Nursing Assessment: Sensorineural Function (Ear) Student Outline PDF

**Chapter 47** **Nursing Assessment: Sensorineural Function (Ear)---Student outline** **Anatomy (EAR)** - **External ear** - includes the auricle (pinna) and the external auditory canal - **Middle ear** - an air-filled cavity, includes the tympanic membrane laterally and the otic cap...

**Chapter 47** **Nursing Assessment: Sensorineural Function (Ear)---Student outline** **Anatomy (EAR)** - **External ear** - includes the auricle (pinna) and the external auditory canal - **Middle ear** - an air-filled cavity, includes the tympanic membrane laterally and the otic capsule medially. - **Inner ear** - is housed deep within the temporal bone. - **Hearing** - Hearing is conducted over two pathways: air and bone - **Balance and Equilibrium** - Body balance is maintained by the cooperation of the muscles and joints of the body (proprioceptive system), the eyes (visual system), and the labyrinth (vestibular system). - **Gerontological considerations** - Atrophy of the external ears - Thinning and drying of ear canal - Hardening of cerumen - Earwax accumulates - Thickening of the eardrum - Impaired transmission of sound - Change in vestibulospinal reflex - Progressive imbalance and increased falls - Degeneration of organ of Corti (presbycusis) - Loss of ability to discriminate words or comprehend conversations. **Hearing Loss** - Conductive - Weber test - Sound heard best in affected ear (hearing loss) - Rinne test - Sound heard as long or longer in affected ear (Hearing Loss) - Sensorineural - Weber Test - Sound heard best in normal hearing ear. - Rinne Test - Air conduction is audible longer than bone conduction in affected ear. - Mixed conductive-sensorineural **Assessment-History** - Patient health history - Common complaints- changes in hearing acuity, earache, drainage, and tinnitus. - Past medical history- Infections, medication. - Family history - Social history- A patient with decreased hearing may withdraw from situations in which communication skills are needed. They may become depressed and unable to continue in their chosen profession. **Assessment-Physical** - Includes inspection and palpation of external ear - Inspection of internal ear with otoscope or special device - Hearing evaluation - Whisper Test- To exclude one ear from the testing, the examiner covers the untested ear with the palm of the hand. Then the examiner whispers softly from a distance of 1 or 2 ft from the unoccluded ear and out of the patient's sight. The patient with normal hearing acuity can correctly repeat what was whispered. - Weber Test- The Weber test uses bone conduction to test lateralization of sound. A tuning fork, set in motion, is placed on the patient's head or forehead. The exam is considered normal if the person hears the sound equally in both ears or describes the sound as centered in the middle of the head. The Weber test is useful for detecting unilateral hearing loss - Rinne Test- In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions: against the mastoid bone (for bone conduction) and, when the sound is no longer audible, 2 in from the opening of the ear canal (for air conduction). As the position changes, the patient is asked to indicate which tone is louder or when the tone is no longer audible. The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss **Diagnostic Evaluation** - Audiometry- - Loss in 0-15 Decibels is normal hearing loss - Loss in 15-25 Decibels is slight hearing loss - Loss in 25 - 40 Decibels is mild hearing loss - Loss in 50 - 55 Decibels is moderate hearing loss - Loss in 55 -- 70 Decibels is moderate to severe hearing loss - Loss in 70 - 90 Decibels is severe hearing loss - Loss in \> 90 Decibels is profound hearing loss - Imaging- - **Tympanogram**: This test measures the movement of the eardrum in response to changes in air pressure, helping to assess the middle ear\'s function and detect issues like fluid buildup or eustachian tube dysfunction. - **Auditory Brainstem-Evoked Response (ABR)**: This is a neurophysiological test that measures the brain\'s electrical activity in response to sound stimuli. It helps evaluate hearing ability and diagnose auditory nerve disorders. - **Electronystagmography (ENG)**: ENG assesses the vestibular system by measuring eye movements. It involves tracking involuntary eye movements that occur when the inner ear is stimulated, helping to diagnose balance disorders. - **Platform Posturography**: This test evaluates a person\'s balance by measuring their ability to maintain stability on a platform that can move or tilt. It helps identify balance impairments and the underlying causes. - **Sinusoidal Harmonic Acceleration**: This test assesses the vestibular system\'s function by subjecting the patient to controlled movements in a sinusoidal pattern. It helps evaluate balance and motion sensitivity. - **Middle Ear Endoscopy**: This procedure involves using an endoscope to visualize the middle ear, allowing for the diagnosis and potential treatment of conditions like ear infections, fluid, or abnormalities. **Chapter 49** **Nursing Management: Patients with Hearing and balance disorders** - **Hearing loss** - **Pathophysiology** - Hearing loss may be the result of a conduction problem, a sensorineural loss, a mix of both, or a psychogenic issue. - **Risk Factors** - Family history of sensorineural impairment - Congenital malformations of the cranial structure (ear) - Low birth weight (less than 1,500 g) - Use of ototoxic medications (e.g., gentamicin, loop diuretics) - Recurrent ear infections - Bacterial meningitis - Chronic exposure to loud noises - Chronic exposure to loud volume using headphones or earbuds - Perforation of the tympanic membrane - **Focused Assessment** - Speech deterioration - Fatigue - Indifference - Social withdrawal - Insecurity - Indecision and procrastination - Suspiciousness - False pride - Loneliness and unhappiness - Tendency to dominate the conversation - **Clinical Manifestations and Assessment** - Early manifestations of deafness and loss may include tinnitus (ringing sound in the ear in the absence of an external source), increasing inability to hear when in a group, and a need to turn up the volume of the television. Hearing loss or difficulty hearing also trigger changes in attitude, ability to communicate, awareness of surroundings, and even ability to protect oneself, affecting a person's quality of life - **Gerontologic Considerations** - Cerumen becomes harder and drier, tympanic membrane may atrophy, the cell at the base of the cochlea degenerates. - **Medical Management** - **Implanted Hearing Devices** - Cochlear Implant - Aural Rehabilitation - Hearing Aids - Body, usually on the trunk (mild-profound) - Behind the ear (mild-profound) - In the ear (mild-moderately severe) - In the canal (mild0moderately severe) - Hearing Aid Problems - Inadequate amplification - Pain from mold - Whistling noise - Patient Education\--Tips for Hearing Aid Care - **Nursing Management** - Communicate effectively - **BOX 49-5**Communicating with People Who are Deaf - Maintain a Quiet Environment - **Conditions Affecting the External Ear** - Cerumen Impaction - Foreign Bodies - Otitis Externa (swimmer's ear) **Conditions Affecting the Middle Ear** - **Tympanic membrane perforation** - Clinical manifestations and Assessment - Perforation of the tympanic membrane is usually caused by infection or trauma. - Symptoms of tympanic membrane perforation include whistling sounds upon sneezing and blowing the nose, reduced hearing, purulent drainage from ear(s), and/or otalgia. - Medical and Nursing Management - Most heal spontaneously within weeks after rupture. - If caused from a head injury or temporal bone fx, a patient is observed for CSF. - Patient may need a tympanoplasty (surgical repair of the tympanic member) - Education - Take antibiotics and other meds as prescribed. - Blow the nose gently, one side at a time, for 1 week after surgery. - Sneeze and cough with the mouth open for a few weeks after surgery. - Avoid heavy lifting (over 10 lb) standing and bending over for a few weeks after surgery. - Popping and crackling sensations in the operative ear are normal for approximately 3-5 weeks after surgery. - Temporary hearing loss is normal in the operative ear due to fluid, blood, or packing in the ear. - Report excessive or purulent ear drainage to the surgeon. - Change the cotton ball in the ear as needed. - Avoid getting water in the operative ear for 2 weeks. You may shampoo the hair 2 -- 3 days postoperatively if the ear is protected from water. - Head injury involved- - **Otosclerosis** - Clinical Manifestations and Assessment - Otosclerosis may involve one or both ears and manifests as a progressive conductive or mixed hearing loss. The patient may or may not complain of tinnitus. Otoscopic examination usually reveals a normal tympanic membrane. Bone conduction is better than air conduction on Rinne testing. The audiogram confirms conductive hearing loss or mixed loss, especially in the low frequencies. - Medical and Nursing Management - There is no known nonsurgical treatment for otosclerosis. Some providers prescribe sodium fluoride to slow the progression of the otosclerosis; however, its efficacy is still debated **Otitis Media** - Three types: - **Acute Otitis Media**: Sudden onset of symptoms like ear pain and fever, often following a respiratory infection, usually treated with antibiotics if bacterial. - **Chronic Otitis Media**: Persistent inflammation lasting weeks or longer, potentially leading to hearing loss and ear drainage, often requiring surgery or ongoing management. - **Serous Otitis Media**: Fluid accumulation in the middle ear without infection, typically following respiratory issues, causing a feeling of fullness and mild hearing loss, sometimes treated with observation or drainage procedures. **Middle Ear Masses** - **Conditions Affecting the Inner Ear** - **Motion sickness** - Clinical Manifestations and Assessment - Motion sickness manifests itself with diaphoresis, pallor, nausea, and vomiting caused by vestibular overstimulation. - Medical and Management - Antihistamines -- Dimenhydrinate, Meclizine hydrochloride - Anticholinergic -- Scopolamine patches - **Meniere\'s disease-** is a disorder of the inner ear that causes vertigo, tinnitus, a feeling of fullness or pressure in the ear, and fluctuating hearing loss that significantly impacts a patient's quality of life. - Pathophysiology - result of fluctuating pressure within the inner ear or the mixing of inner ear fluids. The membranous labyrinth of the inner ear contains a fluid called endolymph. - Risk Factor - More common in adults in the 40's - Clinical Manifestations and Assessment - include fluctuating, progressive sensorineural hearing loss; tinnitus or a roaring sound; a feeling of pressure or fullness in the ear; and episodic, incapacitating vertigo, often accompanied by nausea and vomiting - Medical Management - Pharmacologic Therapy - Antihistamines -- meclizine, Benzodiazepines - Antiemetic -- promethazine - Betahistine hydrochloride and diuretic - Surgical Management - Endolymphatic Sac