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Chapter 52: Nursing Care of Patients With Sensory Disorders: Vision and HearingPART 2: HEARING DISORDERSHearing Disorders:Hearing Loss:Most common disability in US.Acquired or congenitalRanges from difficulty understanding words or hearing certain sounds to total deafness.Can affect communication, social activities, work activities and diminish quality of life.Conductive Hearing Loss: Mechanical problem.Interference with conduction of sound impulses to inner ear through external auditory canal, eardrum or middle ear.Causes:CerumenForeign bodiesInfectionPerforation of tympanic membraneTraumaFluid in middle earCystTumorsOtosclerosisMost can be corrected. Hearing aid suggested for those that cannot be fixed. (Scarred tympanic membrane or otosclerosis).Sensorineural Hearing Loss: Sensorineural hearing loss: Originates cochlea and involves hair cells and nerve endings.Results from disease or trauma to sensory or neural components of inner ear. Causes: complications of infections (measles, mumps, meningitis) Ototoxic drugs, trauma, noise, neuromas, arteriosclerosis, and aging process.Neural hearing loss: Originates in nerve brainstem.Presbycusis: Caused by aging process. From degeneration of organ of Corti.Begins at 5th decade of life.Inability to decipher high-frequency sounds (s, z, t, f, and g)Interferes with ability to understand what’s being said.Difficulty understanding higher-pitched female than lower-pitched males.Other Types of Hearing Loss:Mixed hearing loss: has both conductive and sensorineural hearing loss. (Combo)Central hearing loss: CNS cannot interpret normal auditory signals. (CVA and tumors)Functional hearing loss: “Psychogenic hearing loss” no organic cause or lesion found. (Triggered by emotional stress)Therapeutic Measures:Goal to improve hearing.Hearing aid should be considered.Surgical intervention Implantable middle hearing aidsCochlear implantsNursing Process for the Patient with Hearing Impairment:At risk:Those taking ototoxic drugs:Aminoglycoside antibiotics (Garamycin)Other antibiotics (E-Mycin & Vanomycin)Diuretics (Bumex & Lasix)Other drugs (Bayer & Ecotrin)Renal or hepatic diseaseTwo or more ototoxic drugsPreviously used ototoxic drugsDeveloping hearing impairmentAssess tinnitusSensorineural hearing lossVestibular dysfunctionMonitor for signs of vertigo, horizontal nystagmus, nausea, vomiting and spinning or rocking sensation while sitting still.Objective Data: Normal conversation with patient.Difficulty understanding conversationClarity of speech.Physical exam (whisper test, Rinne and Weber tests)Underlying causing of problem.Exam of external ear.Assistive hearing devices noted.Subjective Data:WHAT’S UPBox 52.2:Communicating With a Patient Who Has a Hearing Impairment:Do not avoid conversation.Obtain to pts attention before speaking.Ensure hearing device is operational.Ensure optimal environment.Face and stand close to person and maintain eye contact.Do not smile, chew gum or cover mouth while talking.Avoid standing in glare of bright sunlight.Speak clearly and at a normal rate and volume.Do not shout.Difficulty with high-pitch sounds, lower your voice.Encourage non-verbal rm the listener of topics to be discussed and when a change of topic occurs.Use short sentences and check for understanding.Allow extra time for listener to respond.Use written communication.Use active listening with attentive body posture.Box 52.3:Care of Hearing Aids:Apply hair or medicinal sprays before inserting hearing aid.Insert hearing aid over a soft surface to prevent damage.Turn hearing aid on and increase volume once its inserted.Check battery or lower volume if sound is not clear or is intermittent.Minimize whistling noise by ensuring that the volume is not too high.Remove before showering or bathing.Clean daily with dry, soft cloth.Turn volume down and then off when not in use.External Ear:Infections:Patho and Etiology:Infection is most common disorder external ear. External Otitis: infection that most commonly occurs.Exposure to moisture, contamination or local trauma.May be caused by bacterial or fungal pathogens.Staph is most frequent causative organism.Pneumocystis: seen in pts with HIV.Bacterial or fungal external otitis: water left in ear.Most common in summer months.Localized infection: Called ear canal furuncle (abscess) when hair follicle becomes infected.Carbuncle when several hair follicles