ADVENTIST MEDICAL CENTER COLLEGE

San Miguel, Iligan City

SCHOOL OF NURSING

HEALTH ASSESSMENT
Related Learning Experience (Skills Lab)
Second Semester, AY 2022 – 2023

EAR ASSESSMENT RUBRIC

Name _______________________________________________________________________________________ Section _________ Date __________________ Score _______

I. COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
CRITERIA AND PROCEDURE EXCELLENT VERY SATISFACTORY SATISFACTORY POOR SCORE
4 3 2 1

Preliminaries and Client Preparation Demonstrated all Demonstrated 10 Demonstrated 9 Demonstrated 8 or

1. Student must wear the required and appropriate attire as well as observe proper (11) preliminary preliminary and client preliminary and less of the
grooming prior to the examination. and client preparation activities client preliminary and
preparation preparation client preparation
2. Gather equipment (watch with a second hand, assessment form, pen, clipboard).
activities activities activities
3. Demonstrate courtesy, introduce self, and verify client’s identity. Explain to the
client that after the nursing health history, you will proceed to the physical
assessment or physical examination.
4. Do hand hygiene and observe other infection control procedures.
5. Provide privacy.
6. Position the client to be seated comfortably.
7. Provide a quiet environment.
8. Be sure that the room is having a comfortable temperature.
9. Ensure that during the interview, there are no interruptions and distractions.
10. Ask questions in a straightforward manner, be sensitive, and avoid being
judgmental.
11. Be alert to signs of hearing loss such as inappropriate answers, frequent requests
for repetition, and so on.
History of Present Health Concern EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
Changes in Hearing Demonstrated Missed one to two Missed three to Missed five or more
1. Describe any recent changes in your hearing. complete (13) and assessment interview four assessment assessment
2. Are you ever concerned that you may be losing your ability to hear well? comprehensive on history of present interview on interview on
3. Are all sounds affected with this change or just some sounds? interview on health concern history of history of present
4. Do you have any ear drainage? Describe the amount and any odor. history of present present health health concern
5. Do you have any ear pain? If the client answer yes, use COLDSPA to explore the symptom. health concern concern
a. Character: Describe the pain.
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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?
6.Do you experience any ringing, roaring, or crackling in your ears?
7.Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or
unbalanced?
Personal Health History and Family History EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
1. Have you ever had any problems with your ears such as infections, trauma, or earaches? Demonstrated Missed one Missed two Missed all
2. Describe any past treatments you have received for ear problems (medication, surgery, complete and assessment interview assessment assessment
hearing aids). Were these successful? Were you satisfied? comprehensive on personal health interview on interview on
3. Is there a history of hearing loss in your family? interview on history and family personal health personal health
personal health history history and history and family
history and family family history history
history
Lifestyle and Health Practices EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
1. Do you live or work in an area with frequent or continuous loud noise? How do you protect your ears Demonstrated Missed three or
from the noise? complete (7) and Missed one Missed two more assessment
2. Do you spend a lot of time swimming or in water? How do you protect your ears when you swim? comprehensive assessment interview assessment interview on
3. Has your hearing loss affected your ability to care for yourself? To work? interview on on lifestyle and health interview on lifestyle and health
4. Has you hearing loss affected your socializing with others? lifestyle and health practices lifestyle and practices
5. When was your last hearing examination? practices health practices
6. Do you wear a hearing aid?
7. How do you care for your ears? Describe how you clean your ears?

II. COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

External Ear Structures EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Inspection and Palpation Performed Missed one step in the Missed two Missed all steps in
1.Inspect the auricle, tragus, and lobules for size, shape, position, symmetry, color, texture, lesions, and complete assessment of the steps in the the assessment of
discharge. assessment of the external ear structures assessment of the external ear
2. Inspect pinna noting its level with the corner of the eye. external ear the external ear structures
2. Palpate the auricle, tragus & mastoid process for tenderness. structures structures
Hearing and Equilibrium Tests EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
1. Whisper test or whisper voice test (for low- pitch deficits).
a. Ask the client to gently occlude or cover the ear not being tested and rub the tragus with a finger in a Performed Missed one step in the Missed two Missed three or
circular motion. Start with testing the better hearing ear and then the poorer one. complete (8) and assessment of the steps in the more steps in the
b. Stand about 1-2 ft. behind client (so that the client cannot see your lips move), and whisper two-syllable comprehensive hearing and assessment of assessment of the
word such as “popcorn” or “football”. assessment of the equilibrium tests the hearing and hearing and
c. Note client’s ability to hear sounds by asking the client to repeat it back to you. hearing and equilibrium equilibrium tests
equilibrium tests tests
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d. If the response is incorrect the first time, whisper the word one more time. Identifying 3 out of 6
whispered words is considered passing the test.
2. Watch tick test (for high – pitch deficits).
a. Have client cover the opposite ear being tested.
b. Hold ticking watch within 5 inches from ear. Note client’s ability to hear sound.
3. Romberg test (Test for inner ear vestibular function to evaluate equilibrium).
a. Have client stand with feet together, arms at sides, eyes opened, then eyes closed for 20 seconds. Stand
close by in case client loses balance.
b. Note client’s ability to maintain balance. Observe for swaying. (Client maintains balance or position for
10 seconds without swaying or with minimal swaying).

Post-examination Activities EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

1. Show appreciation to your client for cooperating. Exhibited all (5) Missed one step of the Missed two Missed three or
3. Perform hand hygiene. post-examination post-examination steps of the more steps of the
4. Disinfect materials that will still be reused prior to storing them. activities activities post- post-examination
5. Document findings in the client record supplemented by narrative notes. examination activities
activities

CONFIDENCE EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Performed entire Performed entire Performed Not able to perform
procedure with procedure with entire entire procedure
great confidence moderate confidence procedure with with confidence
minimal
confidence
TIMING (AT LEAST 30 MINUTES) EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
Performed entire Performed entire Performed Performed the
procedure within procedure with 5 entire entire procedure
the allotted time minutes excess on the procedure with with 15 minutes or
(20 minutes) allotted time 10 minutes more excess of the
excess on the allotted time.
allotted time

TOTAL
Note: Refer to your textbook for the rationale of each area of assessment.

Perfect Score: 36 points

Range of Scores:
34 – 36 --------------------------------------- Excellent
31 – 33 --------------------------------------- Very Satisfactory
28 – 30 --------------------------------------- Satisfactory
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27 and below ------------------------------- Poor

Assessed by:

___________________________________
Name and Signature of RLE Instructor
/rsp
5/5/21