Diagnosing Hearing Problem in Elderly Patient

Management of Patients with Multiple Sensory Deficits
Identify three initial nursing diagnoses for Mrs. Henson and list the defining characteristics that would support each of your identified nursing diagnoses.
The three initial diagnoses for Mrs. Henson would be to observe her responses when initiating conversation or talking to her, determine if the patient has cerumen impaction, and performing a whisper test. These diagnoses are aimed at determining the patient’s ability to hear and respond to the nurse and others. Observing the patient when having a conversation will allow the nurse to gauge the patient’s facial expression and attention. The patient could be getting distracted due to her other ailments and conditions and this might be the reason she is not able to hear instructions being given. Nurses are trained to be more patient with patients with hearing aids because they might lose attention. Observing the patient when talking to her will allow the nurse to see if the patient is receptive to what she is being told. The lack of reception and response would mean that the patient does not hear what she is being told and there is a need for further testing. This would also allow the nurse to rule out other issues like fatigue as reported by the physical therapy assistant. Elderly patients might fail to follow instructions being given when they are tired and this might be caused by fatigue. Therefore, it is vital that we rule out the possibility of the patient being fatigued.
The second diagnosis would be determining if the patient has cerumen impaction. This is a buildup of secretions and sloughed epithelial cells. This accumulation could result in symptoms like hearing loss, dizziness, otorrhea tinnitus, or other symptoms. Cerumen could also prevent the necessary assessment of the ear canal. Cerumen which is basically a buildup of ear wax can happen to anyone, but it is most likely to occur in people who use hearing aids. In order to diagnose for cerumen impaction, the nurse will make use a special instrument called an otoscope to be able to see if there is any wax buildup in the ear. Hearing aids users are most at risk of this because the hearing aids might be pushing the wax further inside the ears. Hearing aids also prevent the ear wax from being removed naturally by motions like chewing and jaw movements. Therefore, any person who uses hearing aids should be checked regularly and have their ears cleaned to remove any buildup of wax.
Performing a whisper test will establish the level of hearing of the patient. A whisper test is aimed at gauging the patient's hearing at different levels in order to also test the effectiveness of her hearing aids. Since she is already using hearing aids, it is vital that the nurse determines how effective the hearing aids are working in order to rule them out as the issue. The use of the whisper test might not be the recommended test for hearing loss, however, it can still be used to diagnose a patient who is suffering from hearing impairment and to also test for the effectiveness of their hearing aids.
What assessments would the nurse perform to assess Mrs. Henson’s hearing ability?
Numerous studies have indicated that assessments for hearing impairment are rarely conducted for elderly adults and patients. In most cases, the first step for any hearing impairment assessment is checking for cerumen occlusion. However, considering the patient's ongoing ailments it is vital that other assessments be carried out to determine if the patient has a hearing impairment and to also rule out a failure of her hearing aids. Observation of the patient while speaking to her would offer the necessary clues as to whether the patient is able to hear. In case the nurse notices that the patient is leaning towards or tilting her head towards the person speaking to her then she might have difficulty hearing. Another assessment that can be used is the hearing handicap inventory for the elderly (HHIE), which is a 10-item self-administered questionnaire aimed at assessing the social and emotional effects of hearing impairment. This questionnaire has been found to have good sensitivity and specificity for moderate and marked hearing loss.
The nurse could also make use of the tuning-fork test to assess the patients hearing loss. The patient already wears bilateral hearing aids and this clearly shows they have a hearing problem. However, since the patient seems non-responsive to instructions, her hearing problem could have become worse especially due to her stroke or because of her age. Using the tuning-fork test while the patient is wearing her hearing aids will assist in determining if she is able to hear or her hearing has been impacted further. Finally, the nurse should also check her ear canal to ensure that there is no blockage caused by the buildup of cerumen. The patient is already wearing hearing aids and they have the potential to cause a buildup of wax because the natural cleaning of the ear is not possible. The hearing aids could also be pushing the wax further inside the ear. Using an otoscope, the nurse will check the patient's ears for any buildup of wax. If there is any buildup then the ear canal will be blocked and the nurse will not be able to see through.
