HEALTH ASSESSMENT
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NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
Collecting Subjective Data
History of present health concern
(CHANGES IN HEARING)
1. Describe any recent changes in your
hearing.
o Decrease in ability to hear in one ear – may
be associated with otitis media or cerumen
impaction
o Otitis media – red, bulging membrane
decreased or absent light reflex, an
infection of rapid onset that usually presents
with ear pain
o Cerumen impaction – build-up of layers
of earwax within the ear canal to the point
of blocking the canal and putting pressure
on the eardrum
o Sudden sensorineural loss (SSHL) or sudden
deafness (up to 3-day period) may be a
medical emergency, thus should be
referred for immediate follow-up
o Sudden sensorineural loss – when hearing
loss is due to problems of inner ear, also
known as nerve-related hearing loss
o Causes vary from unknown: infections,
trauma, toxicity and other neurologic or
circulatory disorders
2. Are you ever concerned that you may be
losing your ability to hear well?
o Have client take self-assessment: “Ten ways
to recognise hearing loss” provided by the
NIDCD on page 343
3. Are all sounds affected with this change or
just some sounds?
o Presbycusis - occurs gradually and initially
affects the ability to hear higher pitched
(higher frequency) sounds (woman’s voice)
followed by loss of low-frequency sounds
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(OTHER SYMPTOMS)
1. Do you have any ear drainage? Describe
the amount and any odour.
o Drainage (otorrhea) – indicates infection
o Purulent, bloody drainage – suggests
infection of external ear (external otitis)
o Purulent drainage – associated with pain
and popping sensation: characteristics of
otitis media with perforation of the
tympanic membrane
2. Do you have any ear pain? If the client
answers yes, use COLDSPA to explore the
symptom.
֍ Earache (otalgia) can occur with ear
infections, cerumen blockage, sinus
infection, or teeth and gum problems
o Character: Describe the pain
֍ Pain caused by “swimmer’s ear” differs
from pain felt in middle ear infections
֍ Pain that occurs when manipulating,
wiggling, the pinna may suggest otitis
externa (swimmer’s ear)
o Onset: When did it begin?
o Location: Where is it? Does it radiate?
֍ Clients with ear infections may
experience nausea and dizziness
o Duration: How long does it last?
o Severity: Rate pain on a scale of 1 to 10,
with 10 being the worst. Are you able to
continue your usual activities? Are you able
to sleep?
o Pattern: Have you taken any measures to
relieve it (medications)? Has it helped?
o Associated factors/ How does it Affect you:
Do you have an accompanying sore throat,
sinus infection or problems with your teeth
or gums?
HEALTH ASSESSMENT
NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
3. Do you experience any ringing, roaring or
crackling in your ears?
o Ringing in ears (tinnitus) – may be
associated with excessive earwax build-up,
high blood pressure, or certain medications
(such as streptomycin, gentamicin,
kanamycin, neomycin, ethacrynic acid,
furosemide, indomethacin or aspirin), loud
noises or other causes
4. Do you ever feel like you are spinning or
that the room is spinning? Do you ever feel
dizzy or unbalanced?
o Vertigo – may be associated with an inner
ear problem, client feel they are spinning
around and objective vertigo is when client
feel that the room is spinning around them
o It is important to distinguish dizziness from
vertigo
Personal health history
1. Have you ever had any problems with your
ears such as infections, trauma or
earaches?
o History of repeated infections can affect
tympanic membrane and hearing
2. Describe any past treatments you have
received for ear problems (medication,
surgery, hearing aids). Were these
successful? Were you satisfied?
o Client may be dissatisfied with past
treatments for ear or hearing problems
o (older adult considerations) may have had
a bad experience with certain hearing aid
and may refuse to wear one. Client may
also associate a negative self-image with a
hearing aid
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Family history
1. Is there a history of hearing loss in your
family?
o Age-related hearing loss tends to run in
families
Lifestyle and health practices
1. Do you work or live in an area with frequent
or continuous loud noise? How do you
protect your ears from the noise?
o Continuous loud noises can cause hearing
loss unless ear guards are worn
o Clients exposed to high noise level need to
be informed of their options for using
hearing protective devices
2. Do you spend a lot of time swimming or in
water? How do you protect your ears when
you swim?
o Otitis externa (swimmer’s ear) can occur
when water stays in ear canal for long
periods of time, providing perfect
environment for germs to grow and infect
the skin
o Patient experiences pain when the pinna
and tragus are moved, tenderness behind
the ear may occur but patient would not
experience pain when wiggling the ear
o Symptoms:
֍ Itchiness inside ear
֍ Redness
֍ Swelling of ear
֍ Pain in the ear when pressure is applied
or when ear is pulled (pain may be
severe)
֍ Drainage of pus
HEALTH ASSESSMENT
NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