Decompression - A shunt or drain is inserted in the endolymphatic sac through a postauricular incision. - Middle and Inner Ear Perfusion - Ototoxic medications, such as streptomycin or gentamicin, can be administered to patients by infusion into the middle and inner ear. - Intraotologic Catheters - In an attempt to deliver medication directly to the inner ear, catheters provide a conduit from the outer ear to the inner ear. - Vestibular Nerve Sectioning - Cutting the nerve prevents the brain from receiving input from the semicircular canals. **Tinnitus** - Selected Ototoxic Substances - Diuretics: Ethacrynic acid, furosemide, acetazolamide - Chemotherapeutic agents: Cisplatin, nitrogen mustard - Antimalarial agents: Quinine, mefloquine, chloroquine - Anti-inflammatory agents: Salicylates (aspirin), indomethacin - Chemicals: Alcohol, arsenic - Aminoglycoside antibiotics: Amikacin, gentamicin, kanamycin, netilmicin, neomycin, streptomycin, tobramycin - Other antibiotics: Erythromycin, minocycline, polymyxin B, vancomycin - ACE inhibitors: Enalapril, moexipril, ramipril - Acetic acids: Diclofenac, indomethacin, ketorolac - Alpha blockers: Doxazosin - Antiarrhythmics: Flecainide, propafenone, quinidine, tocainide - Calcium-channel blockers: diltiazem, nifedipine, nisoldipine - H1-blockers: Cetirizine, fexofenadine - Metals: Gold, mercury, lead **Benign Paroxysmal Positional Vertigo** - Pathophysiology - is thought to be due to the disruption of debris in the labyrinth, termed otoconia (small crystal particles of calcium carbonate that detach and float in the endolymph and cause symptomatology). - Clinical Manifestations and Assessment - Dizziness and peripheral vertigo will be elicited with the affected ear pointing downward. The eyes are examined for a brief period for nystagmus present while the head is maintained in a provoking position, which also commonly accompanies vertigo. - Medical and Nursing Management - Repositioning techniques - Vestibular suppressants - Vestibular rehabilitation **Ototoxicity** - **Acoustic Neuroma** - Pathophysiology - Acoustic neuromas are slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. - Clinical Manifestations and Assessment - unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. - If the tumor is large, the trigeminal nerve may be involved, resulting in facial paresthesia, hypesthesia - Facial paresis and disturbance in taste result from facial nerve involvement, which occurs less commonly. - Medical and Nursing Management - Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy. **Pediatric** - **Hearing Impairment** - About 1.6% of newborns do not pass the newborn hearing examination. Hearing impairment is expressed in terms of decibels (dB), which are units of loudness and rated according to severity. - Otoacoustic emission (OAE) (either transient-evoked \[TEOAE\] or distortion-product \[DPOAE\]) - A measure of low intensity sounds from the cochlear hair cells in response to clicks from a probe placed in the ear canal. - Sensitive in frequency range above 1500Hz - May show false negative for loss below 1000 -- 1500 Hz - Detects inner ear hearing loss by evaluating cochlear and hair cell function - Does not detect neural damage to cranial nerve VIII - Can be sensitive to outer ear canal obstruction of middle ear effusion, leading to false-positive results. - Auditory brainstem response (ABR) - Electrical response to auditory stimuli from three surface scalp electrodes. - Reflects activity of cochlea, cranial nerve VIII, and auditory brainstem pathways. - Detects hearing loss from 1000 -- 8000 Hz - May show false-negative results for losses in the 500 tot 2000 Hz levels - Will give a positive result if there is damage to cranial nerve VIII or brainstem pathways even if cochlear loss is not present. - Behaviors Suggestive of hearing impairment - Infant - Diminished or absent startle reflex to loud sounds - Does not awaken when environment is very noisy - Awakens only to touch - Does not turn head to sound at 3-4 months - Does not localize sound at 6-10 months - Babbles little or not at all - Toddler and preschooler - Speaks unintelligibly, in a monotone, or not at all. - Communicates needs through gestures. - Appears developmentally delayed. - Appears emotionally immature, yells inappropriately. - Does not respond to doorbell or telephone. - Appears more interested in objects than people and prefers to play alone. - Focuses on facial expressions rather than verbal communications. - School-age child and adolescent - Asks to have statements repeated. - Answers questions inappropriately, except when able to view speaker's face. - Daydreams and is inattentive. - Performs poorly at school or is truant. - Has speech abnormalities or speaks in a monotone. - Sits close to or turns television or radio up loudly. - Prefers to play alone. - Communication techniques for Children who have a hearing impairment - Cued Speech - Supplement to lipreading; eight hand shapes represent groups of consonant sounds, and four positions about the face represent groups of vowel sounds; based on the sounds the letters make, not the letters themselves; child can "see-hear" every spoken syllable a hearing person hears - Oral Approach - Uses only spoken language for face-to-face communication; avoids use of formal signs; uses hearing aids and residual hearing - Total Communication - Uses speech and sign, fingerspelling, lipreading, and residual hearing simultaneously; child selects communication technique depending on the situation **Health promotion---The child with a hearing impairment chapter 45** **P 1136**