Pearson's Comprehensive Medical...

Pearson's ComprehensiveMedical Assisting

Administrative and Clinical Competencies

CHAPTER

THIRD EDITION

Pearson's Comprehensive Medical Assisting:Administrative and Clinical Competencies, 3/eBeaman | Routh | Papazian-Boyce | Sesser | Mills | Maly

Copyright © 2015, 2011 by Pearson Education, Inc.All Rights Reserved

Assisting with Eye and Ear CareLesson 1:The Study of the Eye

39



Lesson Objectives

Upon completion of this lesson, students should be able to:

1. Define the terms to learn for this chapter.

2. Name and explain two types of hearing impairment.

3. Explain procedures to irrigate the ear and instill ear medications.

4. Explain the procedure to evaluate hearing acuity using an audiometer.



Study and Care of the Ear

• Otology is the study of hearing.

• Otologists, otorhinolaryngologists, or ENT doctors specialize in treating the ear.

• Every physical exam includes an examination of the nose and throat as well as the ears.




• Infections that affect the throat or nose may also affect the ear.

• The ear is the organ of hearing and balance.

• Most parts of the ear are internal and are protected by the temporal bone of the skull.




• Ear Examinations

Instruments used in the office for ear examinations:

• Otoscope (a lighted instrument with a small, disposable speculum inserted into the ear canal to examine the tympanic membrane)

• Tuning fork

• Audiometer



FIGURE 39-6 Examination of the ear using an otoscope.Wavebreakmedia/Shutterstock




• Ear Examinations

A healthy eardrum should be pearly gray and concave.

An infected eardrum appears reddened, swollen, and bulging.




• Irrigation of the Ear

Necessary to remove impacted cerumen (earwax) or a foreign matter from the ear

Patients may be apprehensive about the discomfort of the procedure and it is the responsibility of the MA to put them at ease as much as possible.



Irrigation of the Ear

1. Check the physician’s orders.

2. Perform hand hygiene.

3. Assemble the equipment.

4. Check the name, concentration, and expiration date of the irrigating solution three times.

5. Identify the patient, and explain the procedure.

6. Apply gloves.




7. Have the patient sit with the affected ear tilted slightly downward.

8. Place a towel over the patient’s shoulder, and ask the patient to hold the emesis basin.

9. Clean the external ear with a moistened cotton ball.




10.Pour the warmed solution into a sterile basin and fill the syringe with 50 cc of solution.

11.For adults, pull the earlobe up and back to straighten the ear canal; for children under 3 years pull the earlobe down and back to straighten the ear canal.




12.Expel air from the syringe and insert the tip into the ear canal; aim the stream of flow toward the roof of the canal.

13.Repeat until the return from the ear is clear.

14.Remove the basin, dry the outer ear, and remove the towel.



PROCEDURE 39-6 Irrigation of the EarFIGURE A Irrigating the ear to remove a foreign body.




15.Give the patient cotton balls to wipe any external drainage.

16. Instruct the patient about home care if needed. Ask the patient if he or she has any questions.

17.Dispose of any waste material properly.

18.Perform hand hygiene.

19.Document the procedure, noting the type of drainage and any patient symptoms such as pain or dizziness.




• Instillation of Ear Medications

Commonly performed by medical assistants

MAs may be required to instruct a patient how to administer eardrops.

Instruct the patient to use the same steps that you would use performing instillation of medications in the office.




• Instillation of Ear Medications

Provide the patient with a printed list of instructions and review the guidelines with them in the office.

Have patient demonstrate steps prior to leaving



Instilling Ear Medication

1. Check physician’s orders.



4. Identify patient.

5. Check the medication label three times for the correct name, expiration date, and concentration.

6. If the medication is cold, warm it by rolling between the palms.




7. Have the patient tilt the head away from the affected ear or lie down with the affected ear facing up.

8. Pull the earlobe up and back for an adult, down and back for a child.

9. Place the dropper in the ear canal without touching the sides of the canal.




10.Instill the appropriate number of eardrops along the side of the canal.



PROCEDURE 39-7 Instilling Ear MedicationFIGURE A Straightening the ear canal of an adult by pulling the ear up and back.



PROCEDURE 39-7 (continued) Instilling Ear MedicationFIGURE B Straightening the ear canal of an infant by pulling the ear down and back.



PROCEDURE 39-7 (continued) Instilling Ear MedicationFIGURE C Instilling eardrops.




11. Instruct the patient to remain in the same position for 3 to 5 minutes.

12.Give instructions for home care if needed. Ask the patient if he or she has any questions.

13.Dispose of the equipment and clean the area.

14.Perform hand hygiene.




15.Document the procedure appropriately.




• Hearing Acuity

Hearing is essential in the process of learning to talk because speech is based on imitation of sounds and mimicking the way words are used to communicate.

There are many degrees of hearing loss.




• Hearing Acuity

Various forms of hearing impairments fall into one of two main categories

• Sensorineural hearing loss

• Conduction hearing loss





Nerve damage due to damage of the organ of Corti, or to the auditory nerve

Organ of Corti, located in the cochlea (a part of the inner ear), contains hairlike fibers that convert the waves of sound that travel through the ear

Sound waves are then sent to the brain via the auditory nerve





When the sound waves reach the inner ear but are unable to be converted into electrical impulses which are sent to the brain, damage is present.