3. Has your hearing loss affected your
socializing with others?
o Clients who have decreased hearing may
withdraw, isolate themselves or become
depressed because of the stress of verbal
communication
4. When was your last hearing examination?
5. Do you wear hearing aid?
o Some internal hearing aids may not be
visible to interviewer
6. How you care for your ears? Describe how
you clean your ears.
o Earwax is natural, self-cleaning agent that
should not be regularly removed unless it is
causing a problem
o Warm, moist washcloth should be used to
clean the outside of ears but nothing
should be inserted into the ear canal
o Few drops of mineral oil, baby oil, glycerine
or commercial drops may be placed in ear
to moisten the earwax to allow it to
naturally work its way out of ear
Collecting Objective Data
Physical Examination
Preparing the client:
o Make sure client is seated comfortable
o Explain in detail what will be done
o Answer questions client may raise
o Carefully note how client responds to the
examination
Equipment:
o Watch with a second hand for Romberg
test
o Tuning fork (512 or 1,024 Hz)
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o Otoscope
Physical Assessment:
Before performing the examination, make sure
to:
o Recognise the role of hearing in
communication and adaptation to the
environment, particularly in regard to aging
o Know how to use the otoscope effectively
when performing the ear examination
o Understand the usefulness and significance
of basic hearing tests
General Routine Screening
o Inspect the auricle, tragus and lobule
o Palpate the auricle and mastoid process
o Perform the whisper test
Focused Specialty Assessment
o Inspect the external auditory canal
o Inspect the tympanic membrane (eardrum)
o Perform the Weber test if the client reports
diminished or lost hearing in one ear
o Perform the Rinne test differentiate
between conductive and sensorineural
hearing loss
o Perform the Romberg test
Inspection and Palpation of External ear
structures
1. Inspect the auricle, tragus ad lobule
o note shape, size and position
֍ Ears are smaller than 4cm or larger than
10cm
֍ Misaligned or low-set ears may be seen
with genitourinary disorders or
chromosomal defects
֍ Microtia – a congenital deformity in
which the external ear and sometimes
the ear canal are not fully developed
HEALTH ASSESSMENT
NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
֍ Macrotia – a congenital excessive
enlargement of the external ear
֍ Ear malformations – often related to
other congenital anomalies: face, jaw,
dental, and kidney disorders
֍ (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
֍ (older adult considerations) often have
elongated earlobes with linear wrinkles
o Continue inspecting the auricle, tragus and
lobule
o Observe for lesions, discolouration and
discharge
֍ Some abnormal findings suggest various
disorders:
> Enlarged preauricular and
postauricular lymph nodes - infection
> Tophi (non-tender, hard, cream-
coloured nodules on helix or
antihelix, containing uric acid
crystals) – gout
> Blocked sebaceous glands –
postauricular cysts
> Ulcerated, crusted nodules that
bleed – skin cancer (most often seen
on helix due to skin exposure)
> Redness, swelling, scaling or itching –
otitis externa
> Pale blue ear colour – frostbite
֍ Otitis externa - a condition that causes
inflammation (redness and swelling) of
the external ear canal, which is the tube
between the outer ear and eardrum
2. Palpate the auricle and mastoid process
֍ Painful auricle or tragus – associated
with otitis externa or post auricular cyst
֍ Tenderness over the mastoid process
suggests mastoiditis
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֍ Mastoiditis - serious infection in the
mastoid process, which is the hard,
prominent bone just behind and under
the ear
֍ Tenderness behind ear may occur with
otitis media
Inspection of internal ear: Otoscopic
Examination
1. Inspect the external auditory canal
o use otoscope
o note any discharge along with the colour
and consistency of cerumen (earwax)
֍ abnormal findings associated with
specific disorders:
> foul-smelling, sticky, yellow discharge
– otitis externa or impacted foreign
body
> bloody, purulent discharge – otitis
media with ruptured tympanic
membrane
> blood or watery discharge
(cerebrospinal fluid) – skull trauma,
refer client immediately to physician
> impacted cerumen blocking the
view of external ear canal –
conductive hearing loss
> refer any client with presence of
foreign bodies: bugs, plants, food to
health care practitioner for prompt
removal due to possible swelling and
infection. If object in ear is button-
type battery, medical attention is
urgent as leaking chemicals can
burn and damage the ear canal
even within an hour
֍ (older adult considerations) harder, drier
cerumen tends to build up as cilia in the
ear canal becoming more rigid
֍ Coarse, thick, wire-like hair may grow at
ear canal entrance as well, this is an
HEALTH ASSESSMENT
NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
abnormal finding only if it impairs
hearing
o Observe colour and consistency of ear
canal walls and inspect character of any
nodules
֍ Abnormal findings in the ear canal may
include:
> Reddened, swollen canals – otitis
