Ear Assessment and nursing diagnoses (Do assessment on an adult using an otoscope)
In the boxes, describe your findings. Do not use the word “Normal” or approximations of it, such as N/A, expected, etc. State what you found using terminology appropriate for the area. See the textbook for appropriate wording. If there are no signs or symptoms of any problems, for instance, it would be appropriate to write: Denies tenderness, pain, and paresthesia; no lesions or breakdown observed. No evidence of pathology noted. Then proceed to describe what you assess in terms of observation and palpation (auscultation and percussion are not used in ear assessment). Weber and Kelley’s textbook has a helpful guide with pictures and verbiage you may find helpful: Assessment Guide 17-1, in the chapter on ear assessment (note especially the textbook verbiage in the center and right columns.) You may use textbook terminology in this class because it is expected. Do not use the findings of other students since the plagiarism detection program will flag the duplicate wording you use as plagiarism. Many videos are also available to assist you. There is one on Canvas in the current module, and YouTube has a number of them as well. Ear Assessment and Nursing Diagnoses
Do not use the work of other students. That is plagiarism, and our detection program will flag it. If confirmed it will mean the grade of F in the class: It isn’t worth it!
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| Current Symptoms: Ears | Assessment Findings |
| Interview Guide | |
| 1. Recent changes in hearing (if yes were all or just some sounds affected)? | If yes, describe, if no, then state “denies changes in hearing.” Denies changes in hearing bilaterally |
| 2. Ear discharge (if yes, amount/odor)? | Denies ear discharge bilaterally |
| 3. Ear pain (if yes, is there accompanying sore throat, sinus infection, or problem with teeth or gums)? | Denies otalgia currently bilaterally. States he had ear pain “about one month ago” when he was diagnosed with a sinus infection. |
| 4. Ringing or crackling sounds in ears? | Denies tinnitus bilaterally |
| Past History | |
| 1. Previous ear or hearing problems such as infections, trauma, or earaches (medications, surgery, hearing aids)? | Reports he had “swimmers ear” (otitis externa) bilaterally January 2020 that was treated with Ofloxacin 10 gtt bid for 10 days. Denies further history. |
| Family History | |
| 1. Family history of ear problems or hearing loss? | Reports paternal grandpa wears hearing aides due to working around heavy machinery. |
| Lifestyle and Health Practices | |
| 1. Live or work around frequent or continuous loud noise? Use of ear buds daily? | Denies working around loud noises; uses ear buds everyday to workout |
| 2. Use of ear protection from noise or while in water? | Denies use of ear protection from noise; does wear ear protection while in water |
| 3. Has any hearing loss affected ability to work or care for self or others? | Denies hearing loss |
| Physical Assessment: External Ear Structures | (List findings bilaterally) |
| 1. Inspect the auricle, tragus, and lobule for size and shape, bilaterally. Describe bilateral position, lesions/discoloration, and discharge. | Bilaterally Auricle is 6.5 cm, rounded, intact, light in color (represents patients skin tone), smooth has no drainage and no odor. No visible lesions. Bilaterally Tragus is triangular in shape, light in color (represents patients skin tone) and has no drainage or lesions present. The lobules are attached, no visible lesions, piercings or scars. |
| 2. Palpate the auricle and mastoid process bilaterally. Describe findings, including symptomatology or tenderness if they are present. | Auricle bilaterally is soft, non-tender, resilient in shape and flexible. Mastoid process bilaterally is hard, non tender and has no nodules or lesions present |
| Otoscopic Examination | |
| 3. Bilaterally inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and any nodules. (Address each of these items bilaterally.) | Bilaterally the external auditory canal is hairy, pink in color, and has small amounts of thick dark yellow cerumen Bilaterally the external auditory canal has no lesions, nodules, discharge, odor, or scaring,
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| 4. Inspect and describe the tympanic membranes bilaterally, using the otoscope, for color and shape, and landmarks. | The left tympanic membrane is silver in color, smooth and round. The cone in the left ear I located at 0700. The right tympanic membrane is silver in color, smooth and round The cone in the left ear is located at 0500. |
| 5. List a common ear disorder or abnormal assessment finding that would be discoverable in an ear or hearing assessment.
| Otitis externa is a common ear disorder, upon assessment the external auditory canal would exhibit purulent or serous ear drainage and have inflammation. The tragus would be tender or painful upon palpation and pulling the auricle for examination may cause pain in the patient. |
| 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 30.4–60.9 cm (1–2 ft) behind the client. Repeat on the other ear. | Bilaterally able to correctly repeat the word “picnic” as whispered |
| 4. Perform the Romberg test to evaluate equilibrium With feet together and arms at the side close eyes for 20 seconds. Observe for swaying. (Refer to textbook, Chapters 16 and 26.) | Properly maintains position without swaying for 20 seconds. |
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Most people you will have access to for the assessment are likely to be symptom-free with no pathologic findings. If you do assess someone with a nursing problem, you can complete the last part of this assignment using that problem. If the person you assessed had no pathological findings, select a common disorder or pathologic finding and complete the remainder of the assignment for a disorder you select. Using the diagnostic reasoning process described in chapter 5 of your textbook, synthesize one of each of the three types of nursing diagnoses described below for a potential client with the problem you listed in area #5, above. Ear Assessment and Nursing Diagnoses
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You will use the three of the types of nursing diagnoses (ND) described in Chapter 5 of your Weber and Kelley textbook: Ear Assessment and Nursing Diagnoses
- A Health Promotion ND
- A Risk ND and
- A Collaborative Problem or Actual ND.
You will find a list of possible diagnoses in Appendix C and D in your textbook.
| 1. Problem or diagnosis you have selected to use to complete your nursing diagnoses | List here: Otitis media | |
| Synthesis | Instructions/Items to include | Nursing Diagnosis |
| 2. List one “Health Promotion” nursing diagnosis appropriate for your client with the condition you describe in 1, above. | Health Promotion nursing diagnoses often begin with “Readiness for enhanced learning” as described in Appendix C of your textbook, under Domain 1. They are also discussed in Table 5-1 and 5-2. | Readiness for enhanced health management: use of antibiotics |
| 3. List one “risk for” nursing diagnosis for the condition you listed above in 1. | Risk diagnoses are described in tables 5-1 and 5-2, and in Appendix C in each of the domains, but particularly in Domain 11. They usually begin with the words, “Risk for….” | Risk for falls: unsteady equilibrium from otitis media |
| 4.List EITHER one “Collaborative Problem” that would be appropriate for a client with the condition described in section 5, above OR list an actual nursing diagnosis from Appendix C. | Collaborative problems are described in table 5-2 and are listed in Appendix D. They begin with “Risk for Complications (RC) of….”
Actual nursing diagnoses are scattered through Appendix C | Risk for complications of Hearing impairment: complication of otitis media |