Nursing Management of Hearing Impairment in Nursing Facility
Contents
1. Philadelphia Davis Dinces E A 2008 Cerumen Retrieved February 26 2007 from the UpTo Date for Patients Web site http www uptodate com patients content topic do topicKey 9EIC32upmPs x9 amp selecte dTitle 1 15 amp source search_result Ford G R amp Courteney Harris R G 1990 Another hazard of ear syringing Malig nant external otitis The Journal of Laryn gology and Otology 104 9 709 710 Freeman R B 1995 Impacted cerumen How to safely remove earwax in an office visit Geriatrics 50 6 52 53 Garahan M B Waller J A Houghton M Tisdale W A amp Runge C F 1992 Hearing loss prevalence and management 16 in nursing home residents Journal of the American Geriatrics Society 40 130 134 Garstecki D C amp Erler SF 1999 Older adult performance on the Communication Profile for the Hearing Impaired Gender differences Journal of Speech Language and Hearing Research 42 785 796 Gates G A amp Mills J H 2005 Presbycusis Lancet 366 1111 1120 Gates G A Murphy M Rees T S amp Fra her A 2003 Screening for handicapping hearing loss in the elderly Journal of Fam ily Practice 52 56 62 Grossan M 1998 Cerumen removal Cur rent challenges Ear Nose amp Throat Jour nal 77 541 546 548 Heron R amp Wharrad H J 2000 Preva lence and nursing staff awareness of hear ing impairment in older hospital patients Journal of Clinica2. difficult Ask residents to suggest things you can do to facilitate communication such as speaking toward a better ear or moving to a better lighted area Spotlight your face e Face a window or a lamp so the light illuminates your mouth as you speak e If the room is dark move to another area with better lighting e Recognize that residents with hearing loss often rely heavily on lip reading new topic Give clues when changing subjects Do not change the subject without warning as it may confuse the resident e Keep the resident on track with phrases such as Now want to talk to you about our upcoming family night so the resident can become ready for a Keep it simple Avoid slang before you continue Use plain simple English or the resident s primary spoken language e Rephrase the idea in short simple sentences if the listener does not respond e Evaluate or verify what you have said or written using the resident s response Training nursing personnel on the use care and maintenance of hearing aids and ALDs is vital to providing quality nursing care to residents with hearing impairment Table 3 provides key use care and maintenance information that all nursing personnel caring for resi dents should know about hearing aids and ALDs Hearing Aids Types Care and Maintenance A hearing aid is a bat tery powered sound amplifying de vice used by residents with hear
3. in the ear or intra aural aid This one piece aid contains all of the components within the earmold Other hearing aid devices include the in the canal aid the completely JOURNAL OF GERONTOLOGICAL NURSING VOL 34 NO 11 2008 in the canal aid eyeglasses aid and body hearing aid Kozier et al 2003 Wallhagen et al 2006 The manu facturer s specific guidelines should be followed for proper hearing aid use care and maintenance ALDs Types Care and Mainte nance ALDs are any kind of device other than hearing aids used to help individuals with hearing impairment function better in daily communi cation ALDs are appropriate for older adults with mild to moderate hearing loss because these devices can provide satisfactory auditory function without the use of a hear ing aid In addition ALDs may be used with hearing aids when they are they may tune out bothersome background noise Jerger Chimiel Florin Pirozzolo amp Wilson 1996 Unfortunately people with hearing impairment often resist using these visible devices ASHA n d Jupiter amp Spivey 1997 The following are examples of common categories of ALDs e Pocket talker or hardwire de vices are composed of a microphone that the speaker talks into an ampli fier to make the sounds louder and a wire leading to earphones worn by the resident The earphones have adjustable volume These kinds of ALDs are simple to use and appro priate for enga
4. of hearing impair ment key definitions individuals at risk assessment criteria and tools description of practice and steps for evaluation and outcomes We believe the implementation of this evidence based practice guideline will improve the quality of life and quality of care of nursing facility residents REFERENCES American Speech Language Hearing Asso ciation 1997 Guidelines for audiology service delivery in nursing homes ASHA 39 2 Suppl 17 15 29 American Speech Language Hearing Asso ciation 2002 Guidelines for audiologic screening In ASHA Desk Reference Au diology and Speech Language Pathology Vol 4 pp 372 381 Rockville MD Au thor American Speech Language Hearing Associa tion n d Assistive technology Retrieved July 20 2005 from http www asha org public hearing treatment assist_tech htm Appollonio I Carabellese C Frattola L amp Trabucchi M 1996 Effects of sensory aids on the quality of life and mortality 15 of elderly people A multivariate analysis Age and Ageing 25 89 96 Bagai A Thavendiranathan P amp Detsky A S 2006 Does this patient have hear ing impairment Journal of the American Medical Association 95 416 428 Begg E J Barclay M L amp Kirkpatrick C M 2001 The therapeutic monitoring of an timicrobial agents British Journal of Clini cal Pharmacology 52 Suppl 1 35S 43S Brender E Burke A E amp Glass R M
