The goal of treatment for this patient is both curative and preventive.
The acute otitis media should have no recurrence after the surgery and after patient’s
discharge from the hospital. This will be achieved by the surgery, antibiotic treatments
and modifications of the risk factors present. Dental caries should be addressed and
should have no recurrence after diet and lifestyle modifications. Kevin’s anxiety can be
slowly reduced for a period of time before adulthood. It will be measured by the amount
of interaction he gives to other people aside from his parents and grandparents. Dietary
problems are not easy to manage, the goal for this is for Kevin to eat sufficient amount of
nutritious foods and avoid sweets. Diet and lifestyle modification can be achieved with the
help of his family. To measure the goal regarding diet and lifestyle, anthropometric
measurements should be done during follow-up. Z-scores are reliable measurements for
nutrition and growth. The family, as seen in the case is also sick in the sense that it does
not provide a healthy environment for the patient to grow mentally and psychologically by
being overprotective. Patient’s guardians should be instructed by a specialist or advised
to attend seminars, so improvement of anxiety can be observed in the patient.
Implementations - Otitis media is one of the most reason of pediatric consults and
the most common reason why was being prescribed antibiotics or undergo surgery
(Marom, et. al., 2014). Aside from the surgery by an otorhinolaryngologist, patient must
also be given a 10-day course of amoxicillin–clavulanate, a treatment that is more
superior compared to a 5-day regimen in children with acute otitis media (Hoberman et.
al., 2017). For his dental caries, the patient must be referred to a dentist for tooth
extraction and asked to undergo regular visits for maintenance of oral hygiene. Diet and
lifestyle modifications can be given by the nurse by teaching what to give during breakfast,
lunch, snack and dinner. Avoidance of sweet beverages can reduce the occurrence of
childhood obesity and dental disease (Hoare et. al., 2014). If no improvement is observed,
patient can be referred to a nutritionist or dietician. A nurse can also provide counsel on
why being overprotective is harmful for Kevin’s mental health and its long term effects.
Lastly, patient must have vaccination for active immunity in order to prevent acquiring
communicable diseases. Patient is no longer being breastfed which gives passive
immunity; therefore, he has no protection from maternal antibodies (Bowatte et. al., 2015).
The importance of patient follow-up and compliance to medications and intervention is
one of the most important contribution of the nurse on every case aside from directly
taking care of the patient himself.
Involvement of the interdisciplinary team in child and family centred care
The dentist can address oral problems and give advise to the parents how to
prevent it. The physician and the nurse should identify the modifiable risk factors present
in the patient and establish rapport. They should investigate the cause of Kevin’s
problems and be the ones who address it. The child’s psychological problem, recurrence
of infectious disease and poor diet is a reflection of an unhealthy family. The nurse can
talk to the parents and grandparents what food to prepare and what food to avoid with or
without the help of a nutritionist and dietician. Explain to the relatives that the child’s health
is of outmost concern. Communication, respect and partnership with the family will
ultimately provide optimal health, patient safety, health equity and give patient a better
experience. Patient’s safety can be given by parents if only properly instructed by a nurse,
a medical professional who understands both the living condition of the patient and
medical aspect of the treatment.
Potential co-morbid complications and extended care education
In order to promote a complete and successful recovery, the patient and the
patient’s relatives should be aware of the expected results and possible short term and
long term complications. After the surgery, the patient could have post operative
infections. Cleaning and proper care of the wound site is important in order to avoid post
operative infection. Patient and relatives must be warned of the possibilities of poor
hygiene. Before discharge, the patient and his relatives must be taught how to prevent
dental caries and how avoiding sweet beverages can help with dental caries as well as
other problems such as malnutrition. Poor nutrition can lead to either obesity or stunted
growth. Nutrition also affects school performance. Relatives are the one who affects the
patient’s mental health and nutrition since they control every aspect of Kevin’s life. Poor
mental health can provide long term complications to Kevin’s emotional health even on
adulthood. What he experienced as a child will reflect when he is old. Instructing them to
avoid being overprotective and encourage communication to other people is necessary.
Hygiene is important as well to prevent infectious disease. After returning to the remote
community, they must be reminded that poor living condition and poor hygiene can
predispose Kevin to recurrence of acute otitis media. Coming back to the remote
community from where they are not monitored by the medical team is a problem since
the family might go back from the original lifestyle. Change must be encouraged.
Relatives must also be instructed how to recognize if acute otitis media recurred (patient
may experience pain, fever and ear discharge). Compliance to medications are also
important to be emphasized as patients tend not to complete antibiotic regimen after two
to three days when they already feel the improvement. Follow-up should be given
importance as well. This is to monitor the patient’s overall health.
Conclusion
Taking care of a child involves multiple health personnel from multiple specialties
where a nurse is one of them as well as the patient’s parents and grandparents since
there are a number of factors affecting a pediatric patient’s overall health. Children are
very dependent to adults and have a very delicate immune system. This is the reason
why they need special care compared to individuals in the adulthood stage. When
encountered with a pediatric patient, one must keep in mind that it is not only the patient
himself is the patient, the whole family should also be the patient as well. The family
provides the environment for the child and the child is the most susceptible to a bad
environment. The nurse and the whole medical team should treat every patient as
individual with unique set of needs; therefore, management that is different from other
patients since not all patients are the same, some of them may suffer from different
problems such as anxiety, poor living conditions, poor hygiene and malnutrition. If left
untreated, a diseased patient may suffer throughout his life that may not be reversible or
very hard to reverse. This is why nursing assessment, nursing diagnosis, planning,
implementations and evaluation is important to a nurse’s practice. A good nurse must be
able to look at all the aspect of a patient’s life, identify risk and prevent diseases. To
provide optimal patient care for a child, the healthcare providers and relatives should
respect, communicate and work with one another.
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