HEARING IMPAIRMENT

NCM 117 RLE

Learning Objectives:

At the end of the discussion, the students should be

able to:
1. Learn to assess a client with hearing impairment.
2. Know the plan of care for a client with hearing
impairment.
3. Utilize the nursing process in the care and
management of a client with hearing impairment.
 HEARING IMPAIRMENT

Description:
• Disability that may range in severity from slight to profound
hearing loss
• Include subdivisions or subclasses of deafness (inability to
process linguistic information) and hard of hearing (use of a
hearing aid enables processing of linguistic information)
 HEARING IMPAIRMENT

Incidence/Statistics:
• One of the most common disabilities
• 1-6 per 1000 well infants have hearing loss of varying degrees
(AAP, Task Force on Newborn and Infant Hearing, 1999; Gifford,
Holmes, and Bernstein, 2009)
• About 1 million children with hearing impairment ranging in
age from birth to 21 years
• About 1/3 of these children have other disabilities such as
visual or cognitive deficits/impairment
 Types of Hearing Loss
• Slight to moderately severe hearing loss: a person who has
residual hearing sufficient to enable successful processing of
linguistic information through audition, generally with the use of a
hearing aid.
• Severe to profound hearing loss: a person whose hearing
disability prevents successful processing of linguistic information
through audition with or without a hearing aid.
❖Hearing-impaired persons who are speech impaired tend not to
have a physical speech defect other than that caused by the
inability to hear
 CLASSIFICATION
• Hearing defects may be classified according to:
• Etiology
• Pathology
• Symptom severity
❖Each is important in terms of treatment, possible
prevention, and rehabilitation.
 CLASSIFICATION
❖Pathology Disorders of hearing are divided according to the
location of the defect. Location of the defect determines the
nature of interference with transmission of sound along the
neural pathway.
1. Conductive or middle-ear hearing loss:
• results from interference of transmission of sound to the middle
ear
• most common of all types of hearing loss involves mainly
interference with loudness of sound
• bone conduction remains intact
• can be caused by foreign objects in the middle ear
• most frequently a result of recurrent serous otitis media
 CLASSIFICATION
2. Sensorineural hearing loss:
• involves damage to the inner ear structures or the auditory nerve
• results in distortion of sound and problems in discrimination or inability
to distinguish high-frequency sound
• most commonly caused by congenital defects of inner ear structures or
consequences of acquired conditions, such as kernicterus, acquired
infections, administration of ototoxic drugs, or exposure to excessive
noise
❖ Although the child hears some of everything going on around him or
her, the sounds are distorted, severely affecting discrimination and
comprehension.
 CLASSIFICATION

3. Mixed conductive-sensorineural hearing loss:

• results from interference with transmission of sound in the
middle ear and along neural pathways
• frequently results from recurrent otitis media and its
complications
 CLASSIFICATION

4. Central auditory imperception:

• includes all hearing losses that are not linked
to defects in the conductive or sensorineural
structures
• results in receptive-expressive disorder in
which the child has difficulty processing,
patterning, and interpreting information
• They are usually divided into organic or
functional losses.
Type of central auditory imperception
• A. Organic hearing loss:
• the defect involves the reception of auditory stimuli along the central
pathways and the expression of the message into meaningful communication

• Examples:
• aphasia: the inability to express ideas in any form, either written or verbal
• agnosia: the inability to interpret sound correctly
• dysacusis: difficulty in processing details or discriminating among sounds
Type of central auditory imperception
B. Functional hearing loss:
• no organic lesion exists to explain a central auditory loss

Examples:
• conversion hysteria: an unconscious withdrawal from
hearing to block remembrance of a traumatic event
• infantile autism
• childhood schizophrenia
 CLASSIFICATION

• Hearing impairment can be classified according to:

1) hearing threshold level: the measurement of an
individual’s hearing threshold by means of an audiometer
2) the degree of symptom severity as it affects speech

❖These classifications offer only general guidelines

regarding the effect of the impairment on any individual
child because children differ greatly in their ability to use
residual hearing.
 ETIOLOGY
❖Causes of hearing impairment can be grouped into four categories:
genetic/familial, intrauterine/prenatal, perinatal, and postnatal
❖Etiology of hearing loss may be caused by a number of prenatal and
postnatal conditions:
• a family history of childhood hearing impairment
• anatomic malformations of the head or neck
• low birth weight
• severe perinatal asphyxia
• perinatal infection (cytomegalovirus, rubella, herpes, syphilis,
toxoplasmosis, bacterial meningitis), chronic ear infection, cerebral
palsy, Down syndrome, prolonged neonatal oxygen supplementation or
administration of ototoxic drugs
 RISK FACTORS

• High-risk neonates who survive formerly fatal prenatal or

perinatal conditions may be susceptible to hearing loss
from the disorder or its treatment.
• For example, sensorineural hearing loss may be a result
of continuous humming noises or high noise levels
associated with incubators, oxygen hoods, or intensive
care units, especially when combined with the use of
potentially ototoxic antibiotics.
 RISK FACTORS
• Environmental noise:
• Sounds loud enough to damage sensitive hair cells of the inner ear can
produce irreversible hearing loss.
• Very loud, brief noise, such as gunfire, can cause immediate, severe,
and permanent loss of hearing.
• Longer exposure to less intense but still hazardous sounds, such as
loud persistent music via headphones, sound systems, concerts, or
industrial noises, may also produce hearing loss
• Loud noises combined with the toxic substances such as smoking or
secondhand smoke produce a synergistic effect on hearing that causes
hearing loss
 Treatment/Therapeutic Management
❖Treatment of hearing loss depends on the cause and type
of hearing impairment.