5. 2002 Hearing loss is the de creased ability or complete inability to hear the normal range 20 to 25 dB Written by Linda Adams Wendling PhD RN CNAA BC CNE and Cathy Pimple MS ARNP Edited by Susan Adams PhD RN and Marita G Titler PhD RN FAAN JOURNAL OF GERONTOLOGICAL NURSING VOL 34 NO 11 2008 TABLE 1 Tool Abnormal Findings Hearing Handicap Inventory for the 0 to 8 no hearing handicap 9 to 24 mild to moderate hear Elderly Screening ing handicap HHIE S Ventry amp 25 to 40 severe hearing Weinstein 1983 handicap Kind of Hearing Impairment Conductive sensorineural or mixed hearing loss BEDSIDE HEARING IMPAIRMENT ASSESSMENT SCREENING INSTRUMENTS Key Procedure Steps Administer in a quiet setting to cognitively intact residents at admission quarterly annually and with a significant change Selected References Scudder Culbertson Waldron amp Stewart 2003 Sindhusake et al 2001 Wiley Cruickshanks Non dahl amp Tweed 2000 Nursing Home Hearing Handi cap Index NHHI Schow amp Ner bonne 1980 0 to 20 no hearing handicap 21 to 40 slight hearing handi cap 41 to 70 mild to moderate hearing handicap 71 severe hearing handicap Conductive sensorineural or mixed hearing loss Administer in a quiet setting to cognitively intact residents at admission quarterly annually and with a significant change Scudde
6. 2006 Audiometry Journal of the Ameri can Medical Association 295 460 Brinkmann K L 1991 Why can t your pa tient hear you RN 54 1 46 48 Brookhouser P E 1994 Prevention of noise induced hearing loss Preventive Medicine 23 665 669 Cacchione P Z Culp K Dyck MJ amp La ing J 2003 Risk for acute confusion in sensory impaired rural long term care elders Clinical Nursing Research 12 340 2557 Centers for Medicare amp Medicaid Services 2003 RAI users manual Washington DC U S Government Printing Office Considerations in screening adults older per sons for handicap hearing impairments 1992 ASHA 34 8 81 87 ConsultGeriRN org 2005 February Want to know more Sensory changes Nursing assess ment and care strategies Retrieved October 7 2008 from http www consultgerirn org topics sensory_changes want_to_know_ more item_6 Cook R 1998 Ear syringing Nursing Stan dard 13 13 5 56 59 Crews J E amp Campbell V A 2004 Vision impairment and hearing loss among com munity dwelling older Americans Impli cations for health and functioning Ameri can Journal of Public Health 94 823 829 Davidson T M 2000 Ambulatory health care pathways for ear nose and throat disorders Retrieved August 27 2008 from http drdavidson ucsd edu Portals 0 Ambuindex htm Dillon P M 2003 Nursing health assess ment A critical thinking case studies ap proach
7. Evidence Based Guideline Nursing Management of Hearing Impairment in Nursing Facility Residents earing impairment is a seri ous problem among older adults in America It affects their functional ability which in turn significantly affects their quality of life U S Administration on Aging AOA 2002 Hearing impairment is one of the most prevalent chronic conditions among older adults ex ceeded only by arthritis heart dis ease and hypertensive disease U S AOA 2002 National Center for Health Statistics 2008 National In stitutes of Health NIH 2007 Hearing loss which leads to hearing impairment is the most common sen sory deficit in older adults One in three people older than age 60 and half of adults older than 85 have hearing loss leading to hearing impairment Ken nedy Malone Fletcher amp Plank 2004 The prevalence of hearing impairment among older adults in nursing homes is even greater Kennedy Malone Fletch er amp Plank 2004 Up to 98 of older adults residing in long term care facili ties have hearing impairments Ameri can Speech Language Hearing Associa tion ASHA 1997 Considerations in Screening 1992 Norwood Chapman amp Burchfield 1999 Although the prevalence of hear ing impairment is significant RNs licensed practical nurses LPNs and certified nursing assistants CNAs in nursing facilities often feel inadequately prepared to care for those who are h
8. NG IMPAIRMENT Risk factors for hearing loss lead ing to hearing impairment include e Age older than 65 Wallhagen et al 2006 e Residence in nursing facili ties Garahan Waller Houghton Tisdale amp Runge 1992 e Cognitive decline Cacchione Culp Dyck amp Laing 2003 Strouse Hall amp Burger 1995 e Visual impairments Crews amp Campbell 2004 Rudberg Furner Dunn amp Cassel 1993 e History of chronic otitis media Yueh Shapiro MacLean amp Shekelle 2003 e Excessive noise exposure Brookhouser 1994 Mayo Clinic 2007 Morata 1998 e Use of ototoxic medications Begg Barclay amp Kirkpatrick 2001 Palomar Abdulghaini Bodet amp Andreu 2001 e Male gender U S AOA 2002 Garstecki amp Erler 1999 NIH 2007 Older individuals frequently ex hibit several of these risk factors si multaneously and are at an increased risk for hearing impairment ASSESSMENT CRITERION Because of the high prevalence of hearing loss in nursing facility resi JOURNAL OF GERONTOLOGICAL NURSING VOL 34 NO 11 2008 dents all residents should be evalu ated for hearing impairment on ad mission and on an ongoing basis e g significant change in status or as needed but minimally on an an nual basis ASHA 1997 Bagai et al 2006 Centers for Medicare amp Med icaid Services 2003 ASSESSMENT TOOLS Several bedside assessment tools are available for RNs to screen and asses
