5 Assessing Ears
5 Assessing Ears
Assessing Ears
328
17 • • • ASSESSING EARS 329
“perceptive” or “sensorineural hearing.” Therefore, a conductive are often gradual and go unrecognized by clients until a severe
hearing loss would be related to a dysfunction of the exter- problem develops. Therefore, asking the client specific ques-
nal or middle ear (e.g., impacted ear wax, otitis media, foreign tions about hearing may help in detecting disorders at an early
object, perforated eardrum, drainage in the middle ear, or oto- stage.
sclerosis). A sensorineural loss would be related to dysfunc-
tion of the inner ear (i.e., organ of Corti, cranial nerve VIII, or COLLECTING SUBJECTIVE DATA:
temporal lobe of brain).
THE NURSING HEALTH HISTORY
In addition to the usual pathway for sound vibrations
detailed previously, the bones of the skull also conduct sound First it is important to gather data from the client about the
waves. This bone conduction, though less efficient, serves to current level of hearing and ear health as well as past and fam-
augment the usual pathway of sound waves through air, bone, ily health history problems related to the ear. During data col-
and finally fluid (Fig. 17-3). lection, the examiner should be alert to signs of hearing loss
such as inappropriate answers, frequent requests for repetition,
etc. Collecting data concerning environmental influences on
Health Assessment hearing and how these problems affect the client’s usual activi-
ties of daily living (ADLs) is also important. Answers to these
Beginning when the nurse first meets the client, assessment types of questions help you to evaluate a client’s risk for hear-
of hearing provides important information about the client’s ing loss and, in turn, present ways that the client may modify
ability to interact with the environment. Changes in hearing or lower the risk of ear and hearing problems.
Pars flaccida
Incus
Short process
of malleus
Pars tensa
Handle
of malleus
Umbo
A Cone of light
B
FIGURE 17-2 (A) Right tympanic membrane. (B) Normal otoscopic view of the right tympanic membrane. (Moore, K.L. & Agur, A.
(2002). Essential clinical anatomy, 2nd ed. Philadelphia: Lippincott Williams & Wilkins.)
330 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Conductive Phase:
Air conduction
Bone conduction
Sensorineural phase
Changes in Hearing
Describe any recent changes in your A sudden decrease in ability to hear in one ear may be associated with otitis media. Sudden
hearing. sensorineural hearing loss (SSHL) or sudden deafness (up to a 3-day period) may be a medical
emergency and thus should be referred for immediate follow-up. Causes vary from unknown
etiology to infections, trauma, toxicity, and other neurologic or circulatory disorders (National
Institute on Deafness and Other Communication Disorders [NIDCD], 2010a; 2011b).
OLDER ADULT CONSIDERATIONS
Presbycusis, a gradual hearing loss, is common after the age of 50 years.
Are you ever concerned that you may be Have the client take the self-assessment “Ten Ways to Recognize Hearing Loss” provided by the
losing your ability to hear well? NIDCD (2011b) (Box 17-1, p. 333).
Are all sounds affected with this change Presbycusis often begins with a loss of high-frequency sounds (woman’s voice) followed later by
or just some sounds? the loss of low-frequency sounds.
Other Symptoms
Do you have any ear drainage? Describe Drainage (otorrhea) usually indicates infection. Purulent, bloody drainage suggests an infection of
the amount and any odor. the external ear (external otitis). Purulent drainage associated with pain and a popping sensation
is characteristic of otitis media with perforation of the tympanic membrane.
Do you have any ear pain? If the client Earache (otalgia) can occur with ear infections, cerumen blockage, sinus infections, or teeth and
answers yes, use COLDSPA to explore the gum problems.
symptom. Pain caused by “swimmer’s ear” differs from pain felt in middle ear infections. If wiggling the
Character: Describe the pain. outer ear without pain, the condition is most likely not swimmer’s ear (Centers for Disease Con-
Onset: When did it begin? trol and Prevention [CDC], 2011b).
Location: Where is it? Does it radiate? Clients with ear infections may experience nausea and dizziness.
Duration: How long does it last?