externa
> Exostoses (non-malignant nodular
swellings)
> Polyps may block the view of
eardrum
֍ Exostoses - Usually, two bony swellings
(exostoses) slowly appear on the lower
wall of the deep part of your ear canal,
often with a third, smaller lump in the
upper part
֍ Polyps - abnormal tissue growths that
most often look like small, flat bumps or
tiny mushroom like stalks
2. Inspect the tympanic membrane (eardrum)
o Note colour, shape, consistency and
landmarks
o Entire tympanic membrane (TM) may not
be completely visible at one glance
o Rotate the otoscope around to view
images
o Use largest speculum that the ear canal will
allow
o Once inserted into ear canal, otoscope
may need to be positioned slightly anterior
to see TM
֍ Abnormal findings in the tympanic
membrane:
> Red, bulging eardrum and distorted
diminished or absent light reflex –
acute otitis media
> Yellowish, bulging membrane with
bubbles behind – serous otitis media
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Email: diarynisn@gmail.com
> Bluish or dark red colour – blood
behind eardrum from skull trauma
> White spots – scarring from infection
> Perforations – trauma from infection
> Prominent landmarks – eardrum
retraction from negative ear pressure
resulting from an obstructed
eustachian tube
> Obscured or absent landmarks –
eardrum thickening from chronic
otitis media
֍ (older adult consideration) eardrum
may appear cloudy. Landmarks may be
more prominent because of atrophy of
tympanic membrane associated with
the normal process of aging
o To evaluate mobility of tympanic
membrane, perform pneumatic otoscopy
with a bulb insufflator attached
o Observe the position of tympanic
membrane when bulb is inflated and again
when air is released
֍ With otitis media, membrane does not
move or flutter when bulb is inflated
General Observation of hearing and
equilibrium tests
1. Check page 352
Perform whisper test
o Ask client to gently occlude the ear not
being tested, rub the tragus with a finger in
a circular motion
o Start the testing the better hearing ear then
the poorer one
o With head 2ft behind client, whisper two-
syllable word
o Ask client to repeat it back
o If response is incorrect the first time, whisper
the word one more time
o Identifying three out of six whispered words
is considered passing the test
HEALTH ASSESSMENT
NURSING ASSESSMENT OF PHYSICAL SYSTEMS:
ASSESSING EAR
֍ Unable to repeat the two-syllable word
after two tries indicates hearing loss and
requires follow up testing by an
audiologist
֍ (cultural consideration) blacks had best
hearing followed by Hispanics and
whites
2. Perform Weber test of client reports
diminished or lost hearing in one ear
o Strike a tuning fork softly with back of hand,
place it at center of client’s head or
forehead
o Ask whether client hears sound better at
left, right or both ears
o Hold tuning fork by handle and do not
touch the tines
֍ With sensorineural hearing loss, client
reports lateralization of sound to the
good ear, this is because of limited
perception of sound due to nerve
damage in bad ear, making sound
seem louder in the unaffected ear
3. Perform the Rinne test
o Rinne test compares air and bone
conduction sounds
o Strike tuning fork and place the base of fork
on client’s mastoid process
o Ask client to tell you when the sound is no
longer heard
o Move prongs of tuning fork to the front of
external auditory canal
o Ask client to tell you if sound is audible after
fork is moved
֍ With conductive hearing loss, bone
conduction (BC) sound is heard longer
than or equally as long as air
conduction sound (BC is greater or less
than AC)
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Email: diarynisn@gmail.com
֍ Conductive hearing loss occurs when
sound is not conducted through outer
ear canal to eardrum and ossicles of
middle ear
֍ Possible causes: fluid in middle ear,
middle ear infection (otitis media),
allergies (serous otitis media),
eustachian tube dysfunction, perforated
eardrum, benign tumors, impacted
cerumen, infection of ear canal
(external otitis) or presence of foreign
body
֍ Eustachian tube dysfunction - when the
mucosal lining of the tube is swollen, or
does not open or close properly
֍ Perforated eardrum - a hole or tear in
the thin tissue that separates your ear
canal from your middle ear (eardrum)
֍ Sensorineural hearing loss occurs with –
damage to inner ear (cochlea) or nerve
pathways between inner ear and brain -
Most common type of permanent
hearing loss, it decreases one’s ability to
hear faint sounds
֍ Causes include: ototoxic drugs, genetic
hearing loss, aging, head trauma,
malformation of inner ear, loud noise
exposure
4. Perform the Romberg test
o Testing client’s equilibrium
o Ask client to stand with feet together, arms
at sides, eyes open
o Then with eyes closed
o When performing test, put arms around
client without touching to prevent falls
֍ Client moves feet apart to prevent falls
or starts to fall from loss of balance –
may indicate vestibular disorder
֍ Vestibular disorder -
The vestibular system includes the parts
of the inner ear and brain that help
HEALTH ASSESSMENT
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NURSING ASSESSMENT OF PHYSICAL SYSTEMS: Twitter: @DiaryniSN
ASSESSING EAR Email: diarynisn@gmail.com

