Common Presentations Assignment Word Count:

NURS 090156
B000232267 Patricia Sherman

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

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 1

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

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. 3

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 nurseled, 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 4

they may not have discovered the full information, thus patronising or being dismissive of patients can lead to a poor professional relationship (Bowes et al 2011). On reflection I will now ensure I actively include patients listening to their thoughts within the consultation. I was surprised by the lack of articles relating to this problem though there is several relating to foreign bodies in general and with the culture of wearing earphones I wonder if there are possibly patients with these ear buds still in situ. As we like to reminisce with stories of our experiences I hope this will convey and remind that we all see things rare and commonplace and to share best practice.

Action plan I remain confident in my ability to continue performing ear examinations as well as obtaining accurate histories thus achieving a safe and satisfactory consultation, but remaining aware of my limitations and knowledge of when to refer. Mills (2005) points out the significance of a thorough medical, family and social history, including present and past occupation, any medication, and general health problems and finally the importance of recording if the hearing loss is gradual or sudden. As I reflected on my essay I realised that my attitude towards patients who comment on speaking to someone or having used the internet has been changed by my findings and hopefully I can now appreciate that they are not being presumptuous but possibly trying to help.

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=920c2c00-2872-4e94-8006a483efef2d11%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] 6

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.