9. Process Evalu ation Monitor and the Outcome Evaluation Monitor both included in the full guideline should be admin istered following implementation of the guideline Outcome indicators are out comes expected to change or im prove with consistent use of the guideline The major outcome indicators that should be moni tored over time include Jennings amp Head 1997 Shapiro amp Shekelle 2004 JOURNAL OF GERONTOLOGICAL NURSING VOL 34 NO 11 2008 e Ensuring residents are screened for hearing impairment on admission and on an ongoing basis e Residents with hearing impair ment are treated and referred to an ENT physician and or audiologist e Residents with hearing impair ment receive appropriate nursing interventions The Outcome Evaluation Monitor in the full guideline is to be used to monitor and evaluate the usefulness of the hearing impairment guide line in improving outcomes of older adults with hearing impairment who reside in nursing facilities SUMMARY This article has described the key points in the evidence based prac tice guideline entitled Nursing Man agement of Hearing Impairment in Nursing Facility Residents The guideline outlining the nursing man agement of nursing facility residents with hearing impairment is support ed by 175 articles 94 research articles both experimental and descriptive and 81 nonresearch articles expert opinion The full guideline includes the significance
10. aids and ALDs and thus lack knowledge about proper care and management Jennings amp Head 1997 Norwood Chapman amp Burchfield 1999 12 TABLE 2 STRATEGIES TO COMMUNICATE WITH NURSING FACILITY RESIDENTS WITH HEARING IMPAIRMENT nursing personnel Note the resident s preferred communication method e Note that this may be verbal written lip reading or American Sign Language Ensure this preference is evident on the resident s care plan available to all Explore with resident family or legal responsible party the availability of and process to acquire assistive listening devices and hearing aids if needed Face the resident directly to speak turned on e Establish eye contact e Be sure to look directly at the resident preferably at eye level before starting If the resident wears a hearing aid ensure it is secure in the correct ear and e Check for visual impairment ask Can you read a newspaper If the resident wears eyeglasses ensure the glasses are on and clean e Know that the resident must be able to see you to hear you Do not turn away in the middle of a sentence Avoid noisy backgrounds from all sides e Understand that a conversation is difficult to hear over background noises because the sound is coming from all sides e Ask the resident to sit with his or her back to the wall so sound is not coming Do not try to talk above loud noises this makes hearing more
11. as not been trained on the use of an audioscope then the Whisper test can be used All nursing facility residents with suspected hearing problems or abnormal screenings for hear ing impairment should be referred to the primary care provider to ini tiate interventions e g cerumen management and to an ear nose and throat ENT physician and or audiologist for audiometric evalua tion hearing diagnosis and hearing rehabilitation DESCRIPTION OF PRACTICE Nursing interventions carried out for individuals with hearing impairment consist of communica tion strategies hearing aids and as sistive listening devices and ceru men management Communication Hearing impairment has a pro found effect on nursing facility residents communication abilities Nursing staff can contribute to the physical and emotional well being of residents with hearing impairments by becoming sensitive to their needs Table 2 provides a synthesis of rec ommendations found in the litera ture related to key communication strategies Hearing Aids and Assistive Listening Devices Hearing aids and assistive listening devices ALDs have been reported to significantly improve quality of life Appollonio Carabellese Frattola amp Trabucchi 1996 National Coun cil on the Aging 1999 All nursing personnel are responsible for the care and management of these devices yet many nursing staff have not received formal training regarding hearing