Severity: Rate your pain on a scale of
1–10 with 10 being the most severe.
Are you able to continue your usual
activities? Are you able to sleep?
Pattern: Have you taken any measures
to relieve it (medications, other)? Has it
helped?
Associated factors/How does it Affect
you? Do you have an accompanying sore
throat, sinus infection, or problems with
your teeth or gums?
17 • • • ASSESSING EARS 331
QUESTION RATIONALE
Do you experience any ringing, roaring or Ringing in the ears (tinnitus) may be associated with excessive earwax buildup, high blood pressure, or
crackling in your ears? certain ototoxic medications (such as streptomycin, gentamicin, kanamycin, neomycin, ethacrynic acid,
furosemide, indomethacin, or aspirin), loud noises, or other causes.
Approximately 10% of the population experiences tinnitus reactions that vary from mild awareness to
severe irritability, causing frustration, insomnia, or inability to concentrate. Some people adapt to this,
while it may impair up to 5% of these people in carrying out their ADLs (Holmes & Padgham, 2011).
Do you ever feel like you are spinning or Vertigo (true spinning motion) may be associated with an inner-ear problem. It is termed subjec-
that the room is spinning? Do you ever tive vertigo when clients feel that they are spinning around and objective vertigo when clients feel
feel dizzy or unbalanced? that the room is spinning around them. It is important to distinguish vertigo from dizziness.
Have you ever had any problems with your A history of repeated infections can affect the tympanic membrane and hearing (Evidence-Based
ears such as infections, trauma, or earaches? Health Promotion and Disease Prevention 17-1, p. 333).
Describe any past treatments you have Client may be dissatisfied with past treatments for ear or hearing problems.
received for ear problems (medication,
OLDER ADULT CONSIDERATIONS
surgery, hearing aids). Were these suc-
The older client may have had a bad experience with certain hearing aids and may
cessful? Were you satisfied?
refuse to wear one. The client may also associate a negative self-image with a hearing aid.
Family History
QUESTION RATIONALE
Is there a history of hearing loss in your Age-related hearing loss tends to run in families (PubMed Health, 2010a).
family?
Do you work or live in an area with fre- Continuous loud noises (e.g., machinery, music, explosives) can cause a hearing loss unless the
quent or continuous loud noise? How do ears are protected with ear guards. Farmers were found to have a high incidence of noise-induced
you protect your ears from the noise? hearing loss, yet many do not use hearing protective devices. Clients exposed to high noise levels
need to be informed of their options for using hearing protective devices (McCullagh & Robertson,
2009) (Evidence-based Health Promotion and Disease Prevention 17-1, p. 333).
Do you spend a lot of time swimming or Otitis externa, often referred to as swimmer’s ear, can occur when water stays in the ear canal for long
in water? How do you protect your ears periods of time, providing the perfect environment for germs to grow and infect the skin. Germs found
when you swim? in pools and at other recreational water venues are one of the most common causes of swimmer’s ear.
Symptoms include: itchiness inside ear, redness and swelling of the ear, pain in the ear when pressure
is applied to the ear or the ear is pulled on (pain may be severe), drainage of pus (CDC, 2011b). After
bathing or swimming, the external auditory canal should be dried using a hair dryer on the lowest heat
setting. People who swim frequently should use a barrier to protect their ears from water. However,
impermeable earplugs act as a local irritant and have been shown to predispose the ear canal to otitis
externa. A tight-fitting bathing cap offers better protection (Bereznicki & Peterson, 2008).
Has your hearing loss affected your Hearing loss or ear pain may interfere with the client’s ability to perform usual ADLs. Clients may
ability to care for yourself? To work? not be able to drive, talk on the telephone, or operate machinery safely because of decreased
hearing acuity. The ability to perform in occupations that rely heavily on hearing, such as a recep-
tionist or telephone operator, may be affected.
Has your hearing loss affected your Clients who have decreased hearing may withdraw, isolate themselves, or become depressed
socializing with others? because of the stress of verbal communication.
When was your last hearing examination? Annual hearing evaluations are recommended for clients who are exposed to loud noises for long
periods. Knowing the date of the examination helps to determine recent changes.