A. Conductive Hearing Loss

• Many conductive hearing defects respond to medical or
surgical treatment, such as antibiotic therapy for acute
otitis media or insertion of tympanostomy tubes for
chronic otitis media.
• When the conductive loss is permanent, hearing can be
improved with the use of a hearing aid to amplify sound.
 Types of Hearing Aids

• those worn in or behind

the ear
• models incorporated into
an eyeglass frame
• types worn on the body
with a wire connection to
the ear
Revolutionary Non-Surgical Hearing Device/ Passive Devices
Bone-anchored Conduction Implant/ Hearing System
 Nursing Responsibility

• The nurse should be

familiar with the types,
basic care, and
handling of hearing
aids, especially when
the child is
hospitalized.
 PROBLEMS WITH A HEARING AID

• acoustic feedback: an annoying whistling sound usually

caused by improper fit of the ear mold
❖Sometimes the whistling may be at a frequency that the
child cannot hear but that is annoying to others. In this
case, if children are old enough, they are told of the noise
and asked to readjust the aid.
NURSING RESPONSIBILITY
 PROBLEMS WITH A HEARING AID

• As children grow older, they may be self-conscious about

the device.
❖Effort may be made to make the aid invisible, such as
styling the hair to cover behind-the-ear or in-the-ear
models and encourage the use of attractive frames for
glasses with connected hearing aids.
❖Give children responsibility for the care of the device as
soon as they are able because fostering independence is
a primary goal of rehabilitation.
NURSING RESPONSIBILITY
 NURSING RESPONSIBILITY

• Communicate with children with hearing

impairment or who are hearing challenged with the
use of photographs, drawing pictures and sign
language or demonstration to learn new skills.
• Provide a sign language interpreter.
 Treatment/Therapeutic Management
B. Sensorineural Hearing Loss
• Treatment for sensorineural hearing loss is much less
satisfactory. Because the defect is not one of intensity of
sound, hearing aids are of less value in this type of defect.
• Children with sensorineural hearing loss have lost or
damaged some or all of their hair cells or auditory nerve
fibers.
• Often these children cannot benefit from conventional
hearing aids because they only amplify sound that cannot
be processed by a damaged inner ear.
 Treatment/Therapeutic Management
1. Cochlear implant:
• a surgically implanted prosthetic device
• provides a sensation of hearing for individuals who
have severe or profound hearing loss
• bypasses the hair cells to directly stimulate
surviving auditory nerve fibers so that they can
send signals to the brain
• These signals can be interpreted by the brain to
produce sound and sensations.
• The trend is toward early use of cochlear implants,
usually by 18 months of age, to give the child
maximum opportunity to develop listening,
language, and speaking skills.
 Treatment/Therapeutic Management

2. Multichanneled implants:
• more sophisticated device
• stimulates the auditory nerve at a number of
locations with differently processed signals
• This type of stimulation allows a person to use the
pitch information present in speech signals, leading
to better understanding of speech.
COCHLEAR IMPLANTS
 Nursing Care Management

ASSESSMENT
• Assessment of children for hearing impairment is a
critical nursing responsibility.
• Identification of hearing loss within the first 3 to 6 months
of life is essential to improve the language and
educational outcomes for children with hearing
impairments.
 Nursing Care Management

Hearing Assessment
• A thorough health assessment should also include an evaluation
of hearing, including both history and observation, because good
hearing is necessary for the development of age appropriate
skills.
• Parents and grandparents are usually attuned to hearing difficulty
in children and may be suspicious of it in advance of its official
detection.
• When taking an auditory history, be certain to ask the
accompanying adult or parent an overall question such as, “Do
you have any reason to believe your child doesn’t hear as well as
other children?”
 Nursing Care Management: Assessment
Adverse Effects and Clinical Manifestations of Hearing Impairment
Delayed language/ speech development and articulation difficulty
• Adverse effects of hearing impairment may include delayed language
development which depends in large part on auditory stimulation
• During early childhood, the primary importance of hearing impairment is the
effect on speech development.
• A child with a mild conductive hearing loss may speak fairly clearly but in a
loud, monotone voice.
• A child with a sensorineural defect usually has difficulty in articulation.
❖ Children with articulation problems need to have their hearing tested.
 Nursing Care Management: Assessment

