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Ear
is the sensory organ for hearing and equilibrium.
1. malleus (hammer)
2. incus (anvil)
3. stapes (stirrups)
d
Eustachian tube
= another part of the middle ear connecting the middle
ear to the nasopharynx.
PLANNING
- It is important to conduct the ear and hearing exam.
in an area that is quiet. In addition, the location should
allow the client to be positioned sitting or standing at
the same level as the nurse.
PERFORMANCE
1. Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate. Discuss how
the results will be used in planning further care or treatments.
- Tip the clients head away from you, and straighten the ear
canal. For an adult, straighten the ear canal by pulling the
pinna up and back.
- Hold the otoscope either
a. right side up, with your fingers between the otoscope
handle and the clients head
b. upside down, with your fingers and the ulnar surface
of your hand against the clients head.
- Gently insert the tip of the otoscope into the ear canal,
avoiding pressure by the speculum, against either side of the
ear canal.
9. Inspect the tympanic membrane for color and gloss.
10A. Perform the watch tick test. The ticking of a watch has
a higher pitch than the human voice.
- Have the client occlude one ear. Out of the clients
sight, place a ticking watch 2 to 3 cm (1 to 2 in.) from
the unoccluded ear.
- Ask what the client can hear. Repeat with the other ear.
10B. TUNING FORK TESTS
* Webers test done to assess bone conduction by
examining the lateralization (sideward
transmission) of sounds.
EVALUATION
- Perform a detailed follow-up examination of the neurologic
system based on findings that deviated from expected or
normal for the client. Relate findings to previous assessment
data if available.