Do you wear a hearing aid? Some internal hearing aids may not visible to the interviewer. This will alert the nurse before doing
an ear exam. Sometimes hearing aids worn are not functioning well and need to be adjusted.
Clients may not be aware of this until someone indicates that they are not hearing well.
Continued on following page
332 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
How do you care for your ears? Describe Earwax is a natural, self-cleaning agent that should not be regularly removed unless it is causing
how you clean your ears. a problem. A warm, moist washcloth should be used to clean the outside of the ears, but nothing
should be inserted into the ear canal.
A few drops of mineral oil, baby oil, glycerin, or commercial drops may be placed in the ear to
moisten the earwax to allow it to naturally work its way out of the ear.
It is important to see an otolaryngologist (ear, nose, and throat [ENT] doctor) when experiencing
ear discharge, fullness, ear pain, reduced hearing, or other persistent ear symptoms. The doctor
may recommend ways to remove excess earwax, such as irrigation (syringing), wax-dissolving
eardrops, and manual cleaning with a microscope and specialized instruments.
Never insert anything into your ear canal including cotton-tipped swabs,
pens, hairpins, and so on. Never use an “ear candle” to remove earwax.
These are ineffective and may cause burns, obstruction of the ear canal, or perfora-
tion of the tympanic membrane. Irrigation devices should only be used by health care
professionals.
(American Academy of Otolaryngology—Head and Neck Surgery [AAO-HNS], 2012).
Case Study
The case study introduced at the beginning of the chapter is now used to demonstrate how a nurse would use
the COLDSPA mnemonic to explore Ms. Lopez’s reported fever and earache.
After investigating Ms. Lopez’s report of fever and earache, and denies the need for hearing protection. She reports
the nurse continues with the health history. Ms. Lopez that she swims infrequently in the summer months (1–2
remembers a couple of ear infections as a child but has times per month), and denies any ear issues associated with
never had an ear infection as an adult. She denies any pre- swimming. She has never had a formal hearing evaluation
vious treatments for ear problems. She denies ear trauma. and denies the use of a hearing aid. She does report the use
She denies a family history of hearing loss. She does not of cotton-tipped applicators to “clean out” her ears each
work in an area with frequent or continuous loud noises, morning after she showers.
17 • • • ASSESSING EARS 333
The following questions will help you determine if you need to have your hearing evaluated by a medical professional:
Do you have a problem hearing over the telephone?
Yes No
Do you have trouble following the conversation when two or more people are talking at the same time?
Yes No
Do people complain that you turn the TV volume up too high?
Yes No
Do you have to strain to understand conversation?
Yes No
Do you have trouble hearing in a noisy background?
Yes No
Do you find yourself asking people to repeat themselves?
Yes No
Do many people you talk to seem to mumble (or not speak clearly)?
Yes No
Do you misunderstand what others are saying and respond inappropriately?
Yes No
Do you have trouble understanding the speech of women and children?
Yes No
Do people get annoyed because you misunderstand what they say?
Yes No
If you answered “yes” to three or more of these questions, you may want to see an otolaryngologist (an ear, nose, and throat
specialist) or an audiologist for a hearing evaluation.
The material on this page is for general information only and is not intended for diagnostic or treatment purposes. A doctor or
other health care professional must be consulted for diagnostic information and advice regarding treatment.
• Avoid the use of ototoxic drugs unless prescribed by a • Get treatment for tonsil and adenoid infections and in-
qualified health care worker and properly monitored for flammation.
correct dosage. • Keep child home from day care if possible when there is an
• If you have a newborn, avoid feeding from bottle while outbreak of ear infections.
infant is lying on back. • Teach child to avoid putting foreign bodies in ears.
• Have newborn infant screened for hearing. • Avoid use of instruments to remove wax from ears due to
• Get treatment for ear infections as soon as they are noticed; chance of impacting it further. See professional care for
follow up with health care provider after symptoms seem wax removal.
to be gone to make sure there is no fluid left in the ear.