12. ation 289 1976 1985 Zivic R C amp King S 1993 Cerumen im paction management for clients of all ages Nurse Practitioner 18 3 29 33 36 39 ABOUT THE AUTHORS Dy Adams Wendling is Associate Professor and Ms Pimple is Assistant Professor Emporia State University Emporia Kansas Dr Adams is Associate Director Research Translation and Dis semination Core Gerontological Nurs ing Interventions Research Center The University of Iowa College of Nursing Iowa City Iowa Dr Titler is Direc tor Research Quality and Outcomes Management Department of Nursing Services and Patient Care University of Iowa Hospitals and Clinics and Director Research Translation and Dissemination Core Gerontological Nursing Interven tions Research Center The University Iowa College of Nursing Iowa City Towa Guidelines in this series were pro duced with support provided by grant P30 NR03979 Principal Investigator Toni Tripp Reimer The University of Iowa College of Nursing National Institute of Nursing Research National Institutes of Health Address correspondence to Linda Adams Wendling PhD RN CNAA BC CNE Associate Professor Empo ria State University 1127 Chestnut Emporia KS 66801 e mail ladamswe emporia edu
13. ch Consonants such as f sh ch h t p and s are high frequency sounds that become inaudible with presbycusis resulting in the inability to comprehend words Bagai et al 2006 Brender Burke amp Glass 2006 Wallhagen et al 2006 e Conductive hearing loss results from a physical disruption in the transmission of sound waves through the external or middle ear Ignatavicius amp Workman 2006 Wallhagen et al 2006 Causes of conductive hearing loss include ex ternal blockage perforated eardrum genetic or congenital abnormality otitis media and otosclerosis Bagai et al 2006 Wallhagen et al 2006 The most common cause of conduc tive hearing loss in older adults is buildup of cerumen in the auditory canal Wallhagen et al 2006 Zivic amp King 1993 As individuals age cerumen becomes drier and the cilia become coarse and stiff reducing their function and causing ceru men buildup Zivic amp King 1993 Cerumen impaction obstructs sound transmission and can cause up to a 40 to 45 dB loss Meador 1995 Zivic amp King 1993 The estimated incidence of cerumen impaction in nursing home residents is nearly 40 Freeman 1995 Mixed hearing loss includes both conductive and sensorineural com ponents Bagai et al 2006 Kennedy Malone et al 2004 In other words there may be damage in the outer or middle ear and in the inner ear co chlea or auditory nerve INDIVIDUALS AT RISK FOR HEARI
14. cks the external auditory canal resulting in hearing loss pain or infection Freeman 1995 Kozier et al 2003 Meth ods to remove cerumen impaction include both ceruminolytic agents and aural lavage irrigation which is discussed in the full guideline Removal must be performed by a trained RN with a physician s order Cook 1998 Grossan 1998 Rodg ers 1997 Stubbs 2000 Thurgood amp Thurgood 1995 Only a physician or an advanced practice nurse should remove impacted cerumen under di rect vision and a curette Although ear irrigations are re portedly a common procedure for cerumen management ASHA 2002 Dinces 2008 Sinclair 2005 they are invasive and have the potential to cause discomfort or even injury to the resident RNs must achieve competence in aural lavage irrigation prior to performing the procedure Aural lavage is contraindicated if the resident has a perforated tym panic membrane acute or chronic otitis media otitis externa myrin gotomy tubes or a mastoid cavity 14 CARE AND MAINTENANCE OF HEARING AIDS AND ASSISTIVE LISTENING DEVICES Hearing Aid General Care and Maintenance REMOVE THE HEARING AID 1 Turn the hearing aid off and then lower the volume The on off switch may be represented by an O off M microphone T telephone or TM telephone mi crophone If the hearing aid is not turned off the batteries will continue to run 2 Remove the earmold by rotating it sl
15. e resident s ear as this prevents the resident from word flow resident to understand e Do not use baby talk Speak clearly at a moderate pace Speak slowly and pause occasionally to help the resident keep up with the e Enunciate each word carefully and avoid mumbling Do not mouth or exaggerate expressions as this makes it more difficult for the e Do not use a high pitched tone use a lower deeper voice Use longer phrases a drink e Understand that longer phrases tend to be easier for residents to understand and provide more meaning clues than do shorter phrases For example Will you get me a drink of water presents less difficulty than does Will you get me Beware of listener bluffing e Know that when it is too difficult to listen some residents may agree with everything even when they do not understand what is being said the sound into the ear Kozier Erb Berman amp Snyder 2003 For prop er functioning it is necessary that caregivers handle the hearing aid appropriately during insertion re moval regular cleaning and battery replacement There are several different kinds of hearing aid devices A common one is the behind the ear or postaural aid This kind fits snugly behind the ear and the hearing aid case holds the microphone and amplifier with the receiver attached to the earmold by a plastic tube Another widely used device is the
