Unit # 10 B Assessment of Ears

Transcription

1 In The Name of God (A PROJECT OF NEW LIFE HEALTH CARE SOCIETY KARACHI) Unit # 10 B Assessment of Ears Shahzad Bashir RN, BScN, DCHN, MScN (Std. DUHS) Instructor New Life College of Nursing Updated, January 12, 2016 Acknowledge: Myung-Hee Pak, RN, MSN, CNS

2 Learning Objectives Identify the structures and functions of the Ear Discuss how the nurse focus and prioritize subjective /objective data collection - pt safety issues Identify normal and abnormal findings Identify teaching opportunities for health promotion and risk reduction r/t the ear system Demonstrate application of the knowledge: Think like Nurse & Act like Nurse: Pulling it ALL together: Reflection and critical thinking 2

3 Ear Anatomy Sensory organ of the body Used for hearing and maintaining equilibrium Composed of 3 sections External ear Middle ear Internal ear 3

4 Structure and Function External ear External auditory canal Tympanic membrane Middle ear Malleus (hammer), incus (anvil), and stapes (stirrup) Eustachian tube Inner ear Vestibule Vestibule and semicircular canals Cochlea Frequency range of 20 20,000 Hz Decibel range

5 Conti. 5

6 Cont 6

7 Conti. 7

8 Structure and Function (cont.) Hearing Levels of auditory system Peripheral Brainstem Cerebral cortex Pathways of hearing Air conduction Bone conduction 8

9 Cont 9

10 Middle Ear Anatomy 10

11 Inner Ear Anatomy 11

12 Structure and Function (cont.) Hearing loss Conductive Sensorineural (perceptive) Equilibrium Vertigo 12

13 Structure and Function (cont.) Developmental Care Infants and children The adult The aging adult Cross-cultural Care Otitis media Cerumen Hearing loss 13

14 Equipment Otoscope Nasal speculum Penlight Tuning fork in 256, 512 and 1024 Hz Tongue blade Watch Gauze square Cotton-tipped applicators 14

15 Assessment of the Ears Subjective Data Hx. Earaches Infections Discharge (otorrhea) Hearing loss Environmental noise Tinnitus Vertigo 15

16 Assessment of the Ears Objective data: Inspect and palpate external ear: Note color, lesions, tenderness, discharge If S/S of ear infection, inspect unaffected ear first to avoid transferring infected material. 16

17 Inspect/Palpate EAR 17

18 Otitis Externa 18

19 Keloid scar 19

20 Otoscopic Examination 1. Ask the client to sit comfortably with the back straight and the head tilted slightly away from you toward his or her opposite shoulder. 2. Choose the largest speculum that fits comfortably into the client s ear canal (usually 5 mm in the adult) and attach it to the otoscope. Holding the instrument in your dominant hand, turn the light on the otoscope to on. 3. Use the thumb and fingers of your opposite hand to grasp the client s auricle firmly but gently. Pull out, up, and back to straighten the external auditory canal. Do not alter this positioning at any time during the otoscope examination. 20

21 Conti. 4. Grasp the handle of the otoscope between your thumb and fingers and hold the instrument up or down. 5. Position the hand holding the otoscope against the client s head or face. This position prevents forceful insertion of the instrument and helps to steady your hand throughout the examination, which is especially helpful if the client makes any unexpected movements. 21

22 Conti. 6. Insert the speculum gently down and forward into the ear canal (approximately 0.5 inch). As you insert the otoscope, be careful not to touch either side of the inner portion of the canal wall. This area is bony and covered by a thin, sensitive layer of epithelium. Any pressure will cause the client pain. 7. Move your head in close to the otoscope and position your eye to look through the lens. 22

23 Otoscopic Examination Insert otoscope and examine ear canal noting: redness, swelling, lesions, discharge or foreign bodies Inspection of Tympanic Membrane normally TM - Pearly gray, shiny, translucent Flat, slightly pulled in at center Skin intact, no redness/ discharge Canal- clear, no obstructions 23