COLLECTING OBJECTIVE DATA: response? This initial observation provides you with clues as
PHYSICAL EXAMINATION to the status of the client’s hearing.
Inspect the auricle, tragus, and Ears are equal in size bilaterally (normally 4–10 cm). Ears are smaller than 4 cm or larger than
lobule. Note size, shape, and position The auricle aligns with the corner of each eye and 10 cm.
(Fig. 17-4). within a 10-degree angle of the vertical position.
Earlobes may be free, attached, or soldered Malaligned or low-set ears may be seen with
(tightly attached to adjacent skin with no apparent genitourinary disorders or chromosomal
lobe). defects.
CULTURAL CONSIDERATIONS
Most African Americans and Caucasians
have free lobes, whereas most Asians have
attached or soldered lobes, although any type
is possible in all cultural groups (McDonald,
2010; Overfield, 1995).
OLDER ADULT CONSIDERATIONS
The older client often has elongated
earlobes with linear wrinkles.
Continue inspecting the auricle, tragus, The skin is smooth, with no lesions, lumps, or Some abnormal findings suggest various
and lobule. Observe for lesions, discol- nodules. Color is consistent with facial color. disorders, including:
orations, and discharge. Darwin’s tubercle, which is a clinically insignificant • Enlarged preauricular and postauricular
projection, may be seen on the auricle (Fig. 17-5). lymph nodes—infection
No discharge should be present. • Tophi (nontender, hard, cream-colored
nodules on the helix or antihelix, contain-
ing uric acid crystals)—gout
• Blocked sebaceous glands—postauricular
cysts
• Ulcerated, crusted nodules that bleed—
skin cancer (most often seen on the helix
due to skin exposure)
• Redness, swelling, scaling, or itching—otitis
externa
• Pale blue ear color—frostbite (see Abnor-
mal Findings 17-1 on page 342)
Palpate the auricle and mastoid Normally the auricle, tragus, and mastoid process A painful auricle or tragus is associated with
process. are not tender. otitis externa or a postauricular cyst.
Inspect the external auditory canal. A small amount of odorless cerumen (earwax) Abnormal findings associated with specific
Use the otoscope (see Assessment is the only discharge normally present. Cerumen disorders include:
Guide 17-1 on page 335). color may be yellow, orange, red, brown, gray, or • Foul-smelling, sticky, yellow discharge—
black. Consistency may be soft, moist, dry, flaky, otitis externa or impacted foreign body
Note any discharge along with the or even hard. • Bloody, purulent discharge—otitis media
color and consistency of cerumen with ruptured tympanic membrane
(earwax). CULTURAL CONSIDERATIONS
• Blood or watery drainage (cerebrospinal
Most Europeans and Africans, 97% or
fluid)—skull trauma (refer client to physi-
more, have wet earwax; Asians and Native
cian immediately)
Americans have dry earwax, with transition
• Impacted cerumen blocking the view
in southern Asia. The gene accounting for this
of the external ear canal—conductive
has been isolated and is associated with lower
hearing loss
sweat production of the apocrine glands, pos-
• Refer any client with presence of foreign
sibly an adaptation to cold (Wade, 2006).
bodies such as bugs, plants, or food to
OLDER ADULT CONSIDERATIONS the health care practitioner for prompt
In some older clients, harder, drier ceru- removal due to possible swelling and
men tends to build as cilia in the ear canal infection. If the object in the ear is a
become more rigid. Coarse, thick, wire-like button-type battery, medical attention is
hair may grow at the ear canal entrance as urgent as leaking chemicals can burn and
well. This is an abnormal finding only if it damage the ear canal even within 1 hour
impairs hearing. (Cunha, 2011).
Observe the color and consistency of The canal walls should be pink and smooth, Abnormal findings in the ear canal may
the ear canal walls and inspect the without nodules. include:
character of any nodules. • Reddened, swollen canals—otitis externa
• Exostoses (nonmalignant nodular swellings)
• Polyps may block the view of the eardrum
(see Abnormal Findings 17-2 on page 343).