control balance and eye movements. If Exostosis

the system is damaged by disease,
aging, or injury, vestibular disorders can
result

Nursing Diagnoses

Health Promotion Diagnoses

Microtia
o Readiness for enhanced verbal
Congenital abnormality where the external ear
communication related to expressed desire
does not fully develop
for hearing aid

Tophi
Risk Diagnoses
Hard external ear nodules associated with
o Risk for Injury related to hearing impairment
deposits of uric acid crystals in advanced gout
o Risk for Loneliness related to hearing loss

Abnormalities of Tympanic Membrane

Actual Diagnoses
o Acute Pain related to infection of external
Acute Otitis Media
or middle ear
Note the red, bulging membrane; decreased
o Impaired Social Interaction related to
or absent light reflex.
inability to interact
o Impaired verbal communication related to
Blue/Dark Red Tympanic Membrane
hearing loss
Indicates blood behind eardrum due to
trauma.
Abnormalities of the External Ear and Ear Canal

Perforated Tympanic Membrane

Malignant lesions
Perforation results from rupture caused by
increased pressure, usually from untreated
Otitis externa
infection or trauma.

Serous Otitis Media

Note the yellowish, bulging membrane with
bubbles behind it.
Build-up of cerumen in ear canal
Scarred Tympanic Membrane
White spots and streaks indicate scarring from
Polyp
infections.

Retracted Tympanic Membrane

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