Holistic Health Assessment Essay

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Holistic Health Assessment Essay

Holistic Assessment of an Adult Ear Using an Otoscope (Observation) and Palpation

Assessment or examination of the ear for appropriate and correct diagnosis uses the techniques of inspection or observation as well as palpation. Because there are internal structures in the ear, the inspection aspect is facilitated by the use of an otoscope (Ball et al., 2019). This paper presents some of the findings that may come out of the examination of an adult patient’s ears. Holistic Health Assessment Essay

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Table 1: Examination of an adult ear

Part/ Procedure Findings
Inspection of the external ear structures (including the auricle, tragus, and lobule) ·         The gross structure of the ears including the lobules of the auricles appears the same in size and shape on both sides.

·         The tragus and antitragus do not appear swollen or inflamed bilaterally.

·         There are no piercings bilaterally on the lobule, the helix, or the tragus.

·         The intertragic notch shows no sign or evidence of otorrhea or ear discharge bilaterally.

·         There are no visible lesions bilaterally on both ears, and the color of the ears is homogeneous with the rest of the body.

·         There is no discoloration on both sides.
Palpation of the external structures of the ear (including the auricle and mastoid process) ·         The auricle, the helix, the tragus, and antitragus all do not show any tenderness or swelling bilaterally.

·         Also, there are no masses that are palpable bilaterally.

·         On palpation of the mastoid process, the patient denies any tenderness on both sides.

·         The auricle feels soft and flexible bilaterally on palpation.
Bilateral inspection of the external auditory canal using the otoscope ·         The patient denies any discomfort when the otoscope is inserted in the external auditory canal on both sides.

·         Inspection of the external auditory canal reveals a clear canal with just a little cerumen that is brown in color.

·         There is no otorrhea visible bilaterally.

·         The canal walls are smooth with no evidence of nodules or inconsistencies bilaterally.
Bilateral inspection of the tympanic membranes ·         The tympanic membrane shows no perforation or sclerosis on both sides.

·         There are also no visible fluid levels behind the tympanic membrane bilaterally.

·         However, there are bubbles that are visible on otoscopy on the right side.

·         There is no cholesteatoma in the attic area of the membrane bilaterally.

·         The tympanic membrane shows a visible bulge and demonstrates reduced mobility on pneumatic otoscopy on the right side too.

·         The tympanic membrane on the left is round, smooth, and has no bulge or any other visible abnormality.
A common ear disorder or abnormal finding discoverable in an ear assessment Acute otitis media (AOM)

·         In this condition, the tympanic membrane shows an opaque reaction to light and may also bulge.

·         Fluid may be demonstrated in the middle ear through otoscopy and visible through the tympanic membrane.

·         There is inflammation shown by redness of the tympanic membrane and the patient may have fever and tenderness on inserting the otoscope.

·         The fluid behind the tympanic membrane may also be pus at times (Hammer & McPhee, 2018).
Nursing Diagnoses for AOM in Adults
A health promotion nursing diagnosis for AOM A risk nursing diagnosis for AOM A collaborative problem or actual nursing diagnosis for AOM Holistic Health Assessment Essay
Readiness for enhanced learning on the prevention of acute otitis media Risk for developing intra-temporal abscess if AOM is left untreated Risk for complications of intracranial and intra-temporal conditions

 References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

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Holistic Health Assessment Essay