Inspect the tympanic membrane The tympanic membrane should be pearly, gray, Abnormal findings in the tympanic mem-
(eardrum). Note color, shape, consis- shiny, and translucent, with no bulging or retrac- brane may include:
tency, and landmarks. tion. It is slightly concave, smooth, and intact. A • Red, bulging eardrum and distorted,
cone-shaped reflection of the otoscope light is diminished, or absent light reflex—acute
normally seen at 5 o’clock in the right ear and otitis media
7 o’clock in the left ear. The short process and • Yellowish, bulging membrane with
handle of the malleus and the umbo are clearly bubbles behind—serous otitis media
visible (see Fig. 17-2A and B, p. 329). • Bluish or dark red color—blood behind
the eardrum from skull trauma
OLDER ADULT CONSIDERATIONS
• White spots—scarring from infection
The older client’s eardrum may appear
• Perforations—trauma from infection
cloudy. The landmarks may be more promi-
• Prominent landmarks—eardrum retrac-
nent because of atrophy of the tympanic
tion from negative ear pressure resulting
membrane associated with the normal pro-
from an obstructed eustachian tube
cess of aging.
• Obscured or absent landmarks—eardrum
thickening from chronic otitis media (see
Abnormal Findings 17-2 on page 343).
To evaluate the mobility of the tym- The healthy membrane flutters when the bulb is With otitis media, the membrane does not
panic membrane, perform pneumatic inflated and returns to the resting position once move or flutter when the bulb is inflated.
otoscopy with a bulb insufflator the air released.
attached by using an otoscope with
bulb insufflators. Observe the position
of the tympanic membrane when the
bulb is inflated and again when the air
is released.
Box 17-2 on p. 340 describes hearing CULTURAL CONSIDERATIONS More than 30% of people over age 65 have
loss and testing. In general, African Americans have some type of hearing loss; 14% of people
slightly better hearing at low and high between 45 and 64 years of age have hear-
frequencies (250 and 6000 Hz); Caucasians ing loss. In addition, close to 8 million people
have better hearing at middle frequencies between the ages of 18 and 44 have hearing
(2000 and 4000 Hz). African Americans are loss.
less susceptible to noise-induced hearing loss
(Helzner et al., 2005). Adults should be screened every 10 years
through age 50 and at 3-year intervals there-
after (American Speech-Language-Hearing
Association [ASHA], 2011b).
Perform the whisper test by asking Able to correctly repeat the two-syllable word as Unable to repeat the two-syllable word after
the client to gently occlude the ear not whispered. two tries indicates hearing loss and requires
being tested and rub the tragus with a follow-up testing by an audiologist.
finger in a circular motion. Start with
testing the better hearing ear and then
the poorer one. With your head 2 feet
behind the client (so that the client
cannot see your lips move), whisper a
two-syllable word such as “popcorn”
or “football.” Ask the client to repeat it
back to you. If the response is incorrect
the first time, whisper the word one
more time. Identifying three out of six
whispered words is considered passing
the test. The whisper test has been
studied in both pediatric and adult
clients to evaluate hearing acuity and
has been found to have a high sensitiv-
ity and specificity (Pirozzo, Papinczak,
& Glasziou, 2003).
Perform Weber’s test if the client Vibrations are heard equally well in both ears. No With conductive hearing loss, the client
reports diminished or lost hearing lateralization of sound to either ear. reports lateralization of sound to the poor
in one ear. The test helps to evalu- ear—that is, the client “hears” the sounds
ate the conduction of sound waves in the poor ear. The good ear is distracted
through bone to help distinguish by background noise and conducted air,
between conductive hearing (sound which the poor ear has trouble hearing. Thus
waves transmitted by the external and the poor ear receives most of the sound
middle ear) and sensorineural hearing conducted by bone vibration.
(sound waves transmitted by the inner
ear). Strike a tuning fork softly with the With sensorineural hearing loss, the client
back of your hand and place it at the reports lateralization of sound to the good
center of the client’s head or forehead ear. This is because of limited perception of
(Fig. 17-6). Centering is the important the sound due to nerve damage in the bad
part. Ask whether the client hears the ear, making sound seem louder in the unaf-
sound better in one ear or the same in fected ear.
both ears.
