Assessment of the Ears

Checklist

Name: Romero, Richelle Grace M. Date: April 11, 2019 Score:_________________

Criteria: 4 – Very satisfactory 2 – Fair

3 – Satisfactory 1 – Needs Improvement

I. Collecting Subjective Data: The Nursing Health History

4 3 2 1

Preliminaries

1. Gather the necessary materials/equipment Performed

needed.
2. Demonstrate courtesy. Performed

3. Explain the procedure to the client. Performed

History of Present Health Concern Findings

4. Describe any recent changes in your hearing. The client denies any recent changes in
hearing.
5. Are you ever concerned that you may be losing The client is concerned that she may be
your ability to hear well? losing her ability to hear well.
6. Are all sounds affected with this change or just The client does not have any changes in
some sounds? hearing therefore it does not affect her.
Other Symptoms

7. Do you have any ear drainage? Describe the The client does not have any ear
amount and any odor. drainage.
8. Do you have any ear pain? If the client answer The client denies any ear pain.
yes, use COLDSPA to explore the symptom.
a. Character: Describe the pain.
b. Onset: When it begin?
c. Location: Where is it? Does it radiate?
d. Duration: How long does it last?
e. 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?
f. Pattern: Have you taken any measures to
relieve it (medications, others)? Has it
helped?
g. Associated factors: How does it affect you?
Do you have an accompanying sore throat,
sinus infection, or problems with your teeth
and gums?
9. Do you experience any ringing, roaring, or The client denies experiencing any
crackling in your ears? ringing, roaring or crackling in her ears.
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 10. Do you ever feel like you are spinning or that the The client does not feel like she is
room is spinning? Do you ever feel dizzy or spinning or that the room is spinning.
unbalanced? According to her, she does not feel dizzy
or unbalanced.
Personal Health History

11. Have you ever had any problems with your ears The client refuses any problems with
such as infections, trauma, or earaches? ears like infections, trauma and earaches.
12. Describe any past treatments you have received The client did not received any
for ear problems (medication, surgery, hearing treatments for ear problems and has not
aids). Were these successful? Were you experience any medication, surgery and
satisfied? hearing aids.
Family History

13. Is there a history of hearing loss in your family? The client denies history of hearing loss
in her family.
Lifestyle and Health Practices

14. Do you live or work in an area with frequent or The client does not live or work in an
continuous loud noise? How do you protect your area with frequent, continuous loud
ears from the noise? noise. According to her, if she hears loud
noise, the client covers her ears to
protect it.
15. Do you spend a lot of time swimming or in The client does not spend a lot of time
water? How do you protect your ears when you swimming or in water. When swimming,
swim? the client uses ear plug to protect ears.
16. Has your hearing loss affected your ability to The client did not loss her hearing
care for yourself? To work? therefore, this does not affect her ability
to care for herself.
17. Has you hearing loss affected your socializing The client did not loss her hearing
with others? therefore, it does not affect her social
life.
18. When was your last hearing examination? The client did not undergo any hearing
examination yet.
19. Do you wear a hearing aid? The client does not wear a hearing aid.

20. How do you care for your ears? Describe how The client takes care of her ears by not
you clean your ears? exposing it to loud noises. The client
uses ear pick to clean her ears.
Perfect Score

Checklist: 108 points

Findings: 96 points

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 II. Collecting Objective Data: Physical Examination

Preliminaries 4 3 2 1
1. Prepare equipment ( otoscope, tuning fork, watch with Performed
a second hand)
2. Do hand hygiene. Performed
Internal & External Ear Structure Findings
3. Position client on sitting position, or supine for Ears are equal in size bilaterally. Auricle
infant to immobilize head. Inspect the auricle, aligns with the corner of each eye within a
tragus, and lobules for size, shape, position, symmetry, 10-degree angle of the vertical position.
color, lesions & discharge. (pinna level with corner of Earlobes are attached to adjacent skin.
eye).
4. Palpate the auricle, tragus & mastoid process for The auricle, tragus & mastoid process are
tenderness. not tender. The skin is smooth and no
lesions, drainage and lumps being
observed. Ears color is consistent or has
the same skin tone with the facial color.

Hearing and Equilibrium Tests

5. Whisper test or whisper voice test ( for low- pitch When the left ear was being covered, the
deficits). client has 1 mistake and misheard a 2-
Ask the client to gently occlude or cover the ear not syllable word. While, when the right ear
being tested and rub the tragus with a finger in a circular was being covered, the client was able to
motion. Start with testing the better hearing ear and then repeat all the two syllable whispered
the poorer one. words correctly.
Stand about 1-2 ft behind client (so that the client
cannot see your lips move), and whisper two-syllable
word such as “popcorn” or “football”. Note client’s
ability to hear sounds by asking the client to repeat it
back to you.
If the response is incorrect the first time, whisper the
word one more time. Identifying 3 out of 6 whispered is
considered passing the test.
6. Watch tick test ( for high – pitch deficits). The client was able to hear the watch
Have client cover the opposite ear being ticking within 5 inches away from both
tested. Hold ticking watch within 5 inches from ear. Note ears.
client’s ability to hear sound.
7. Weber test Vibrations are heard equally in both ears.
Perform the Weber test if the client reports diminished No lateralization of sound to either ears.
or lost hearing in one ear.
Hold tuning fork by stem. Tap tuning fork
prongs on palm of your hand. Place vibrating tuning in
the middle or center of the client’s head or forehead or on
top of the client’s head. Centering is the important part.
Note client’s ability to hear sound whether on one ear or
the same in both ears (lateralization of sound).
8. Rinne test Right ear’s bone conduction time duration
Place vibrating tuning fork on the mastoid process. is 12 seconds while the air conduction’s
Note the time until the client can no longer hear the duration time is 17 seconds. In the left
sound of the tuning fork and move immediately in front ear, bone conduction’s time duration is 5
of the external ear. Note the time interval. Ask the client seconds while the air conduction’s
to tell you if the sound is audible after the fork is moved. duration time is 14.6 seconds.

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 9. Romberg test ( Test for inner ear vestibular The client was able to maintain her
function to evaluate equilibrium). balance and position for 10 to 20 seconds
Have client stand with feet together, arms at sides, eyes without swaying or any slight minimal
opened, then eyes closed for 20 seconds. Stand close by swaying movement.
in case client lose balance.
Note client’s ability to maintain balance. Observe for
swaying. ( Client maintains balance or position for 10
seconds without swaying or with minimal swaying).

Perfect score

Checklist: 64 points

Findings: 56 points

Evaluated by:

_____________________________
Signature over Printed Name of CI