are involved in forming abscess.Most of them erupt and drain on their own. Otomycosis:Infection by fungal growth.Seen after antibiotic use or topical corticosteroid.More often in hot weather.Infection of auricle: PerichondritisCan result in necrosis of ear cartilage.Signs and symptoms:Most common sign is pain.Pain when moving jaw.Pain when otoscope inserted.ItchingInflammation of external ear.Ear canal swollen or occluded.Hearing diminished.Redness, swelling and drainage.Diagnostic Tests:CBC with elevated WBC.Cultures of discharge.Culture and sensitivity tests.Rinne and Weber tests.Impacted Cerumen:Cerumen (wax) may be impacted, blocking ear canal.Factors: Large amounts of hair in ear canal, exposure to dusty or dirty areas, improper cleaning, aging, use of hearing aids, bony growth secondary to osteophyte or osteoma.Signs and Symptoms:Hearing loss, feeling of fullness, blocked ear if cerumen is impacted.Diagnostic Tests:Otoscopic examAudiometric testingWhisper voice testRinne testWeber testMasses:Patho and Etiology:Benign masses or external ear: usually cysts from sebaceous glands.Others are lipomas, warts, keloids, and infectious polyps.Actinic keratosis: precancerous lesion found in auricle.Malignant tumors: Basal cell carcinoma on pinna and squamous cell in ear canal.Signs and Symptoms:Changes in appearance of skin can occur with benign or malignant masses.Impaired conductive or sensorineural hearing loss occurs with masses.PainEar drainageFacial paralysisDiagnostic Tests:BiopsyImaging studiesAudiometric studiesTrauma:Patho and Etiology:Injuries to external ear causes:Blow to headAutomobileAccidentsBurnsForeign bodiesCold tempsMost common foreign bodies:InsectsCotton ball piecesSigns and Symptoms:LacerationsContusionsHematomasAbrasionsErythemaBlisteringRepeated trauma: cauliflower ear BoxersRugby playersMartial artistsWrestlers Conductive hearing loss: Partially or totally blockedPts with contusions or hematomas:NumbnessPainParesthesia of auricleForeign bodies:Decreased hearingItchingPainInfectionDiagnostic Tests:Imaging studiesAudiometric, whisper, voice Rinne and Weber plications of External Ear Disorders:Infections can spread causing cellulitis, abscesses, middle ear infection and septicemia.MetastasisTemporary or permanent hearing lossDisfigurementDiscolorationScarringTherapeutic Measures for External Ear Disorders:Systemic antibioticsTopical antibioticsAnalgesicsTopical or systemic steroidsThoroughly cleaned beforeWick may be inserted.Cerumen removed with irrigation.DebridementSurgical repairApplication of a protective coveringSurgical managementExcision of cystsNursing Process for the Patient with External Ear Disorders:Data Collection:Subjective Data:Pain FullnessPrevious cerumenImpactionItchingHearing lossOnsetDurationSeverity of symptomsPts occupationPrevious ear problemsUse of hearing aidTypical ear hygieneObjective Data:RednessSwellingDrainageFurunclesCarbunclesLesionsAbrasionsLacerationsGrowthsCerumenScalinessCrustingPain when ear is palpated.Nursing Diagnoses, Planning, and Implementation:Monitor pain using pain scale.Implement non-pharmacological methods.Apply heat as ordered.Offer liquid or soft foods.Explain ear care.Cleanse external ear with wet washcloth.Never insert anything into ear canal.History of ear infections, perforations tympanic membranes or swimmers ear should prevent moisture from entering ear canal should avoid swimming in contaminated water.Frequent swimmers: wear earplugsDo not try home remedies.URI should gently blow nose with both nares open to prevent microbes from being forced into eustachian tube.Teach patient treatment regimen.Explain procedure before removal of cerumen.If wick inserted, monitor for drainage.Teach how to use antibiotics.Teach how to complete prescribed treatment.Evaluation:Pain relieved.Hearing improves or is restored to pre-illness level.States or demonstrates prescribed treatment.Explains or demonstrates measures to maintain wellness of external ear.Middle Ear, Tympanic Membrane, and Mastoid Disorders:Infections:Patho and Etiology:Otitis media:Most common disease of middle ear.Inflammation of nasopharynx cause most cases.Nasopharyngeal mucosa becomes edematous.DischargeEustachian tube becomes blocked.Impairs middle ear ventilation.Three types:Otitis media without effusion:Inflammation of middle ear mucosa without drainage.Acute otitis media: (suppurative otitis media or purulent otitis