17 • • • ASSESSING EARS 339
FIGURE 17-6 The Weber test assesses sound conducted via bone.
Perform the Rinne test. The Rinne Air conduction sound is normally heard longer With sensorineural hearing loss, air conduction
test compares air and bone conduction than bone conduction sound (AC > BC). sound is heard longer than bone conduction
sounds. Strike a tuning fork and place sound (AC > BC) if anything is heard at all.
the base of the fork on the client’s
mastoid process (Fig. 17-7A). Sensorineural hearing loss occurs with
damage to the inner ear (cochlea), or to
Ask the client to tell you when the the nerve pathways between the inner ear
sound is no longer heard. and brain. This is the most common type
of permanent hearing loss. It decreases
Move the prongs of the tuning fork to one’s ability to hear faint sounds. Even loud
the front of the external auditory canal speech may be muffled. Causes include:
(Fig. 17-7B). Ask the client to tell you ototoxic drugs, genetic hearing loss, aging,
if the sound is audible after the fork is head trauma, malformation of the inner ear,
moved. and loud noise exposure (ASHA, 2011c).
Perform the Romberg test. This Client maintains position for 20 seconds without Client moves feet apart to prevent falls or
tests the client’s equilibrium. Ask the swaying or with minimal swaying. starts to fall from loss of balance. This may
client to stand with feet together, arms indicate a vestibular disorder.
at sides, and eyes open, then with the
eyes closed.
When performing this
test, put your arms
around the client without touching
him or her to prevent falls.
SENSORINEURAL HEARING AND HEARING LOSS inner ear. While a number of causes exist, cerumen buildup
Actual hearing takes place when sound waves are channeled and fluid in the middle ear are the most common barriers to
through the auditory canal, causing the tympanic membrane “vibration” transmission.
to vibrate. These vibrations are transmitted through the mid-
dle ear by the auditory ossicles to the inner ear, where they OLDER ADULT CONSIDERATIONS
are converted into nerve impulses that travel to the brain for Conductive hearing impairment is not uncommon in
interpretation. the older client due to greater incidence of cerumen buildup
A sensorineural hearing loss results when damage is and/or atrophy or sclerosis of the tympanic membrane. A
located in the inner ear. Conduction of sound waves is occur-
condition called otosclerosis often occurs with aging as the
ring through normal pathways, but the impaired inner ear
cannot make the conversion into nerve impulses. Possible
auditory ossicles develop a spongy consistency that results
causes of sensorineural hearing loss are prolonged exposure in conductive hearing loss.
to loud noises or using ototoxic medications.
HEARING TESTS
OLDER ADULT CONSIDERATIONS
The tests discussed in this chapter are performed to give the
Presbycusis, a gradual sensorineural hearing loss due examiner a basic idea of whether the client has hearing loss,
to degeneration of the cochlea or vestibulocochlear nerve, what type (conduction or sensorineural) of hearing loss it
is common in older (over age 50) clients. The client with might be, and whether there is a problem with equilibrium.
presbycusis has difficulty hearing consonants and whispered These tests present an opportunity to educate clients about
words; this difficulty increases over time. risk factors for hearing loss. These tests are not completely
accurate and do not provide the examiner with an exact
CONDUCTIVE HEARING AND LOSS percentage of hearing loss. Therefore, the client should be
Bone conduction occurs when the temporal bone vibrates referred to a hearing specialist for more accurate testing if a
with sound waves and the vibrations are picked up by the problem is suspected.
tympanic membrane and/or auditory ossicles. This type of Auditory testing performed with a tuning fork is meant
conduction results in the perception of sound but is virtually for screening only and should not be used for diagnostic pur-
ineffective for interpretation of sounds. poses. Variations from expected findings in any tests using
A conductive hearing loss occurs when something blocks a tuning fork are simply an indication of the need for more
or impairs the passage of vibrations from getting to the elaborate testing and referral.