Nerve deafness can be hereditary, or may be due to loud noises or viral infections.




• Conduction hearing loss

Due to obstruction of sound waves

Foreign material or excess cerumen in the external ear canal, calcification of the bones in the middle ear, infection or fluid buildup in the middle ear, or a combination of these problems may cause conduction hearing loss




• Hearing Acuity

A number of tests used to evaluate hearing acuity

The following abbreviations are used when charting results involving ears:

• AD (aurus dextra) for right ear

• AS (aurus sinistra) for left ear

• AU (aurus uterque) for both ears




• Hearing Acuity

It is recommended that the words for the designated ears be used rather than the abbreviations to avoid errors.




• Hearing Assessment

Tuning fork

• A metal, forked-shaped instrument that produces vibrations when struck

• Held near the patient’s ear or placed on various locations on the head to give a rough hearing assessment



FIGURE 39-8 Testing hearing acuity using a tuning fork.CSMP/Custom Medical Stock Photo





Audiometer

• An electronic instrument that measures more precisely the frequencies or the number of fluctuations per second of energy in the form of sound waves

• Intensity of the sound, or decibel, patients hear is evaluated





Audiometer

• When the patient indicates his or her ability to hear a sound, a recording is made.

• The audiogram is used by the physician to evaluate the patient’s hearing.





Audiometer

• A person with normal hearing should hear all frequencies up to 15 decibels under normal conditions.

• Prolonged exposure to loud noise over 85 decibels can cause temporary or permanent hearing loss.



FIGURE 39-9 Audiometer.



FIGURE 39-10 This illustration shows the decibel level in various locations and associated with different conditions.





Audiometer

• There are many varieties of audiometers in use today.

• Follow the instructions provided by the manufacturer.

• Sales reps often give in-service demonstrations to staff when an instrument is purchased.





Audiometer

• A procedure document should be drawn up based on manufacturer’s instructions and included in the procedures manual.

• MA may be asked to perform audiometer test





Audiometer

• Physician will interpret results

• MA is not permitted to inform patient of results unless instructed by physician to do so



Assisting with Audiometry

1. Check the physician’s orders.


3. Prepare the equipment.

4. Test the equipment and make sure the power is on.

5. Identify the patient, and explain the procedure.




6. Establish signal response that patient will give if no automatic button is available; nodding head or holding up a finger are acceptable signals.

7. Have the patient assume a comfortable position.

8. Place headphones over the patient’s ears.



PROCEDURE 39-8 Assisting with AudiometryFIGURE A Performing a hearing test on a child.Brian Eichhorn/Shutterstock




9. Begin with low frequency and watch the patient for indication that the sound is heard; push the button to record if the machine does not do it automatically.

10.Gradually increase the frequency until the test is completed in the first ear.

11.Proceed to the other ear and repeat the entire procedure.

12.Remove the headphones.




• Additional Diagnostic Tests Related to the Ear

Tympanometry

• A diagnostic test known used to measure the ability of the myringa to move, thereby estimating the pressure in the middle ear





Tympanometry

• If the middle ear is filled with fluid, the tympanic membrane will be more rigid.

• A printout of the results is produced for the physician to evaluate.





Electronystagmography (ENG)

• A special examination that evaluates balance through measurement of the movement of the eyes

• Used to evaluate patients with vertigo and other disorders that affect hearing and vision





Electronystagmography (ENG)

• Electrodes are placed above and below the eye to record electrical activity.

• An ENG can detect nystagmus (involuntary rapid eye movement) in response to stimuli.




• Electronystagmography (ENG)

Water caloric test

• Warm or cool water is placed into the ear canal so that it touches the tympanic membrane

• Air can also be used instead of water for patients who have a damaged eardrum




• Electronystagmography (ENG)

Water caloric test

• Normal response to the stimuli means no nystagmus

• If nystagmus occurs on stimulation, a problem may exist within the ear, nerves associated with the ear, or certain parts of the brain.




• Procedures and Diagnostic Tests

Audiogram

• Chart that shows the faintest sounds a patient can hear during audiometry testing





Audiometric test

• Test of hearing ability by determining the lowest and highest intensity and frequencies that a person can distinguish

• The patient may sit in a soundproof booth and receive sounds through earphones as the technician changes the volume and tones.





Electrocochleography

• Recording of the electrical activity produced when the cochlea is stimulated





Electronystagmography

• Recording of eye movement in response to specific stimuli, such as sound, water, or air

• Used to determine the presence and location of a lesion in the vestibule of the ear, to help diagnose unilateral hearing loss of unknown origin, and to help identify the cause of vertigo, tinnitus, and dizziness





Falling test

• Test used to observe balance and equilibrium

• Patient is observed standing on one foot, then with one foot in front of the other, and then walking forward with eyes open.





Falling test

• The same test is conducted with the patient’s eyes closed. Swaying and falling with the eyes closed can indicate an ear and equilibrium malfunction.