16. earing impaired Heron amp Wharrad 2000 Wilson amp Rodgers 2000 Given the preva lence and significant consequences of hearing impairment it is impor tant that nurses adequately man age hearing impairment in nursing facility residents This article is a condensed version of the published practice guideline entitled Nursing Management of Hearing Impair ment in Nursing Facility Residents Readers are encouraged to ob tain the full guideline which con tains additional essential informa tion It is available at http www nursing uiowa edu products_ services evidence_based htm PURPOSE The purpose of this evidence based practice guideline is to pro vide guidelines for the nursing care of nursing facility residents with hearing impairment The guideline is intended for frontline nursing staff RNs LPNs and CNAs car ing for older adults who are hearing impaired This guideline will also be useful for directors of nursing nurse managers and nursing faculty re sponsible for gerontological nursing competency evaluations and educa tion on standards of nursing care for hearing impairment in older adults in nursing facilities The goal of this evidence based practice guideline is to improve the quality of life for nursing facility residents with hear ing impairment DEFINITIONS OF KEY TERMS Hearing is the sense that enables sound to be perceived Mosby s Med ical Nursing amp Allied Health Dic tionary
17. ging in one on one conversation watching television and listening to the radio However due to the wire connection this kind of ALD may be too restrictive for large group conversations e With personal frequency modulation the speaker wears a small microphone and signals are transmitted along a radio frequency carrier wave to the amplifier which is worn by the resident The person al frequency modulation system can be used for personal use or in larger areas e In infrared systems a micro phone picks up energy from the speaker converts it and transmits it to an infrared converter The converter transmits the signal on an 13 infrared carrier beam The listener wears a receiver which looks like lightweight earphones This kind of system allows residents to be involved in group activities or to watch television in a lounge area However this kind of system can not be used in direct sunlight e The induction loop system consists of a microphone amplifier and wire that surround a designated area The microphone near the speaker transmits the signal to the wire and the signal is picked up by the hearing aid However fluores cent lighting may cause interference and the resident must be sitting within the area of the loop e Other ALDs include tele phone amplifiers amplified an swering machines paging systems computers and wake up alarms Cerumen Management Cerumen removal is indicated when cerumen blo
18. ightly forward and then pulling it outward 3 Remove the battery if the hearing aid will not be used for several days This prevents corrosion of the hearing aid from battery leakage 4 Store the hearing aid in a safe place away from heat and moisture Safe stor age prevents loss or damage CLEAN THE EARMOLD 1 Detach the earmold as indicated Disconnect the earmold from the receiver of a body hearing aid or from the hearing aid case of a behind the ear or eyeglass es aid where the tube meets the hook of the case Do not remove the earmold if it is glued or secured Removal helps in cleaning and prevents damage to the hearing aid 2 If the earmold is detachable soak it in a mild soapy solution Clean the earmold rinse and then dry with a soft cloth Do not use isopropyl alcohol sol vents or oil Alcohol may damage the hearing aid If the earmold is not detach able or is for an in the ear aid clean the earmold with a damp cloth 3 Check that the earmold opening is patent Remove any excess moisture or debris with a soft cloth or cotton ball Then reattach the earmold to the rest of the hearing aid INSERT THE HEARING AID 1 Ask the resident whether the earmold is for the left or right ear Check for correct battery placement Ensure the hearing aid is turned off and the volume is turned down Line up the parts of the earmold with the resident s ear Slightly rotate the earmold forward and insert the ear canal po
19. ing impairment It consists of a micro phone that picks up sound and con verts it to electric energy an ampli fier that magnifies the electric energy a receiver that converts the amplified energy and an ear mold that directs JOGNonline com TABLE 2 CONTINUED STRATEGIES TO COMMUNICATE WITH NURSING FACILITY RESIDENTS WITH HEARING IMPAIRMENT dent with a gentle touch Gain the resident s attention first e Be sure the resident is aware of you before you start talking If the resident is turned away from you or turns away from you alert the resi Communicate dent e Do not hold anything in your teeth e Speak in a quiet environment not farther than 2 to 3 feet away from the resi e Ensure only one person at a time is talking to the resident Allow adequate time for the resident to listen and respond Say the resident s first name and then continue the sentence e Use gestures if you need to clarify a statement or question Do not chew gum or cover your mouth when speaking e Use written communication if unable to communicate verbally Do not shout resident difficult or impossible upset the resident using visual cues Note that shouting makes hearing more difficult and may be painful to the e Understand that shouting distorts the speaker s face and makes lip reading e Recognize that when shouting is amplified by a hearing aid it can frighten and Do not speak directly into th
