I assessed ears w/ the otoscope, now what?

[safarirn]

So I see bubbles behind the tympanic membrane... that means there is fluid in the middle ear. But that doesn't necessarily mean an ear infection...

Or I see redness in the ear canal, close to the tympanic membrane...

My questions..

1. How do you document the above 2 situations? (we never learned this in nursing school)

"Fluid noted to middle ear"?

"Redness noted in ear canal"?

(neither sound right)

2. Do you automatically send home for either (or both) of the above situations? Or do you just call parents to keep an eye on it?

HELP! This otoscope/ ear assessment/ documentation is all new to me.

Thank you for your help!

[BunnyBunnyBSNRN, ASN, BSN]

I usually document along the lines of "no s/sx of infection to ears" or "Right TM bright red and bulging" or "Bilat canals red without other signs of infection". If the stu is in severe pain, I call the parent and instruct to p/u and seek medical attention. If the stu reports mild to mod pain, I'll call the parent and advise of assessment findings and instruct them to contact the child's doc to see if they want to see the kiddo and follow the doc's instructions.