Republic the Philippines

Laguna State Polytechnic University

Province of Laguna
College of Nursing and Allied Health

NURSING CARE MANAGEMENT 101

HEALTH ASSESSMENT

ASSESSMENT OF HEARNING 2

NAME OF STUDENT: ____________________ SECTION & GROUP NUMBER: _______________________

DATE OF RETURN DEMONSTRATION: ________________ CLINICAL INSTRUCTOR: ___________________

Definition or
Purpose

Preparing the 1. Explain the procedure such as how to prepare oneself, purpose, physical
Client and environment, how he/she can participate, client positions, preferences, pain,
Physical vital signs will be taken.
Assessment 2. Ask client to wear gown or as necessary.
3. Provide Privacy
4. Collect subjective data such as current symptoms, past history, family history,
lifestyles and health practices.

Equipment Gather Equipment:

1. Watch with a second hand for Romberg test
2. Tuning fork (512 or 1,024 Hz)
3. Otoscope

ASSESSMENT PROCEDURE
(this can be typewrite based on the sequence of parts to be SCORES
examined and techniques)

STEPS 0 1 2 REMARKS
NOT DONE MASTER
RATIONALE DONE
External Ear Structure
INSPECTION AND PALPATION
1 Inspect the auricle, tragus, and lobule. Note size, shape,
and position.
2 Continue inspecting the auricle, tragus, and lobule.
Observe for lesions, deformities, lumps, discolorations,
and discharge.
3 Move pinna and press on the tragus. Then palpate the
mastoid process.
Internal Ear: Otoscopic Examination
INSPECTION
1 Inspect the external auditory canal. Use the otoscope.
Note any discharge along with the color and consistency
of cerumen (earwax)
2 Observe the color and consistency of the ear canal walls
and inspect the character of any nodules.
3 Inspect the TM (eardrum). Note color, shape,
consistency, and landmarks.
4 To evaluate the mobility of the TM, perform pneumatic
otoscopy with a bulb insufflator attached using an
otoscope with bulb insufflators. Observe the position of
the TM when the bulb is inflated and again when the ais
is released.
5 Perform the whisper test (or whispered voice test) by
asking the client to gently occlude the ear not being
tested and rub the tragus with a finger in a circular
motion. Start with testing the better hearing ear and
then the poorer one. With your head 2ft behind the
client (so that the client cannot see your lips move),
whisper a two-syllable word such as “popcorn” or
“football.” Ask the client to repeat it back to you. If the
response is incorrect the first time, whisper the word
more time. Identifying three of six whispered words is
considered passing the test. The whisper test has been
studied in both pediatric and adult clients to evaluate
hearing acuity and has been found to have a high
sensitivity and specificity (Pirozzo et al., 2003)
6 Perform the Weber test if the client reports diminished
or lost hearing in one ear. This test helps evaluate the
conduction of sound waves through bone to help
distinguish between conductive hearing (sound waves
transmitted by the external and middle ear) and
sensorineural hearing (sound waves transmitted by the
inner ear). Strike a tuning fork softly with the back of
your hand and place it at the center of the client's head
or forehead. Centering is the important part. Ask
whether the client hears the sound better in one ear or
the same in both ears.
7 Perform the Rinne test. The Rinne test compares air and
bone conduction (AC and BC, respectively) sounds.
Strike a tuning fork and place the base of the fork on the
client's mastoid process.

Ask the client to tell you when the sound is no longer

heard.

Move the prongs of the tuning fork to the front of the

external auditory canal. Ask the client to tell you if the
sound is audible after the fork is moved.
8 Perform the Romberg test. This tests the client’s
equilibrium. Ask the client to stand with feet together,
arms at sides, and eyes open, then with the eyes closed.

GIVEN SCORES / TOTAL NUMBER OF SCORES * 50+50 =

_______________________________
Signature of Clinical Instructor/Date