20. l Nursing 9 834 841 Ignatavicius D D amp Workman M L 2006 Medical surgical nursing Critical thinking for collaborative care 5 ed Philadel phia Saunders Jarvis C 2004 Physical examination amp health assessment 4 ed Philadelphia Saunders Jennings M amp Head B 1997 Resident and staff education within an ecological audio logic rehabilitation program in a home for the aged Revue D Orthophonie et Dadi ologie 21 3 167 173 Jerger J Chimiel R Florin E Pirozzolo E amp Wilson N 1996 Comparison of conventional amplification and an assistive listening device in elderly persons Ear and Hearing 17 490 504 Jupiter T amp Spivey V 1997 Perception of hearing loss and hearing handicap on hear ing aid use by nursing home residents Ge riatric Nursing 18 5 201 207 Kennedy Malone L Fletcher K R amp Plank L M 2004 Management guidelines for nurse practitioners working with older adults 24 ed Philadelphia Davis Kozier B Erb G Berman A amp Snyder S 2003 Kozier amp Erb s techniques in clini cal nursing Basic to intermediate skills 5 ed Upper Saddle River NJ Prentice Hall Lewis Cullinan C amp Janken J K 1990 Effect of cerumen removal on the hearing ability of geriatric patients Journal of Ad vanced Nursing 15 594 600 Mayo Clinic 2007 Hearing loss Cop ing and support Retrieved January 12 2005 fro
21. l or bilateral Wallhagen Pettengill amp Whiteside 2006 Hearing impairment refers to hearing loss and or the abnormality of anatomical structure or function of the auditory system that adversely affects an individual s ability to com JOGNonline com municate Mosby s Medical Nursing amp Allied Health Dictionary 2002 There are three major categories of hearing loss in older adults e Sensorineural hearing loss is the result of damage to the inner ear including the cochlea or audi tory eighth cranial nerve Common causes include birth related causes heredity viral or bacterial infec tions mumps spinal meningitis encephalitis trauma tumors noise hypertension coronary artery or vascular disease ototoxic drugs including aminoglycosides diuret ics some antibiotics and cancer medications and Meniere s disease National Institute of Neurological and Communicative Disorders and Stroke NINCDS 1982 1984 e Presbycusis the most com mon kind of hearing impairment in older adults is defined as a sensori neural loss caused by changes in the inner ear Bagai et al 2006 Gates amp Mills 2005 Presbycusis is the term most often used to describe hearing impairment that is age related and generally presents as a gradual and progressive bilateral deafness With presbycusis there is a loss of high pitched tones 1 000 to 8 000 Hz in acuity auditory threshold speech intelligibility and pit
22. lidation of self reported hearing loss The Blue Mountains Hearing Study International Journal of Epidemiology 30 1371 1378 Strouse A L Hall J W 3rd amp Burger M C 1995 Central auditory processing in Alzheimer s disease Ear and Hearing 16 230 238 Stubbs G 2000 Ear syringing and aural care Nursing Times 96 43 35 37 Thurgood K amp Thurgood G 1995 Ear syringing A clinical skill British Journal of Nursing 4 682 687 U S Administration on Aging 2002 Statis tics A profile of older Americans 2002 Re trieved October 7 2008 from http www aoa gov PROF statistics profile 2002 12 aspx Ventry I M amp Weinstein B F 1983 Iden tification of elderly people with hearing problems ASHA 25 7 37 42 Wallhagen M I Pettengill E amp Whiteside M 2006 Sensory impairment in older adults Part 1 Hearing loss American Journal of Nursing 106 10 40 48 Wiley T L Cruickshanks K J Nondahl D M amp Tweed T S 2000 Self reported hearing handicap and audiometric mea sures in older adults Journal of the Ameri can Academy of Audiology 11 67 75 Wilson M amp Rodgers R 2000 Updated cleaning guidelines for the Propulse ear syringe Community Nurse 6 7 33 Yueh B Shapiro N MacLean C H amp Shek elle P G 2003 Screening and manage ment of adult hearing loss in primary care Scientific review Journal of the American Medical Associ
23. lomar G Abdulghaini M Bodet A amp Andreu M 2001 Drug induced ototox icity Current status Acta Oto Laryngo logica 121 569 572 Rodgers R 1997 How safe is your syring ing Community Nurse 3 5 28 29 Rudberg M A Furner S E Dunn J E amp Cassel C K 1993 The relationship of visual and hearing impairments to dis ability An analysis using the Longitudinal Study of Aging Journal of Gerontology 48 M261 M265 Schow R L amp Nerbonne M A 1980 Hear ing levels among elderly nursing home residents Journal of Speech and Hearing Disorders 45 124 132 Scudder S G Culbertson D S Waldron C M amp Stewart J 2003 Predictive validity and reliability of adult hearing screening techniques Journal of the Amer ican Academy of Audiology 14 9 19 Shapiro N L amp Shekelle P G 2004 Work ing paper Quality indicators for the management of hearing loss in vulner able elder persons Retrieved August 27 2008 from the Rand Corporation Web site http www rand org pubs working_ papers 2005 RAND_WR185 pdf Sinclair S 2005 Preferred practice guide line for cerumen management Retrieved August 27 2008 from the College of Audiologists and Speech Language Pa thologists of Ontario Web site http www caslpo com Portals 0 ppg ppg_ cerumenmanagement pdf Sindhusake D Mitchell P Smith W Gold ing M Newall P Hartley D et al JOGNonline com 2001 Va
