Completed Otoscope assignment with nursing diagnosis PDF

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Summary

Otosocope exam on an adult, and written assessment with 3 nursing diagnoses...

Description

Ear Assessment and appropriate nursing diagnoses (Do assessment on an adult) In the boxes, describe your findings. Do not use the word “Normal” or approximations of it, such as N/A, expected, etc. State what you found using terminology appropriate for the area. See the textbook for appropriate wording. If there are no signs or symptoms of any problems, for instance, it would be appropriate to write: Denies tenderness, pain, and paresthesia; no lesions or breakdown observed. No evidence of pathology noted. Then proceed to describe what you assess in terms of observation, (auscultation and percussion are not used in ear assessments) and palpation. Weber and Kelley’s textbook has a helpful guide with pictures and verbiage you may find helpful: Assessment Guide 17-1, in the chapter on ear assessment (note especially the textbook verbiage in the center and right columns.) You may use textbook terminology in this class because it is expected. Many videos are also available to assist you. There is one on Blackboard in the current module, and YouTube has a number of them as well. Do not use the work of other students. That is plagiarism, and our detection program will flag it. If confirmed it will mean the grade of F in the class: It isn’t worth it! Current Symptoms: Ears

Assessment Findings

External Ear Structures 1. Inspect the auricle, tragus, and lobule for size and shape, bilaterally. Describe bilateral position, lesions/discoloration, and discharge. 2. Palpate the auricle and mastoid process bilaterally. Describe findings, including symptomatology or tenderness if they are present.

Ears are equal in size bilaterally. Each auricle aligns with the corner of each eye. Auricle is firm, and pinna recoils after it is folded bilaterally. No discharge present and earlobes are free bilaterally. Auricle is non-tender with palpation, bilaterally. Skin is smooth, no nodules or lesions noted. Mastoid process is smooth, intact and no edema present bilaterally. Patient denies pain or tenderness bilaterally in mastoid process.

Otoscopic Examination 3. Bilaterally inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and any nodules. (Address each of these items bilaterally.) 4. Inspect and describe the tympanic membranes bilaterally, using the otoscope, for color and shape, and landmarks.

Ear canal walls are smooth and pink, no nodules noted bilaterally. Scant amount of soft, yellow, odorless cerumen noted in left canal. No cerumen noted in right canal. Patient denies discomfort with exam and manipulation of pinna bilaterally. Tympanic membrane is shiny, translucent and gray bilaterally. Tympanic membrane is smooth, slightly concave and intact bilaterally. No bulging or retraction noted bilaterally. Cone of light reflection present bilaterally, Noted at 5 o’ clock in right ear and 7 o’ clock in left ear.

Handle of malleus, umbo and short process visible bilaterally.

5. List a common ear disorder or abnormal assessment finding that would be discoverable in an ear or hearing assessment.

Reddened, painful, swollen canals- otitis externa

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Using the diagnostic reasoning process described in chapter 5 of your textbook, synthesize one of each of the three types of nursing diagnoses described below for a potential client with the problem you listed in area #5, above. You will use the three of the types of nursing diagnoses (ND) described in Chapter 5 of your Weber and Kelley textbook: 1. A Health Promotion ND 2. A Risk ND and 3. A Collaborative Problem or Actual ND. You will find a list of possible diagnoses in Appendix C and D in your textbook. Synthesis List one “Health Promotion” nursing diagnosis appropriate for your client with the condition you describe in section 5, above.

Instructions/Items to include Health Promotion nursing diagnoses often begin with “Readiness for enhanced learning” as described in Appendix C of your textbook, under Domain 1. They are also discussed in Table 5-1 and 5-2.

Nursing Diagnosis Readiness for enhanced knowledge: information on treatment and prevention of disease.

List one “risk for” nursing diagnosis for the condition you listed above in section 5.

Risk diagnoses are described in tables 5-1 and 5-2, and in Appendix C in each of the domains, but particularly in Domain 11. They usually begin with the words, “Risk for….” Collaborative problems are describe in table 5-2 and are listed in Appendix D. They begin with “Risk for Complications (RC) of….”

Risk for infection, as evidenced by ear pain and inflammation

List EITHER one “Collaborative Problem” that would be appropriate for a client with the condition described in section 5, above OR list an actual nursing diagnosis

Actual nursing diagnoses are scattered through Appendix C

Acute pain related to inflammation in the external ear canal

from Appendix C....