Pediatric Otis Media- pediatric only

References must not be older then 5 years old
The sample is not “gold standard” it is just for an example of what is looked for.

Sample of clinical protocol

1. Topic: Bacterial Vaginosis
Bacterial vaginosis (BV), formerly known as Gardnerella, is a common syndrome seen in women?s health. It is caused by an overgrowth of one of several species of bacteria including Gardnerella vaginalis, Ureaplasma urealyticum, Mobiluncus species, Mycoplasma hominis, and Prevotella species (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012). Also, a reduction with the Lactobacillus species has also been associated with BV but, whether it is a cause of infection or the result from infection remains an uncertainty (Hoffman et al, 2012). The reason for the overgrowth is not clearly understood.
According to the Centers for Disease Control and Prevention (CDC), BV can affect any woman but certain practices or behaviors may increase the chance of infection such as new or multiple sex partners or douching (2010). It can also affect pregnant and non-pregnant women and women that have never engaged in intercourse before (CDC, 2010).
Diagnosis is accomplished through laboratory tests identifying bacteria associated with BV. Upon inspection of the vagina, a white or gray thin discharge may be present accompanied by a pH > 4.5 (Hawkins, Roberto-Nichols, & Stanley-Haney, 2012). Hoffman et al cite that one of the most reliable findings for diagnosis is the observation of clue cells on a wet prep slide. These epithelial cells contain many bacteria on the cellular border creating an irregular, stippled appearance. This finding correlates with a 95% positive diagnosis of BV (2012). A positive ?whiff test? is another easy diagnostic test. This is accomplished by adding KOH to vaginal secretions which produces a fishy odor (Hoffman et al, 2012). According to Hawkins, Roberto-Nichols, and Stanley-Haney (2012), at least 3 of these criteria must be met for the diagnosis of BV.

2. Goal of Therapy
Since bacteria normally occupy the vaginal space, the goal of therapy is not to eradicate the bacteria but rather to restore vaginal flora back to a balanced state.

3. Data Base
A. Subjective Findings
1. Patient report: Women with BV may report a foul smelling discharge which can worsen after intercourse or during menses.
2. Typical subjective complaints: Complaints may include a thin white or gray vaginal discharge with an unpleasant fishy odor. Some may report itching or burning outside or inside the vagina (CDC, 2012).
3. Less common associated symptoms: BV can cause infections in the uterus that can lead to pelvic inflammatory disease. BV can also increase the chance of developing post-surgical infections after hysterectomy or other gynecological surgeries. It can also increase a women?s risk of contracting other STDs. Pregnant women with BV are at an increased risk for preterm labor (CDC, 2010).

B. Objectives Findings: description and rational by body system
1. Vital signs: BP, HR, and Temp can all be elevated in the presence of infection.
2. General survey: Overall state of health determined by appearance, hygiene, demeanor, and attitude.
3. Neck and lymph nodes: Lymph nodes should be palpated to determine if lymphadenopathy exists. This could indicate a systemic infection.
4. Abdomen: Inspection for obvious masses or lesions and palpation for tenderness or masses. Both could indicate the presence of infection. If BV has progressed to the uterus the patient may experience tenderness upon palpation.
5. Pelvic: External exam looking for the presence of lesions, redness, or discharge. Internal speculum exam looking for the presence of lesions, redness, or discharge. Bimanual exam palpating for cervical tenderness. All of this is completed to determine presence of infection, obvious STD, PID, or cervicitis. Expected abnormal findings may include thin white or gray discharge, foul smelling discharge, or possible redness internally or externally.
C. Analysis
1. Nursing diagnosis
Altered comfort related to discharge, itching, or burning.
Knowledge deficit related to unknown diagnosis.
Anxiety related to embarrassing symptoms.
2. Medical diagnosis
Bacterial vaginosis
3. Common differential diagnosis
Vaginitis
Candida vaginitis
Chlamydia
Gonorrhea
Trichomoniasis
Cervicitis
D. Plan
Diagnostic:
Inspect vagina for thin white or gray discharge
Check discharge for pH > 4.5
Whiff test: Add KOH to specimen to elicit ?fishy? odor
Wet mount looking for clue cells
Medication (Non-pregnant women):
Metronidazole 500mg PO BID for 7 days or
Metronidazole gel 0.75% 1 applicatorful intravaginally at bedtime for 5 nights or
Clindamycin cream 2% 1 applicatorful intravaginally at bedtime for 7 nights.
Alternative medication (Non-pregnant women):
Tinidazole 2g PO daily for 3 days or
Tinidazole 1g PO daily for 5 days or
Clindamycin 300mg PO BID for 7 days or
Clindamycin vaginal ovules 100mg intravaginally at bedtime for 3 days.
Medication (Pregnant, symptomatic):
Metronidazole 500mg PO BID for 7 days or
Metronidazole 250mg PO TID for 7 days or
Clindamycin 300mg PO BID for 7 days.
Medication (Pregnant, asymptomatic, low-risk):
Per CDC recommendations, the use of Clindamycin only in the first half of pregnancy.

Patient education:
1. Avoid intercourse until symptoms subside.
2. No douching during or after treatment.
3. If using Metronidazole, no alcohol during treatment and 48 hours after treatment to avoid an antibuse reaction. Common side effects also include nausea, vomiting, metallic taste, dyspepsia, and dark, red-brown urine.
4. If using Clindamycin, common side effects may include: nausea, vomiting, diarrhea, and abdominal pain.
5. Completion of all antibiotic therapy.
6. GI upset can occur from antibiotic therapy.
7. Patient is to wear cotton underwear, no underwear at bedtime, no vaginal deodorants, and to wipe from to back after toileting.
8. Inform patient that there is no need to treat partner.
9. There is no need for follow-up if treatment is successful. Return only if relapse occurs and consider further vaginal cultures or referral.

Information for plan derived from Hawkins, Roberto-Nichols, and Stanley-Haney (2012).

References

Centers for Disease Control and Prevention, (2010). Bacterial Vaginosis. Retrieved from http://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2012). Guidelines of nurse practitioners in gynecologic settings. (10th ed.). New York: Springer Publishing Company.

Hoffman, B. L., Schorge, J. O., Schaffer, J. I., Halvorson, L. M., Bradshaw, K. D., & Cunningham, F. G. (2012). Williams gynecology. (2nd ed.). New York: McGraw Hill.