Health Assessment- Exam #1

External Ear-components

Auricle and external auditory canal

Middle Ear- Components

3 auditory ossicles- the malleus, incus, and stapes. Has 2 windows into the inner ear- the round and oval windows

Inner Ear- Components of the bony and inner membranous labyrinth

Fluid filled. bony labyrinth- the cochlear, vestibule, and semicircular canals

Conductive Hearing

transmission of sound waves through external and middle ear

Sensorineural Hearing

transmission of sound waves through the inner ear

Causes for Hearing Loss Prior to or at Birth (5)

prematurity, reduced oxygen, mom’s infections, mom’s drug use, and severe jaundice

Causes for Hearing Loss Post Birth (6)

genetics, diseases, chronic ear infections, excessive noise, aging, head injury

Vertigo

sensation of a spinning motion may indicate an inner problem

Subjective Vertigo

when patients feel they are spinning around

Objective Vertigo

when patients feel that the room is spinning around them

Conductive Hearing Loss (and 3 examples)

caused by something that stops sound from getting through the outer or middle ear (could be a foreign body, earwax buildup, or damaged TM)

Sensorineural Hearing Loss (and 3 examples)

occurs when there is a problem in the way the inner ear or hearing nerve works (could be aging, loud noise exposure, or ototoxic medications)

Auditory Neuropathy Spectrum Disorder

when sounds enter the ear normally, but because of damage to the inner ear or the hearing nerve, sound is not organized in a way the brain can understand it

General Routine Screening of the Ear (3)

1. inspect auricle, tragus and lobule

2. palpate the auricle and mastoid process

3. perform the whisper test

Focused Specialty Assessment of the Ear (5)

1. inspect the external auditory canal

2. inspect tympanic membrane

3. perform the weber test if client reports diminished or lost hearing in 1 ear

4. perform the Rinne test to differentiate conductive and sensorineural hearing loss

5. perform the Romberg test

Weber Test

softly strike a tuning fork and place it at the center of the client’s head, ask if they hear it best in one ear or in both. w/ conductive loss pt hears the sound best in the bad ear. w/sensorineural loss pt hears the sound best in the good ear

Rinne Test

compares air conduction (AC) and bone conduction (BC), strike tuning fork and place base of fork first on the mastoid process and move it to front of the canal once the pt no longer hears it and ask if now they can hear again. hearing through AC should be twice as long as BC and sound should continue

Romberg Test

tests equilibrium (inner ear), have pt stand w/ feet together and arms at their sides (have eyes open in this position for 20 seconds and then closed for another 20. Protect the pt with arms around them but not touching

Presbycusis

gradual sensorineural hearing loss, due to degeneration of the cochlear or vestibulocochlear nerve, typically first has difficulty with hearing high-pitched sounds (common is adults age 50+)

Types of Health Assessment: (4)

Initial comprehensive assessment, ongoing or partial assessment, focused or problem-oriented assessment, and emergency assessment

Initial Comprehensive Assessment- what is it and when is it used

Collect subjective data about patient’s health, past health, family history, and lifestyle/health practices. Also objective data gathered during physical exam. Used when a patient first enters a healthcare system and after periodically, to establish baseline data for future comparison

Ongoing or partial assessment- what is it and when is it used

Collection of data after the comprehensive database is established. Acts as a follow up to reassess changes to problems or detect new ones

Focused of problem-oriented assessment- what is it and when is it used

(does NOT replace comprehensive) done when a patient with a baseline comes in with a specific health concern. It is a thorough assessment of a particular problem and does not address unrelated areas.

Emergency assessment- what is it and when is it used

a rapid assessment done in life threatening situations, focuses on ABCs. the only concern during this assessment is to determine the status of the patient’s life sustaining physical functions

4 steps of assessment phase

collecting subjective data, collecting objective data, validating assessment data, and documenting data

6 steps of data analysis

identify abnormal and supportive clues, cluster clues, draw inferences and identify and prioritize client concerns, propose possible collaborative problems to notify PCP, identify need for referral to PCP, and document conclusions

4 nursing interview stages

preintroductory phase, introductory phase, working phase, and summary/closing phase

Preintroductory phase of the nursing interview

nurse reviews medical record before meeting w/ client. it provides insight and medical history

Introductory Phase of the nursing interview

introduce yourself, explain interview purpose, discuss any questions, and assure client of confidentiality. ensure privacy and comfortability. being at eye level, developing trust, rapport, and conveying importance and interest in the client

Working Phase of the nursing interview

gets much information (patient and family history, reason for visit, lifestyle and health practices), interprets and validates information, and then works with the client to identify problems and goals

Summary/Closing Phase of the nursing interview

summarize and validate problems and goals w/the client, identify and discuss possible plans, and finally ask if they have any other concerns or questions

Nonverbal communication

appearance, demeanor, facial expression, attitude, silence, and proactive listening

Verbal communication

open-ended questions, closed-ended questions, laundry list, rephrasing, well-placed phrases, inferring, and providing information

Communication to avoid

not enough/too much eye contact, being distracted or distant, standing when the patient is seated, asking biased or leading questions, rushing the interview

Otosclerosis

often occurs w/ aging as the auditory ossicles develop a spongy consistency resulting in conductive hearing loss

Polyp

growth inside the ear canal due to chronic ear infections or a skin cyst inside ear (cholesteatoma)

Exostosis

“surfer’s ear,” abnormal bone growth within ear canal due to chronic irritation, genetics, or unknown reasons

Microtia

congenital abnormality where the external ear does not fully develop

Tophi

hard external ear nodules associated with deposits of uric acid crystals in advanced gout

Buildup of Cerumen

excess/blocking earwax within canal

Otitis Externa and s/s

“swimmer’s ear,” may occur from fungal infection or inserting a bobby pin/finger/keys into the ear canal. s/s= itchiness inside the ear, redness and swelling, and pain when applying pressure to or pulling on ear

Acute Otitis Media and s/s

an infection in the middle ear behind the tympanic membrane, causes deep, throbbing pressure/pain, muffled hearing, a red/bubling TM, and often a fever (active infection)

Serous Otitis Media or Otitis Media w/ Effusion

buildup of non-infected fluid behind the TM. causes yellowish, bulging membrane with bubbles behind it

Blue/dark red TM

indicates blood behind eardrum due to trauma

Perforated TM

results from rupture caused by increased pressure, usually from infection or untreated trauma

Scarred TM

white spots and streaks indicate scarring from infection

Retracted TM

prominent landmarks are caused by negative ear pressure due to obstructed eustachian tube or chronic otitis media

Tinnitus

ringing, buzzing, or clicking in the ears. may be associated with cerumen blockage, high blood pressure, or ototoxic medications

What part of middle ear can be seen through otoscopic examination?

the TM, short process and handle of the malleus, and the umbo

Mobility of eardrum

perform pneumatic otoscopy w/a bulb insufflator, a health TM flutters when the bulb is inflated and returns to normal when deflated

Ototoxic medications, dangers and examples

can lead to tinnitus or hearing loss. EX= gentamicin, chemo drugs, high-dose aspirin, and many antibiotics