Mastoid antrotomy

• Surgical opening made in the cavity within the mastoid process to alleviate pressure from infection and allow for drainage

Mastoid X-ray

• X-ray taken of the mastoid bone to determine infection, which can be an extension of a middle ear infection





Myringoplasty

• Surgical reconstruction of the eardrum





Myringotomy

• Surgical puncture of the eardrum with removal of fluid and pus from the middle ear

• Used to eliminate a persistent ear infection and excessive pressure on the tympanic membrane





Myringotomy

• A tube is placed in the tympanic membrane to allow drainage of the middle ear cavity.





Otoplasty: corrective surgery to change the size of the external ear or pinna; the surgery can either enlarge or decrease the size of the pinna.

Otoscopy: the use of a lighted instrument to examine the external auditory canal and the middle ear





Rinne and Weber Tuning Fork Tests

• Physician holds a tuning fork

• Physician assess both nerve and bone conduction of sound





Rinne and Weber Tuning Fork Tests

• Rhine test

• Examiner places the base of the vibrating fork against the patient’s mastoid bone and in front of the auditory meatus (air conduction)

• Weber test

• Tuning fork placed on the center of the forehead





Stapedectomy

• Removal of the stapes bone to treat otosclerosis (hardening of the bone); a prosthesis or artificial stapes is implanted.

Tympanometry

• Measurement of the movement of the tympanic membrane that can indicate pressure in the middle ear





Tympanoplasty

• Another term for the surgical reconstruction of the eardrum; also called myringoplasty




• Assisting the Hearing-Impaired Patient

Provide a comfortable office setting for the hearing-impaired patient.

Accommodations (e.g., having available telephones with hearing amplifiers), demonstrate patient-centered care.

Do not lose patience with the patient who is having difficulty hearing your instructions.





Face the patient when speaking to him or her and speak clearly without raising your voice.





Presbycusis is a decline in hearing acuity and a normal part of aging.

Elderly patients may be reluctant to admit that they are having hearing problems; the family will frequently volunteer the information.





Signs that hearing loss has occurred include speaking louder, turning up the volume on the radio or television, and not hearing what is said from another room.





Other signs of aging include:

• Narrowing of the ear canal

• Dryness of ear wax

• Lessened flexibility of the eardrum

• Sclerosis of the ear bones



Critical Thinking Question

1. How can you help minimize the fear a patient may be having due to loss of hearing?




• Ear Safety Guidelines

Remind patients to never put anything in the ear canal.

Earwax is a protective substance produced by the body to prevent foreign objects and substances from getting to the eardrum; attempting to remove earwax is dangerous and could cause perforation of the tympanic membrane.





There is a connection between repetitive exposure to loud noise and deafness.

Young people who listen to loud music on earphones or at concerts are particularly susceptible to this danger.

Workers who engage in duties that require exposure to loud noise should wear protective ear gear.





Patients who are unable to wear hearing aids may need other devices to increase their awareness of their surroundings at home.

• Doorbells that light up when rung

• Telephone amplifiers

• Closed-caption television



Examination of the Nose and Throat

• Physician will use a nasal speculum to inspect the mucous lining of the nose for signs of irritation and infection

• Tongue depressor used to examine the throat for signs of infection, enlarged tonsils, and abnormalities of the tongue or oral cavity

• Throat culture may be ordered if signs of infection are present




• Appropriate antibiotic ordered for the patient if necessary

• Most common cause of throat infection is the Streptococcus bacteria, Group A

When untreated, this organism can cause secondary infections and possibly serious damage to the kidney, heart, and other organs.




• Signs and symptoms of nasal problems

Nosebleeds or epistaxis

Reduced sense of smell

Congestion

Allergic rhinitis (inflammation of the lining of the nose)



Instilling Nasal Medications

1. Check physician’s orders.



4. Identify the patient and explain the procedure.




5. Position the patient with head lower than the shoulders to instill medication into the ethmoid and sphenoid sinuses. To instill medication into the maxillary and frontal sinuses, have the patient assume the same back-lying position with the head turned toward the side to be treated. Place patient in a supine position with a pillow under the neck to lower the head below the shoulders. Make the patient as comfortable as possible.



PROCEDURE 39-9 Instilling Nasal MedicationsFIGURE A Instilling nose drops into the ethmoid and sphenoid sinuses.



PROCEDURE 39-9 Instilling Nasal MedicationsFIGURE B Instilling nosedrops into the maxillary and frontal sinuses.




6. Check the medication three times for correct name, dosage, and expiration date. Draw the medication into a dropper and hold it over the center of the affected nostril, taking care not to touch the dropper to the inside of the nostril.

7. Administer the medication. Repeat in the other nostril if ordered.




8. Tell the patient to stay in that position for 5 minutes to prevent medication from running out of the nostril.

9. Provide tissues for the patient to wipe excess from the skin.

10.Discard the dropper in the biohazard waste container, recap the medication, and return it to the storage place.

11.Clean the area and remove gloves.




1. Provide home instruction if needed. Verify patient understanding.


3. Document the procedure in the patient’s record.



Questions?

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