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27 Objective Data Physical Exam (cont.) Otoscopic examination Position of head and ear Method of holding and inserting otoscope External canal Color Swelling Lesions Discharge Tympanic membrane Color and characteristics Position Integrity of membrane 27

28 Objective Data Physical Exam (cont.) Test hearing acuity Conversational speech Whispered voice test Tuning fork tests Weber test Rinne test 28

29 Objective Data Physical Exam (cont.) Vestibular apparatus Romberg test stand with feet together and arms at sides, close eyes should hold position for 20 seconds without loosing balance Developmental Care Infants and young children 29

30 Ear Drum (light reflex) 30

31 Light cone (Reflex) Tympanic membrane 31

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33 Normal findings Tympanic membrane is pearly gray with well-defined landmarks Light reflex present at 5 o clock in right ear and 7 o clock in left ear Tympanic membrane moves when patient blows against resistance No redness, swelling, tenderness, lesions, drainage, foreign bodies 33

34 Normal TM 34

35 Otomycosis: Fungal Infection 35

36 Cerumen obstructing TM 36

37 Retraction of TM 37

38 Perforated membrane 38

39 Infection-red, bulging TM with Otitis Media 39

40 Hearing Loss Conductive Transmission of sound waves through the external & middle ear is referred to as Conductive Hearing Mechanical dysfunction of external /middle ear Examples include: impacted Cerumen, foreign body, pus or perforated TM, otosclerosis SENSORINEURAL Transmission of sound waves in the inner ear is referred to as Sensorineural hearing. Pathology of inner ear, CNVIII, temporal lobe of brain Example: presbycusgradual nerve degeneration 40

41 Pathways of Hearing 41

42 Causes of Hearing Loss 42

43 Hearing Acuity Without Audiometry, other tests are crude measures. Whisper test: Test one ear at a time Press on tragus Whisper words from 1-2 ft. away Person should be able to repeat back the words 43

44 Weber Test Weber test- valuable when person reports hearing better with one ear. Strike tuning fork and place on midline of skull Tone should be equally loud bilaterally Person should hear the tone by bone conduction (BC) 44

45 Conti 45

46 Conti 46

47 Conti 47

48 Rinne Test Strike and place tuning fork on mastoid process. (Sound heard via bone conduction = BC) Instruct person to signal when sound stops. Quickly reposition fork in front of ear close to ear canal (sound heard via air conduction = AC) Instruct person to signal when sound stops. Normally sound is heard twice as long by AC as by BC. Recorded as AC > BC 48

49 Conti. 49

50 Sample Charting Subjective States hearing is good. No earaches, infections, discharge, hearing loss, tinnitus or vertigo 50

51 Sample Charting Objective Pinna - skin intact with no masses, lesions, tenderness, or discharge. Otoscope- external canals are clear with no redness, swelling, lesions, foreign body, or discharge. Both tympanic membranes are pearly gray, with light reflex and landmarks intact, no perforations. Hearing- whispered words heard bilaterally, Weber test: tone heard midline without lateralization. Rinne test: AC> BC and = bilaterally. 51

52 Sample Nursing Diagnoses Wellness Diagnoses Readiness for enhanced communication r/t use of hearing aid AEB Risk Diagnoses Risk for injury r/t hearing impairment Risk for loneliness r/t hearing loss Actual Diagnoses Disturbed Sensory Perception: Auditory r/t conductive or sensorineural hearing loss AEB Acute pain r/t infection of external or middle ear AEB. Impaired social interaction r/t inability to interact effectively with others secondary to hearing loss AEB.. Disturbed body image r/t concern over appearance and need to wear hearing aid AEB. 52

53 Summary Assessment of the ear includes: Inspection & palpation of external ear Otoscopic exam including ear canal and tympanic membrane Testing hearing acuity Sample documentation 53

54 References 1. Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007). Bates' guide to physical examination and history taking (11th Edi). Philadelphia: Lippincott Williams & Wilkins. Chapter No.06 & 07 p.n Weber, Kelley's. (2007). Health Assessment in Nursing, 3rd Ed: North American Edition. Lippincott Williams & Wilkins. Chapter No.14 &15 p.n