media)Bacterial infection of middle ear mucosa.Fluid becomes trapped in middle ear.Otitis media with effusion: (serous otitis media, nonsuppurative otitis media or glue ear)Non-infective fluid accumulates within middle ear.Signs and Symptoms:Acute otitis media usually follows URI.FeverEaracheFeeling of fullnessPurulent drainage formsNauseaVomitingMastoid tendernessReddened and bulging tympanic membrane.Otitis media with effusion:No signs of infectionFullnessBubblingCrackling in earsSlight conductive hearing loss AllergiesMouth breatherBulging tympanic membraneComplications:PerforationSpontaneous perforation of tympanic membrane.Tympanic membrane perforation causes hearing loss.Damage to ossiclesRepeated infections can cause cholesteatoma.Damage to middle ear as a result of pressure necrosis.Facial paralysisTympanosclerosis: deposits of collagen and calcium on tympanic membrane.MastoiditisChronic mastoiditisDiagnostic Tests:Elevated WBCCultures on ear drainageRinne, Weber and whisper voice tests.Imaging studiesTherapeutic Measures:Topical and systemic antibioticsOral analgesicsModified Politzer ear deviceSurgical intervention ParacentesisMyringotomyLaser-assisted myringotomyReconstructive repair of perforated tympanic membrane is called myringoplasty.Gelfoam over perforation.Mastoidectomy Otosclerosis: Hardening of ear.Patho and Etiology:Results from new bone along with stapesStapes becomes immobile.Causes conductive hearing loss.Hearing loss is most apparent after 4th decade.More common in women than men.Usually affects both ears.Exact cause unknown but thought to maybe be genetic.Signs and Symptoms:Progressive hearing loss.Bilateral conductive hearing loss, particularly with soft, low tones.TinnitusPinkish orange tympanic membrane.Diagnostic Tests:Audiometric testingWhisper voice test and normal conversation show decreased hearing.Rinne testWeber testTherapeutic Measures:No cureHearing aids may be used to improve hearing.Reconstruction of necrotic ossicles.OssiculoplastyProsthesisTotal or partial ossicular replacement prosthesis.Stapedectomy: treatment of choice for otosclerosis.Part or all of stapes is removed and replaced with prosthesis between incus and oval plications: extrusion of prosthesis, infection, hearing loss, dizziness, and facial nerve damage.Nursing Care:BedrestAmbulate to determine tolerance.Lie on side of unaffected ear or on back during first week.AntiemeticsPts safety ensured if dizziness occurs.Oral analgesics for pain.Sneeze with mouth open.Do not blow nose, sniff or fly in an airplane, scuba dive, exercise, lift heavy objects, or use ear plugs for several weeks as instructed.Showering and hair washing may be allowed 2 days after surgery with cotton ball and Vaseline in ear with surgery.If cold develops, contact HCP.Trauma:Etiology and Physiology:Examples of trauma: blasting force, blunt injury to side of head or sudden changes in atmospheric pressure.Blunt injury to head can cause temporal skull fractures and trauma to both middle and inner ear.Barotrauma can be caused by changes in atmospheric pressure.Pressure changes: nose blowing, heavy lifting, sneezing, eustachian tube does not ventilate because of occlusion or dysfunction.Tympanic membrane to rupture.Signs and Symptoms:Pain and hearing loss are the most common symptoms.Fullness of ears.VertigoNauseaDisorientationEdema of affected areaRetracted reddened and edematous tympanic membrane.Diagnostic Tests:Audiometric studiesImaging studiesNursing Process for Patient with Middle Ear, Tympanic Membrane, and Mastoid Disorders:Subjective Data:WHAT’S UP?Objective Data:Vital signsNoting elevation in tempNoting drainageHearing acuity is screened.Whisper voice test, Rinne and Weber tests.Nursing Diagnoses, Planning and Implementation:Instruct pt not to blow his or her nose by pinching off nares.Teach not to insert anything into ear canal.Teach how to correctly remove cerumen from ear.Monitor pain.Use nonpharmacological measures such as heat.Teach how to administer ear drops or ear ointment.Instruct to take all antibiotics even when well.Ask about knowledge regarding surgery.Include pts family in teaching sessions.Teach to avoid trauma to ear.Teach to yawn or perform jaw thrust maneuver.Teach methods of effective communication.Provide pre and postop instructions.Teach how to avoid getting water in ear postop.Evaluation:No pain is present.Pain is decreased.Verbalizes care of ears ad methods to prevent