Common Presentation Assignment 1

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Word Count: 1635

I certify that all material in this essay/assignment which is

not my own is duly acknowledged. I have read and

understand the section in the Faculty handbook dealing

with plagiarism

P.M.L. Sherman

Common

PresentationsAssignment

Word Count:

NURS 090156

B000232267

Patricia Sherman


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Description

For this assignment I have used Gibbs reflective model: a simplistic and easy to use structured guide

which aids towards personally developing oneself (Jones 2007). Furthermore, RCN (2006)

acknowledges reflection as an act of promoting and improving quality of care and professional

autonomous growth through theory and practice.

I have chosen to reflect on a consultation that I undertook with a nineteen year old male who is an

Infantry soldier and like many of his age enjoys listening to music via his earphones.

The consultation commenced with the patient reporting that he had a sensation of something in his

right ear, stating that he was not suffering any discomfort however noises appeared dull. Gradual

hearing loss and a sense of fullness are clinical features normally found with wax build-up or foreign

bodies (Rutter 2005). The patient had discussed his symptoms with his colleagues who suggested he

had wax and it should be syringed. The patient was advised that this would only be done if clinically

indicated; I then proceeded with taking a history in particular asking about any noisy events that

could be related to this problem. The patient mentioned that this problem had been causing him

concern for several weeks. OConnor and Talley (2010) point out that obtaining an accurate history is

the first step to leading to a correct diagnosis. As it is an annual requirement to have hearing tests in

the Army I was able to review his previous hearing test which I found to be within normal range.

The initial inspection of his external ears revealed no irregularities. I then used an Otoscope to

examine his left ear first for comparison purposes; which showed no abnormalities. BSA (2010)

agrees that it is importance to examine the unaffected ear first to be able to compare or reduce

cross infection. I then explained I would continue with his affected ear. When I looked into the aural

canal I noticed immediately a circular shape and an outer circle. I found it difficult to visualise

anything beyond the circular shape so presumed that I was looking at the tympanic membrane. I

explained what I had seen and felt it was possibly a perforation of the tympanic membrane though


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he lacked pain. NHS Choices (2011) advise that earache and dullness of the hearing can be

symptoms of a perforation of the tympanic membrane and continues that tinnitus or a buzzing

sound can also be a common symptoms.

It was evident that a referral to the General Practitioner (GP) was required. The GPs examination

revealed very little, but concurred it was possibly a perforation and the patient should be sent to the

local hospital and be seen by the Ear, Nose and Throat (ENT) consultant. A fellow colleague asked if

the patient would be happy to consent to her inspecting the ear so to gain experience with varying

ear conditions and remarked that she observed the same.

The patient returned the next day and it revealed that the consultant had not seen any abnormality.

Whilst reflecting this astounding outcome, another GP suggested she would review the patient to

see if she could find the abnormality. The patient was happy to consent to this and the GP inspected

at the ear canal and also failed to see anything. My colleague then realised the GPs technique was

to place the earpiece further into the ear and once it was pointed out that she needed to retract the

otscope she was able to visualise the problem. The GP immediately recognised there was a foreign

body in the canal and with forceps was able to remove it with ease. The object appeared to be the

rubber ear-bud from his earphone.

Feelings

I am normally very confident at ear examinations as I have inspected many ears and felt I have a lot

of experience with this task, but was completely at a loss seeing such a perfect circle centrally in the

aural canal. Thus when the GP had failed to see the object I had observed, I then believed I had got it

completely wrong and questioned what I had actually seen.

I felt very discouraged at the possibility of an incorrect diagnosis, and though my colleague had seen

the same thing it at least helped me think I was not hallucinating. I continued to question what I had


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seen as it all felt quite unbelievable. Shearer and Adams (2012) offers that confidence is a major

factor with gained knowledge.

Once the answer was finally found to be a simple foreign body, I felt very satisfied that I had seen

something that both a GP and consultant had failed to see, though this caused me concern at a

foreign body not being visualised and investigated.

Analysis

I have gained a lot of experience with ear examinations as they are a frequent concern with patients

especially with any form of hearing loss. Munson (2007) supports this by identifying that young

soldiers can be quite frightened by a sensation of deafness as this can affect their combat capability

and ultimately career. While Kraszewski (2011) concurs that ear problems are one of the most

common within primary care and practice nurses will see a broad spectrum of conditions, thus

gaining experience within this field.