Case Study
The chapter case study is now used to palpation bilaterally. Scant amount of brown cerumen lines
demonstrate the physical examination of the external auditory canals bilaterally. Bilateral canals with-
Andrea’s ears. out redness, edema, or discharge. Left tympanic membrane
The client’s auricle, tragus, and lobule are pearly gray, shiny, translucent, without bulging or retrac-
present and symmetric bilaterally. The auri- tion. Cone of light present at 7 o’clock. Handle of malleus
cle aligns with the lateral canthus of each and umbo visible. Right tympanic membrane red and bulg-
eye and has a 10-degree angle of vertical position bilaterally. ing with absent light reflex. No bony landmarks visible.
Earlobes are free. The skin on the ears is smooth, without Whisper test: Able to distinguish 2-syllable words from
lesions, lumps, or nodules; color is consistent with that of 2 feet bilaterally. Weber’s test: Sound lateralizes to the right
the face. Auricle, tragus, and mastoid process nontender to ear. Rinne test: AC > BC bilaterally. Romberg test negative.
17 • • • ASSESSING EARS 341
VALIDATING AND
bony landmarks visible. Whisper test: Able to distin-
DOCUMENTING FINDINGS guish 2-syllable words from 2 feet bilaterally. Weber’s
Validate the ear assessment data that you have collected. This test: Sound lateralizes to the right ear. Rinne test:
is necessary to verify that the data are reliable and accurate. AC > BC bilaterally. Romberg test negative.
Document the assessment data following the health care facil-
ity or agency policy.
Case Study
After collecting and analyzing the data for Potential Collaborative Problems
Andrea Lopez, the nurse determines that • RC: Ear infection
the following conclusions are appropriate: • RC: Ruptured tympanic membrane
Refer to primary care provider to diagnose and treat her
Nursing Diagnoses ear condition. To view an algorithm depicting the process
• Acute Pain r/t physical evidence of tym- of diagnostic reasoning for this case, go to .
panic membrane inflammation
• Ineffective Health Maintenance r/t lack of knowledge
about potential tympanic membrane damage from
cotton-tipped applicator use in ears
ABNORMAL FINDINGS 17-1 Abnormalities of the External Ear and Ear Canal
Many abnormalities may affect the external ear and ear canal; among them are infections and abnormal growths. Some are
pictured below.
Polyp.
Exostosis.
17 • • • ASSESSING EARS 343
ABNORMAL FINDINGS
ABNORMAL FINDINGS 17-2 Abnormalities of the Tympanic Membrane
The thin, drum-like structure of the tympanic membrane is essential for hearing. It is also essential for promoting equilib-
rium and barring infection. Damage to the membrane may have grave and serious consequences.
References and Selected Readings Helzner, E., Cauley, J., Pratt, S., et al. (2005). Race and sex differences in age-
Agrawal, Y., Platz, E., & Niparko, J. (2008). Prevalence of hearing loss and dif- related hearing loss: The health, aging and body composition study. Journal of
ference by demographic characteristics among US adults: Data from the the American Geriatric Society, 53(12), 2119–2127.
National Health and Nutrition Examination Survey, 1999–2004. Archives of Hitti, M. (2006). Blacks hear better than whites. Women hear better than
Internal Medicine, 168(14) [online only]. Available at http://archinte.ama-assn. men, study also shows. Available at http://www.webmd.com/healthy-aging/
org/cgi/content/abstract/168/14/1522 news/20060614/blacks-hear-better-than-whites
American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). Holenweg, A., & Kompis, M. (2010). Non-organic hearing loss: new and con-
(2012). Earwax. Available at http://www.entnet.org/HealthInformation/ear- firmed findings. European Archives of Otorhinolaryngology, 268(7), 1213–1219.
wax.cfm Available at http://www.ncbi.nlm.nih.gov/pubmed/20204391
American Speech-Language-Hearing Association (ASHA). (2011a). Conductive Holmes, S., & Padgham, N. (2011). ‘‘Ringing in the ears’’: Narrative review of tin-
hearing loss. Available at http://www.asha.org/public/hearing/Conductive- nitus and its impact. Biological Research for Nursing, 13(1), 97–108. Available
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