Tuesday, April 23, 2013

Physical Assessment: Hearing and Ear

Nursing is an interesting, practical course. That is why, I am always excited to learn how to do physical assessment because there are some things that I find helpful for my client when it comes to assessing first their physical condition and in this way, I can make a quality nursing care plan effective for them. 

Assessing the ears (sense hearing) is this simple.

External Ear Structures
1. Inspect the auricle, tragus and lobule for size and shape, proportion, lesions/discoloration and discharge.
2. Palpate the auricle and mastoid process for tenderness.

Otoscopic Examination
1. Inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and nodules.
2. Inspect the tympanic membrane, using the oroscope, for color and shape, consistency and landmarks.
3. Have client perform the Valsalva maneuver, and observe the center of the tympanic membrane for a flutter. (Except for the older client for this may interfere with equilibrium and cause dizziness.)

Hearing and Equilibrium Tests
1. Perform the whisper test by having the client place a finger on the tragus of one ear. Whisper a two-syllable word 1 and 2 feet behind the client. Repeat on the other ear.
2. Perform the Weber test by using a tuning fork placed on the center of the head or forehead and asking whether the client hears the sound better in one ear or the same in both ears.
3. Perform the Rhinne Test by using a tuning fork and placing the base on the client's mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note teh time interval.
4. Perform the Romberg test to evaluate equilibrium. WIth feet together and arms at the side, close eyes for 20 seconds. Observe for swaying.

Analysis of the Data
1. Formulate nursing diagnoses.
2. Formulate collaborative problems.
3. Make necessary referrals.

Source: Lab Manual to Accompany Health Assessment in Nursing, Third Edition by Janet Weber, Jane Kelley and Ann Sprengel

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