Chapter 17

Assessing Ears

Physical Assessment Guide to Collect Objective Client Data

Questions Findings

External Ear Structures

1. Inspect the auricle, tragus, and lobule for size

Pt. has no tenderness on auricle,
and shape, position, lesions/discoloration, and tragus, normal throughout, color
discharge. consistent with facial color. Skin is
smooth. No discharge is present.

2. Palpate the auricle and mastoid process for

Pt. has no pain, tenderness on
tenderness. palpation

Otoscopic Examination

1. Inspect the external auditory canal with the

Pale gray, translucent appearance.
otoscope for discharge, color and consistency Cone of light and bony landmarks
of cerumen, color and consistency of canal visible, consistency is present
walls, and nodules. bilaterally

2. Inspect the tympanic membrane, using the

Smooth, pearly grey, shiny, no bulging
otoscope, for color and shape, consistency, or retraction, umbo visible, short
and landmarks. process

3. Have the client perform the Valsalva

Heart reacts and goes back to
maneuver, and observe the center of the normal,pt. reported no dizziness
tympanic membrane for a flutter. (Do not do
this procedure on an older client, as it may
interfere with equilibrium and cause
dizziness.)

Hearing and Equilibrium Tests

1. Perform the whisper test by having the client

place a finger on the tragus of one ear. Normal findings
Whisper a two-syllable word 30.4–60.9 cm (1–
2 ft) behind the client. Repeat on the other
ear.

2. Perform the Weber test by using a tuning fork

Normal findings
placed on the center of the head or forehead
and asking whether the client hears the sound
better in one ear or the same in both ears.

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 3. Perform the Rinne test by using a tuning fork
Normal findings
and placing the base on the client’s mastoid
process. When the client no longer hears the
sound, note the time interval, and move it in
front of the external ear. When the client no
longer hears a sound, note the time interval.

4. Perform the Romberg test to evaluate

Normal Findings
equilibrium. With feet together and arms at
the side, close eyes for 20 seconds. Observe
for swaying. (Refer to textbook, Chapters 16
and 26.)

Analysis of Data

1. Formulate nursing diagnoses (wellness, risk,

N/a ; ears are completely normal
actual).

2. Formulate collaborative problems.

N/a ; ears are completely normal

3. Make necessary referrals.

No necessary referrals

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