I feel my confidence stems from training, updates and I feel more importantly regular experience of

actual visualisation of normal and abnormal anatomy. Additionally taking an accurate history of the

presenting complaint directs the consultation to a satisfactory outcome. Kraszewski (2011) clarifies

that a competent knowledge of the anatomy of the ear is required for effective and safe ear care

and having the ability to recognise normal and abnormal findings. The management and safety of

ear care can only be understood through theoretical and practical training and continued practice,

with clinical excellence in ear care being maintained through updating knowledge regularly (Rodgers

2009). Even though I have spent many years looking at ears I have never thought about that the

varying depths ear pieces are put into the ear. I know I have concerns about causing pain which is

probably why I tend to be tentative when insert the otoscope. I often wonder what the outcome

would have been if my colleague had not noticed the depth difference of the earpiece being

inserted.


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I think the reason why I went through so many emotions was the accuracy of the circle seen and

having never seeing anything so perfectly exact in shape. Many things ran through my mind as to a

possible diagnosis. Harkin and Vaz (2001) advocates the importance of having the ability to

recognise a normal tympanic membrane and that it s a requirement to practicing safely and

competently.

I recognise the GP had trusted my clinical judgement, but wonder if the GP had asked how I had

managed to see the object then this issue would not have involved the patient being dispatched to

see an ENT consultant. On contemplation I realise that as the GP normally works under a time

constraint taking time to investigate the problem is not reality and the second GP had added

information to proceed with the investigation. Alternatively if ear care is now predominantly nurse-

led, then will GPs find this skill fading? (Fox 2004)

When the patient arrived for the consultation he felt he had obtained a diagnosis by his colleagues

and I only had to irrigate to alleviate the problem. Many patients appear to be part of a culture that

assume that nurses are able give instant results and deal with the problems without actually doing

anything clinically(Bates 2006). This can be frustrating as the patient is not always aware of the

contra-indication of invasive procedures.

Bowes et al (2011) conducted a study where patients used the internet as a source of information; it

was found they did this to gain better understanding of what may be wrong with them. The study

results showed that patients considered this method important as they felt it helped with

consultation time constraints, furthermore patients felt that the healthcare professional should at

least acknowledge their opinion and discuss their findings.

Within the military environment consultation time constraints tend not to be an issue with a smaller

population; hence patients rarely waiting long for appointments. I do realise the significance of

educating patients on the importance of all procedures that carry potential risks, but realise that


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REFERENCES

Bates, J. (2006). Instant Results. Nursing Standard . Vol 20(23). pp 33.

Bowes P. Stevenson F. Ahluwalia S. Murray E. (2012) 'I need her to be a doctor': patients'

experiences of presenting health information from the internet in GP consultations. [Online]

Available: http://web.ebscohost.com/ehost/detail?vid=13&sid=920c2c00-2872-4e94-8006-

a483efef2d11%40sessionmgr114&hid=121&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&A

N=2011789047[Accessed : 4 March 2013].

British Society of Audiometry(BSA) (2010) Recommended procedure: Ear examination [Online].

Available: http://www.thebsa.org.uk/docs/RecPro/RecProc_EarExam_25Jan2010.pdf [Accessed: 12

March 2013]

Fox, A. (2004.) A new approach to ear care :In, Martin, J. Lucas, .J. (3rd Ed) Handbook of Practice

Nursing .China: Elsevier Churchill Livingston. pp 327342

Harkin, H. Vaz, F. (2001.) Provision of ear care in the primary care setting. Primary Health Care. Vol

10(10.) pp 30-33

Kraszewski,s. (2011). Ear care. Practice Nurse. Vol 41(19) pp 14-20.

Mills, L. (2005). Recognising hearing loss in primary care [Online]. Available:

http://www.independentnurse.co.uk/cgi-bin/go.pl/library/articlehtml.cgi?uid=73876;type=Clinical

[Accessed: 12 March 2013]

Munson, E. (2007).Primary healthcare on the front line. Primary Health Care. Vol 17(4). pp 14-16

NHS Choices(2011) Perforated eardrum [Online]. Available:

http://www.nhs.uk/conditions/Perforated-eardrum/Pages/Introduction.aspx [Accessed: 12 March

2013]


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OConnor, S. Talley, N.(2010)The general principles of history taking: in Clinical Examination. A

Systematic Guide to Physical Diagnosis (6th

ed). Elsevier Churchill Livingston:Austrailia. Pp 16.

Royal College Of Nursing(RCN). (2006) Example of a reflective practice tool [Online] Available:

www.rcn.org.uk/__data/assets/.../Tool4.6-Example_Reflec_Prac.pdf [Accessed: 4 March 2013]

Rodgers, R. (2009). Ear Care. Practice Nursing. Vol 20(2). pp 93-96.

Rutter P (2005) otic conditions : in Symptoms, Diagnosis and Treatment: a guide for pharmacists and

nurses (1st

ed) Elsevier Churchill Livingston: china. pp 42-50.

Shearer, D. Adams, J. (2012). Evaluating an advanced nursing practice course: student perceptions.

Nursing Standard, Vol 26(21), pp35-41.

Common Presentation Assignment 1

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