PENGKAJIAN UMUM

KEPERAWATAN SISTEM
PENDENGARAN

Oleh :
Ida Rosdiana
Prodi Keperawatan Poltekes Tsm
PENGKAJIAN SISTEM PENDENGARAN

Data Biografi
Riwayat Kesehatan
Pemeriksaan Fisik
Pemeriksaan Penunjang
DATA DEMOGRAFI :

Review the patient’s biographical data to

identify :
• Age
• Occupation
• Gender
• Ethnic background.

Use these patient characteristics to guide

the types of health history
HISTORY
Remember to look at each history component
as it relates to the ears.

Ask the patient the following: Do you have...

Hearing loss?
Vertigo?
Tinnitus?
Ear drainage?
Earache?
HEALTH PAST HISTORY

Childhood Illnesses
■ Do you have a history of frequent ear infections?
Hospitalizations/Surgeries/Serious Injuries
■ Have you ever had a severe head injury? A
stroke?
■ Have you ever received intravenous antibiotics?
Serious and Chronic Illnesses
■ Do you have a history of tinnitus? Vertigo?
Immunizations
■ Are your immunizations up to date?
Allergies
Do you have any allergies? If so, what are they
and how do you react?
Medications
What medications are you taking? What
dosage? How often do you take them? For
how long?
Military Service/Exposure to Irritants
Were you ever in the military?
Have you ever been exposed to loud noises?
DRUG HISTORY

Aminoglycosides
Anti-inflammatory agents
Antimalarials
Nonnarcotic analgesics and antipyretics
FAMILY HISTORY :

Familial/Genetic Ear Disorders

 Is there a history of hearing loss in your family?
 Does anyone in your family have malformed or
malpositioned ears?

Familial/Genetic Disorders That Affect the Ears

 Is there a history of family members with delayed
development?
 Do any neurological disorders run in your family?
 Do you have any skeletal problems?
PHYSICAL ASSESSMENT
Equipment
 Gather equipment needed for the exam: Tuning fork
 Otoscope with pneumatic attachment
 Thermometer
 Watch
 Gloves if indicated

Position
 Sitting for adult
 Supine for infant or toddler to stabilize head

Technique
 First, scan your patient head to toe checking for specific
signs of diseases affecting other organ systems
that might alter the ear.
Inspection, Palpation, Otoscopic Exam, Hearing
Tests  External Ear
Inspect:
Angle of attachment
Size, shape, symmetry
Condition of skin, drainage

Palpate:
Consistency, tenderness, nodules
Helix, tragus, mastoid process
Congenital ear anomaly
Low set ear
Impacted cerumen
Palpasi ear n tragus
pALpasi mastoid n helix
Otoscopic Exam  External Ear Canal
Inspect:
Color, drainage, foreign objects, lesions
Tympanic Membrane : Inspect  Color,
position of landmarks, integrity of TM,
mobility of TM
Otoscope insertion with handle up Otoscope insertion with handle down
 No foreign objects.
Canal patent.
Free of redness and drainage.
 Exostosis (“surfer’s ear”): Abnormal benign
growth of bone in external auditory canal—often
results from swimming in cold water.
 Reddened canal: Otitis externa.
■ Exudate and edema: “Swimmer’s ear” or external otitis.
■ Excessive impacted cerumen in older adults can contribute
to conductive hearing loss.
Hearing tests (Test Each Ear Separately)
Whisper Voice Test
Ticking Watch Test
Weber Test
Rinne Test
Schwabah test
Whisper Voice Test
Ticking Watch Test
 Performing Weber test on fore
Performing Weber test on head head
Performing Rinne test on mastoid
Performing Rinne test in front of ear
OTOSCOPE
Pemeriksaan dengan garpu tala
1. Uji Rinne
- yaitu membandingkan hantaran tulang dengan
hantaran udara pada satu telinga
- Normal, hantaran melalui udara lebih panjang
daripada hantaran tulang

2. Uji Weber
- Yaitu membandingkan hantaran telinga yang
sakit dengan telinga yang normal

3. Uji Schwabach
- Yaitu membandingkan hantaran tulang pasien
dengan hantaran tulang pemeriksa dengan
catatan bahwa pendengaran pemeriksa baik
- Bila schwabach memanjang berarti terdapat tuli
konduktif pada pasien, bila memendek terdapat tuli
syaraf
TEST WEBBER
 RINNE WEBER SCHWABAH HASIL
Positif Tdk ada lateralisasi Sama dengan Normal
pemeriksa

Negatif Lateralisasi ke Memanjang Tuli Konduktif

telinga yang sakit

Positif Lateralisasi ke Memendek Tuli Sensori

telinga yang sehat Neural
DIAGNOSTIC TESTING
Non invasif test :
1.Test for aural structure
2.CT
3.MRI

Invasif Test  Arteriografi

Test for Auditory Function  Audiometricx

test
Test for vestibular function :
1.Electronystagmography
2.Platform Posturography
3.Rotary chair assesment

Laboratory test :
1.Blood test
2.Culture
3.Test for presence of CF
4.Tissue specimens
Electronystagmography