24. m _ http www mayoclinic com health hearing loss DS00172 DSECTION coping and support Meador J A 1995 Cerumen impaction in the elderly Journal of Gerontological Nursing 21 12 43 45 Morata T C 1998 Assessing occupational hearing loss Beyond noise exposures Scandinavian Audiology Supplementum 48 111 116 Mosby s Medical Nursing amp Allied Health Dic tionary 5 ed 2002 St Louis Elsevier National Center for Health Statistics 2008 Longitudinal Studies of Aging Retrieved October 7 2008 from http www cdc gov nchs lsoa htm National Council on the Aging 1999 The consequences of untreated hearing loss in older persons Retrieved August 27 2008 from _ http www ncoa org attachments UntreatedHearingLossReport pdf National Institute of Neurological and Com municative Disorders and Stroke 1982 Hearing loss Hope through research NIH Publication No 82 157 Bethesda MD National Institutes of Health National Institute of Neurological and Com municative Disorders and Stroke 1984 Research on presbycusis Bethesda MD National Institutes of Health National Institutes of Health 2007 Hear ing loss Retrieved August 27 2008 from http nihseniorhealth gov hearingloss toc html Norwood Chapman L amp Burchfield S B 1999 Nursing home personnel knowl edge and attitudes about hearing loss and hearing aids Gerontology amp Geriatrics Education 20 2 37 48 Pa
25. r Culbertson Waldron amp Stewart 2003 Sindhusake et al 2001 Wiley et al 2000 0 normal answers 1 2 or 3 abnormal Minimum Data Set MDS Conductive sensorineural or mixed hearing loss Administer in a quiet setting at admission quarterly annually and with a significant change Centers for Medicare amp Medicaid Services 2003 Sindhusake et al 2001 Hand held audio scope 25 to 40 dB pure tone at 500 Hz 1000 Hz 2000 Hz and 4000 Hz test tone 60 dB Hearing is considered normal if sounds from 250 through 8 000 Hz can be heard at volumes of 25 dB or less Conductive sensorineural or mixed hearing loss In a quiet environment ask the pa tient to make a fist with one hand Instruct the patient to identify when they hear a sound by raising a finger or saying yes Present pure tones of random loudness in dB American Speech Lan guage Hearing Associa tion 1997 2002 Bagai Thavendiranathan amp Detsky 2006 Gates Mur phy Rees amp Fraher 2003 Wallhagen Pettengill amp Whiteside 2006 Yueh Shapiro MacLean amp Shek elle 2003 Otoscope Obstruction or damage to exter nal or middle ear Conductive hear ing loss Insert and inspect ear canal and tympanic membrane Dillon 2003 Jarvis 2004 Able to hear 50 combina tion of whispered numbers letters or words at 1 to 2 feet or less Whisper test Conductive senso
26. rineural or mixed hearing loss In a quiet environment stand arm s length behind seated resident Whisper in one ear and ask the resident to repeat what was whis pered The ear not being tested should be masked or occluded Repeat with opposite ear Bagai et al 2006 Wallhagen et al 2006 Sound remains equal normal Sound lateralizes to normal ear hearing loss Hz or 512 Hz firmly on top of the resident s head or forehead Ask the resident if the vibration sounds the same in both ears or different Rinne test Bone conduction greater than air Conductive or Place a vibrating tuning fork 256 Dillon 2003 Jarvis 2004 A i A mixed hearing loss Hz or 512 Hz on the resident s AN conduction twice as long as mastoid process If the resident is bone conduction normal Sensorineural ure o hEr ond Cn Air conduction greater than poannailoss ber of seconds place tuning fork bone but lt 2 to 1 ratio 1 inch from external auditory canal and record time sound is heard Compare bone to air conduction Weber test Sound lateralizes to impaired ear Sensorineural Place a vibrating tuning fork 256 Dillon 2003 Jarvis 2004 a See the full guideline for further instructions or lower 20 to 20 000 Hz of sounds audible to an individual with normal hearing Bagai Thavendiranathan amp Detsky 2006 The loss may in 10 volve the external middle or inner ear and can be unilatera
