measure hearing by AC (air conduction) and BC (bone conductivity)
Place tuning fork on top of head in the center, patient should be able to feel the vibrations in both ears.
determines conductive or sensorineural hearing loss
Conductive loss = client “hears” the sounds in their poor ear. The good ear is distracted
by background noise, conducted air, which the poor ear has trouble hearing. Thus the poor ear receives most of the sound conducted by bone vibration.
With sensorineural loss the client reports lateralization of sound to the good ear, because of limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in
the unaffected ear.
Conductive hearing loss
hearing loss due to problems with the bones of the middle ear
Weber's : CAM
Conductive - Affected ear - Mechanical problem
Sensorineural hearing loss
hearing loss due to failure of the auditory nerve
Weber's test : SUN
Sensorineural - Unaffected ear - Nerve damage
striking a tuning fork and placing behind the person's ear (mastoid) to measure BC. ask the person to tell you when they cannot hear the sound anymore, then move the fork right by the ear canal to measure AC.
AC is normally twice as long as BC
Aging adult ear
ear drum may be more opaque, thicker, and duller than in younger adult
coarse hair at ear canal
elasticity loss of pinna (wrinkling)
gradual nerve degeneration in ear
inflammation of the bony labyrinth, which are a series of intricate structures in the inner ear that play a role in hearing and balance.
Relationship-based healthcare focuses on
What question would the nurse ask to determine the patient’s ADL?
Do you need assistance getting bathed?
According to Leavell & Clark levels of prevention a patient receiving a vaccine is utilizing
The nurse is caring for a patient with a infectious drainage from an abdominal wound. The nurse would wear gloves and
What website would you access to determine the status of an ecoli outbreak in Mexico?
Skin Physical Exam
Inspect and Palpate
press down on area and measure:
+1 : 2 mm
+2 : 4 mm
+3 : 6 mm
+4 : 8 mm
•Shape and contour: profile
•Loss of elastin, collagen, subcutaneous fat
•Reduction of muscle tone
•Wrinkling occurs because the underlying dermis thins