Upon further assessment, it is determined that Mrs. Henson has impacted cerumen. You receive an order for carbamide peroxide (Debrox) two drops each ear twice daily for 3 days to be followed by otic irrigation on day four. What steps should be taken by the nurse to perform the otic irrigation? How will the nurse evaluate if the otic irrigation was successful?
Otic irrigation or ear irrigation is the procedure that is used to remove excess earwax and foreign materials from the ear. While the ear naturally secretes wax for protecting and lubricating the ear and keeping debris out. Under normal conditions the body is able to keep the amount of earwax in the ears under control, however, there are situations when this is not possible and there is an accumulation of earwax that causes the blockage in the ear resulting in hearing loss. The process of otic irrigation involves first warming the irrigation solution to body temperature. The nurse will then assist the patient into a sitting position with the head slightly tilted towards the ear to be irrigated. Draping the patient with a plastic drape and pacing a towel on the patient's shoulder on the side being irrigated. The nurse will straighten the ear canal by pulling the pinna upwards and outwards. The nurse should inform the patient to let her know if the patient experiences any pain or dizziness during the otic irrigation process. The nurse will then place the nozzle into the ear canal entrance and direct the stream of irrigation solution slowly into the top of the ear canal towards the back of the patient's head. The nurse should ensure that they do not occlude the ear canal with the nozzle. The irrigation solution should be allowed to flow out as it is being instilled. Irrigation should continue until the ear canal is clean.
To determine if the otic irrigation was successful, the nurse will perform an otoscopic examination. This examination involves placing an otoscope with a light inside the patient’s ear and checking to see if the blockage has been cleared. The nurse should be able to see the eardrum and the ear canal should be clear. Once the nurse confirms that the otic irrigation was successful, then they should place a cotton ball loosely in the outer ear that was being irrigated.
What general overall strategies can the facility staff implement to optimize communication with Mrs. Henson in view of her hearing impairment and present health status?
A majority of the time the main barrier to communication with patients with hearing impairments is the lack of consideration by the caregivers. It is not always easy for caregivers to know a patient's need without prior interaction with the patient. Therefore, there is a need to have a system in place that identifies or notes the needs of the patient on their medical record. This notification will alert the caregiver of the need to offer communication accommodations to the patient. A breakdown in healthcare communication can have drastic consequences for the patient and this might lead to misdiagnosis or failure by the patient to follow the given instructions. Elderly patients are not comfortable with their hearing and most times they will not accept that they have a hearing problem. This means that they will be unwilling to accept that they cannot hear and they might pretend they are hearing properly. Therefore, nurses should be able to use other visual cues to determine the understanding and hearing of the patient. Making use of communication strategies like keeping eye contact will allow the nurse to see if the patient is understanding what he/she is being told and the instruction being given are understood.
The facility staff should also avoid making assumptions for the patient and directly ask the patient what they require. Asking the patient directly about their communication needs and preferences makes the patient feel comfortable and accommodated, which would result in the patient opening up to the nursing staff. The pace for talking should also be at a normal pace. This allows the patient to keep up with what they are being told. The facility could also make use of visual aids to assist in communicating with the patient. Visual aids allow the patient to see clearly what they are being told and they are more likely to understand and remember the instructions. Visual aids have been shown to be quite effective communication tools that combined with speech can have positive effects on patients like Mrs. Henson. Using multiple communication tools ensures that the patient does not miss out on any vital information.
Facility staff can also encourage participation in the decision-making process. Allowing the patient to directly participate in the decision regarding their care and treatment will make them feel included and will have a lasting change in the patient's outcome. Also, the care facility can increase its staff to also have staff with disabilities to assist in the care of patients. People with disability are better placed to offer solutions that will have a direct impact on them then having others deciding what is best for them. This way a communication strategy would be analyzed and gauged to determine how effective it would be to a particular patient and they can advise before it is implemented.
Staff should understand that communication needs will vary for each patient and they should seek solutions that will be targeted to individual patients. A patient who loses their hearing ability when they are elderly might not be able to use sign language, therefore, communication with them should be done differently than for a patient who is able to use sign language. Elderly patients at the facility who use hearing aids should also be undergoing regular ear checkup to ensure that there is no buildup of cerumen in the ear canal. This will ensure that their ears are cleaned when it is noticed that there is excess cerumen and before the patient loses their hearing ability completely.