V.

Care Maps/Care Pathways: Part I and II

Part I. Nursing Diagnostic Reasoning: Analysis of Data

Step 1: Identify abnormal findings and client strengths

Subjective Data

Objective Data

Dili ko kadungog
Dili ko katarong ug tulog

sakit kayo akong dunggan as

verbalized

Pain
Restless
Irritable
Swelling of the right ear
Discharge of fluid noted

Magbasa akong dunggan as

verbalized.

Step 2. Identify cue clusters

Dili ko
kadungog as
verbalized
-Swelling of the
right ear

sakit kayo
akong
dunggan as
verbalized
-

Pain

Dili ko
katarong ug
tulog as
verbalized
-

Restless
irritable

Step 3 Draw insights and Inference

Risk for
infection
related to the
disease process
of otitis externa

Altered
hearing
perception
caused by
inflammatory
response by
a localized
infection.

The pain
caused by the
inflammatory
response of
otitis externa

the sleeping
pattern altered
due to pain
persist during
sleeping hours

Risk for infection

may be cause by
external
bacterial
infection

Step 4 List possible nursing diagnosis

Disturbed
sensory
perception
:auditory
related to
inability to hear
sound
secondary to

Acute pain
related to
inflammation
of middle ear
secondary to
otitis externa

Sleeping pattern
altered related to
discomfort during
sleep as evidenced
by pain

Risk for infection

related
opportunistic
fungal infection as
evidenced by
discharge of fluid
in the ear

Step 5 Check for defining characteristics: Major and Minor

Major: inability
to hear

Major:
Swelling
of ear canal
noted

Minor: NONE

Major:
discomfort
during sleep

Major: infection
of ear canal
Minor: NONE

Minor: NONE

Minor: NONE

Step 6 Confirm or rule out diagnosis

Confirm because
it can put the
client in danger

Accept diagnosis
because it meets
the defining
characteristics.

Rule out
because it can
be prevented
with health
teaching

Rule out because we

can implement this
with the previous
nursing diagnosis

Step 7 Document Conclusion: Key Nursing Diagnosis/

Problem
Part II. Clinical Care Pathways
Step 1: Key Nursing Diagnoses (Wellness, Risk, Actual, and Collaborative Nursing
Problems)
Risk for infection
Disturbed sensory
Acute pain
related
perception :auditory
related to
opportunistic
related to inability
inflammation of
fungal infection as
to hear sound
middle ear
evidenced by
secondary to acute
secondary to
discharge of fluid
otitis externa
otitis externa
in the ear

Nursing Actions:

Nursing Actions:

Nursing Actions:

INDEPENDENT

INDEPENDENT

INDEPENDENT

Assess causative
factors
contributing
hearing loss
Educate the
patient on how to
clean the ears
COLLABORATIVE
Administer fungal
antibiotic as
prescribed by the
physician

Monitor or record
the
characteristics of
the pain, noted
the report verbal,
nonverbal cues,
and the
hemodynamic
response
(grimacing,
crying, anxiety,
sweating,
clutching his
chest, rapid
breathing, blood
pressure / heart
frequency
change).
Instruct patient
S.O to report
pain immediately.
Provide a quiet,
slow activity, and
comfortable
action ( bed
linen, dry / not
crossed, rubbing
his back).

COLLABORATIVE
Administer
analgesics as

Assess and
monitor clients
ears. Note for
the presence of
infection and
discharges
Encourage
patient to
increase fluid
intake.
Educate the
patient the
importance of
stay out of
water during
healing process
Adjust and
monitor
environmental
factors.

COLLABORATIVE
Administer
antibiotic
as
prescribed
by the
physician

CLIENT OUTCOMES
After 3 weeks of
nursing intervention,
the patient will able
to:
- Improve sense of
hearing.

CLIENT
OUTCOMES

CLIENT
OUTCOMES

Within 8 hours of
providing nursing
interventions, the
patient will be
report reduced
pain to a tolerable

After 8hours of
giving nursing
interventions, the
patient will be
report improve
hearing