further infection.Box 52.5Preoperative Care:Ask about type of surgery and anesthesia.Encourage pt to ask questions.Explain types of pain control.Obtain & document baseline vital signs.Ensure informed operative consent is signed.Document current meds.Leave hearing devices in until surgery.Postoperative Care:Monitor vital signs.Explain occlusive dressing may decrease hearing until removed.Instruct with ear tubes to avoid getting water in ear.Seek medical care if excessive bleeding or drainage occurs.Sneeze with mouth open and avoid blowing nose.Explain activity restrictions.Explain use of pain meds and instruct to take antibiotics as ordered.Instruct pt to call HCP for follow-up appt.Inner Ear:Labyrinthitis:Inflammation or infection of inner ear.Caused by viral or bacterial pathogens.Serous labyrinthitis is type of acute labyrinthitis: sometimes follows drug intoxication or overindulgence in alcohol.Can be caused by allergy.Diffuse suppurative labyrinthitis: when acute or chronic otitis media spreads to inner ear or after middle ear or mastoid surgery.Signs and Symptoms:VertigoTinnitusSensorineural hearing loss.DizzinessNystagmusPain FeverAtaxiaNauseaVomitingBeginning nerve deafness.Diagnostic Tests:CBCHearing evaluationRinne and Weber testTherapeutic Measures:AntibioticMild sedationAntihistaminesBedrestNursing Care:Helping pt manage symptoms and self-care.Educate about safety issues while on bedrest and sedatives to prevent falls and injury.Avoid turning head quickly.Assist to cope with anxiety.Neoplastic Disorders:Benign or malignantAcoustic neuroma: tumor of 8th cranial nerve.Most common benign tumor.Malignant tumor from inner ear is rare.Squamous and basal carcinomas arise from epidermal lining of inner ear.Signs and Symptoms:Progressive unilateral sensorineural hearing loss of high-pitched sounds.Unilateral tinnitusIntermittent vertigoHeadachePainBalance disordersDiagnostic Tests:Neurologic testingAudiometric testingVestibular testingAuditory brainstem evoked response.ElectronystagmographyExam of cerebral spinal fluidCT scanMRITherapeutic Measures:Surgical removal of tumorSteroidsRadiationNursing Care:Preparing patient for surgeryHelping adjust to diagnosis.Meniere Disease: Balance disorderPatho and Etiology:Cause is unknown.Dilation of membranous labyrinth results from disturbance in fluid physiology of endolymphatic system.Thought to stem from hypersecretion, hypoabsorption, deficient membrane permeability, allergies, viral infection, hormonal imbalance, or mental stress.Between ages 40 and 60.Signs and Symptoms:VertigoHearing lossTinnitusNauseaVomitingHeadacheFullness in earsDizzinessUnsteadinessUncoordinated and gait changes when walkingIrritabilityDepressionWithdrawalDiagnostic Tests:Audiometric studiesNeurologic testingRadiographic studiesCaloric stimulation test checksTherapeutic Measures:Prophylactic treatment.Salt-restricted dietDiureticsAntihistaminesVasodilatorsAvoid alcohol, caffeine, and tobacco use.Meclizine for vertigo, tranqs and vagal blockers.BedrestGoals are to preserve hearing and reduce symptoms.MethotrexateSurgical treatmentLabyrinthectomyIntratympanic gentamicin injection.Nursing Care:Managing pts symptomsProviding safetyProvide emotional support.Nursing Process for the Patient with Inner Ear Disorders:Subjective Data:WHAT’S UP?Objective Data:Whisper voice testRinne and Weber testsPhysical examLab dataNutritional deficienciesDehydrationWeight lossWeight gainUnsteady gaitTempNursing Diagnoses, Planning, and Implementation:Encourage pt to express concerns.Monitor for signs of anxiety.Explore with pt techniques that have and have not worked in past.Use calm reassuring approach.Provide quiet environment.Provide info regarding diagnosis and treatment.Institute fall precautions.Ensure environment is safe and free of obstacles.Monitor for signs of headache or fullness.Instruct pt to avoid sudden movement of head.Instruct pt on correct dosage.Instruct pt to avoid use of alcohol, caffeine, and tobacco.Instruct pt to call for assistance.Remain on bedrest until symptoms are relieved.Monitor for signs of nausea, vomiting, inadequate hydration.Use deep breathing, voluntary swallowing and eating slow to suppress vomiting reflex.Medicate as ordered.Salt-restricted diet.Evaluation:Signs of anxiety decreased.Remains free of injury and maintains weight.No signs of dehydration. ................
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