Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide o Normal: Hair follicles and cerumen in the ear canal; tympanic membrane (TM) pearly gray and semitransparent o Deviations from normal: Redness, swelling, discharge, or excessive cerumen in ear canal; tympanic membrane pink, red, blue, white, or yellow; no shine on the TM • Assess hearing acuity: Speak in a normal tone of voice and assess hearing by holding a ticking watch one inch from the patient's ear and ask him what he can hear. o Normal: Able to hear normal voice tones and the tickingwatch. o Deviations from normal: Unable to hear normal voice tones or the ticking watchin one or both ears. • Assess the Weber test: Place a vibrating tuning fork (either 256 or 512 Hz) in the middle of the forehead, chin, or head equidistant from the patient's ears. The patient is asked to report in which ear the sound is heard louder. o Normal: Sound is heard in both ears or in the center (negative Weber). o Deviations from normal: Sound is heard better in one ear or the other (positive Weber). • Assess the Rinne test: The Rinne test is performed by placing a vibrating tuning fork (512 or 256 Hz) against the patient's mastoid bone and asking the patient to say when the sound is no longer heard. Time this interval of bone conduction with a watch, noting the number of seconds. Quickly position the still vibrating tines 1-2 cm from the auditory canal, and again ask the patient to say when the sound is no longer heard. Continue timing the interval of sound due to air conduction heard by the patient. o Normal: Compare the number of seconds sound is heard by bone conduction versus air conduction. Air conducted sound should be heard twice as long as the bone conducted sound (e.g., if bone-conducted sound is heard for 15 seconds, air-conducted sound should be heard for 30 seconds). o Deviations from normal: Bone-conducted sound is greater than or equal to the air- conduction time (negativeRinne). Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal ear or hearing findings. Record and report any significant deviations from the normal. In many agencies, there might be diagrams for documenting areas of ear abnormalities. 2.5 Eyes The room for the eye exam must be well-lit, but with the ability to control the lighting. Equipment needed for the eye and visual exam includes a cotton tip applicator, a ruler, a penlight, an eye chart, and a piece of gauze. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.).

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