27. rtion Gently press the earmold into the ear while rotating it backward 2 Check that the earmold fits snugly by asking the resident if it feels secure and comfortable Adjust the other components of the hearing aid as applicable 3 Turn the hearing aid on and adjust the volume according to the resident s needs TROUBLESHOOT PROBLEMS 1 If the sound is weak or absent a Ensure the volume is turned up b Ensure the earmold opening is not clogged If the opening is clogged gently push it out with a pin or pipe cleaner If the hearing aid is one that sits in the ear the receiver opening is lined with a piece of tubing that can easily be mistaken for cerumen The resident should have a little tool called a wax loop which should be used to remove the cerumen c Check the battery by turning the hearing aid on turning up the volume cupping your hand over the earmold and listening A constant whistling sound indicates the battery is functioning A weak sound may indicate the battery is losing power Replace the battery as necessary Cook 1998 Lewis Cullinan amp Jan ken 1990 Thurgood amp Thurgood 1995 Zivic amp King 1993 Residents with any of these conditions should be referred to an ENT physician for JOGNonline com cerumen removal Meador 1995 If TABLE 3 CONTINUED LISTENING DEVICES CARE AND MAINTENANCE OF HEARING AIDS AND ASSISTIVE kind and size of battery the
28. s for hearing impairment in nurs ing facility residents The most com mon assessment instruments include e Hearing Handicap Inventory for the Elderly Screening HHIE S Ventry amp Weinstein 1983 e Nursing Home Hearing Handicap Index NHHI Schow amp Nerbonne 1980 e Minimum Data Set MDS as sessment e Hand held audioscope e Otoscope e Whisper test e Rinne and Weber assessment tests Dillon 2003 Jarvis 2004 Descriptions and directions for use of these screening assessment instru ments abnormal assessment findings and kinds of hearing impairment are shown in Table 1 Screening Assessment The nursing hearing impairment screening evaluation should consist of a thorough history and physical examination which are essential to the diagnosis and treatment of hear ing impairment The history and physical examination should mini mally consist of a self report evalu ation including an interview of the resident s family and screening for hearing impairment with the MDS In addition the HHIE S or the NHHI are recommended for screen ing cognitively intact residents for hearing impairment The physiological evaluation should include examining the exter nal auditory canal with an otoscope for cerumen foreign bodies and ab normalities and screening for hear 11 ing impairment with a hand held au dioscope If a hand held audioscope is not available or if the RN com pleting the assessment h
29. window 3 Hold the amplifier in your hand under your chin Talk across not into the microphone at a distance of approximately 2 inches finished 4 Be sure the resident can see your mouth easily Speak in a normal tone and volume voice Do not shout Be sure to switch off the amplifier when you are Wallhagen Pettengill amp Whiteside 2006 Sources Kozier Erb Berman amp Snyder 2003 Brinkmann 1991 ConsultGeriRN org 2005 the cerumen has completely occlud ed the canal Zivic amp King 1993 or if a resident with only a single hearing ear has cerumen impaction David son 2000 aural lavage should not be performed and instead the resident should be referred to a physician Complications that may occur with irrigation include otitis externa per foration canal trauma pain cough tinnitus vertigo and otitis media Ford amp Courteney Harris 1990 Grossan 1998 Zivic amp King 1993 EVALUATION OF PROCESS AND OUTCOMES Several indicators should be moni tored over time to evaluate the pro cess and outcomes of implementing this evidence based guideline Pro cess indicators are those interpersonal and environmental factors that can facilitate the use of a guideline and may be evaluated by administering a test before and after implementation The guideline has an example of a pretest posttest entitled The Hearing Impairment Knowledge Assessment Test In addition the
30. y need d Ensure the negative and positive signs on the battery match those indicated on the hearing aid Be sure the new battery fits snugly but comfortably into its compartment If there is resistance either the battery is the wrong size or it is being inserted the wrong way It may be helpful to keep a battery tester at the nurses station as well as a list of the residents who wear hearing aids and the e Ensure the ear canal is not blocked with cerumen If the resident reports a whistling sound or squeal after insertion turn the volume down ensure the receiver is properly attached to the earmold and try reinserting the earmold comfort and fit 2 Refer to the resident s audiologist if any problems persist or if difficulties can not be corrected by the above steps Document pertinent data including any problems the resident has with the hearing aid In addition daily care and main tenance may be recorded on a flow sheet Hearing aid insertion and removal times for each resident may be included on the flow sheet Assistive Listening Devices General Care and Maintenance 1 Determine that the amplifier and batteries are working properly Put the earphones on and listen to your own speech before putting the headphones on the resident Put the earphones on the resident and adjust the headband for 2 Stand or sit approximately 3 feet or less from the resident Ensure you are facing the main source of light e g the
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