Adverse Effects and Clinical Manifestations of Hearing

Impairment
Altered socialization, play and safety issues
• Altered socialization which normally depends so heavily
on verbal communication for interaction
• Hearing impairment hinders cooperative play since the
child has difficulty interacting and responding in groups
• The toddler will need guidance on how to play with others,
and safety issues must be considered.
 Nursing Care Management: Assessment

Adverse Effects and Clinical Manifestations of Hearing

Impairment
• Frustration
• Communication may be difficult, leading to frustration
when words are not understood.
• For example, an inability to hear higher frequencies may
result in the word spoon being pronounced “poon.”
 Nursing Care Management: Assessment
Adverse Effects and Clinical Manifestations of Hearing Impairment
• Impaired attachment between infant and parents - the
parents’voices usually convey warmth and caring
• Impaired learning about the environment - learning is
enhanced when the child can associate sounds with
various objects
• Persistence of immature egocentric behavior for
longer than normal without the child’s ability to interpret
verbal cues regarding sociably acceptable behavior
 Nursing Care Management: Assessment
Adverse Effects and Clinical Manifestations of Hearing Impairment
• Impaired locomotion and increased potential for
injury - auditory cues enhance locomotion by
encouraging rhythmicity and also alert the child to
potential dangers
• Impaired cognitive learning which is normally enhanced
by auditory cues such as explanations of directions and
verbal feedback
 Hearing Assessment : Auditory Screening
Newborn and Infant
❖ Certain infants are high risk for hearing deficits so definitely should be
screened. Should be done by age 3 months not later than 6 months. This
includes infants with:
• History of childhood hearing impairment in the family
• Congenital perinatal infection, such as cytomegalovirus, rubella, herpes, toxoplasmosis, or
syphilis
• Anatomic malformations involving the head or neck
• Birth weight less than 1500 g
• Hyperbilirubinemia at a level exceeding indication for exchange transfusion
• Bacterial meningitis, especially when caused by Haemophilus influenzae
• Severe birth asphyxia: infants with an Apgar score of 0 to 3, those who failed to breathe
spontaneously within 10 minutes of birth, or those with hypotonia persisting to 2 hours of age
• Newborns who received an antibiotic
 Hearing Assessment: Auditory Newborn Screening

Newborn and Infant

• The Joint Committee on Infant Hearing (2000) issued
guidelines on auditory testing or screening of newborns
and infants to detect early hearing loss and implement
intervention programs.
• In most hospitals, all newborns are routinely screened for
hearing.
 Hearing Assessment : Auditory Screening
Newborn and Infant
• A newborn’s hearing is usually assessed through simple response testing—
observing whether an infant stirs or responds to a sound delivered to the
child with a commercial device.
• At birth, the nurse can observe the neonate’s response to auditory stimuli, as
evidenced by the startle reflex, head turning, eye blinking, and cessation of
body movement.
• The infant may vary in the intensity of the response, depending on the state
of alertness.
• A consistent absence of a reaction should lead to suspicion of hearing loss.
• Children who are profoundly hearing impaired are much more likely to be
diagnosed during infancy than less severely affected ones.
 Hearing Assessment : Auditory Screening

Newborn and Infant

• It can also be done by:
1) brainstem auditory-evoked response (BAER) testing
2) transient evoked otoacoustic emissions (TEOAEs)
 Hearing Assessment : Auditory Screening

Newborn and Infant

1) brainstem auditory-evoked response (BAER) testing
• For this method, an earphone is placed on the infant and an
electrode is attached to the scalp.
• When sound is transmitted to the child’s ear through the
earphone, the electrical potential created as the sound is
processed by the brainstem is read by the scalp electrode,
processed by a microcomputer, and plotted on a graph.
• This type of testing may be used at any age and is successful
even in children who are comatose or anesthetized.
 Hearing Assessment : Auditory Screening
Newborn and Infant
2) Smaller units using transient evoked otoacoustic emissions
(TEOAEs)
• A click stimulus delivered to a normal ear produces an echo from
the cochlea.
• This can be detected by a miniature microphone to reveal even
minor hearing loss.
• Although newborn hearing screening can lead to false-positive
results because many infants of this age are still sleepy from birth
analgesia and may have fluid- or vernix-filled ear canals,
repeating the test usually decreases the incidence of false-
positive results.
 Hearing Assessment: Auditory Screening

Older Children
• Routine screening for adequate hearing levels is usually
begun at 3 years of age.
• Testing requires knowledge of the technique, use of an
audiometer, and a quiet, undistracted setting.
 Hearing Assessment: Auditory Screening
Older Children
• If the defect is not detected during early childhood, it likely will become
evident during entry into school, when the child has difficulty learning.
• Unfortunately, some of these children are mistakenly placed in special
classes for students with learning disabilities or CI.
❖ It is essential that the nurse suspect a hearing impairment in any child
who demonstrates the behaviors listed in Box 19-5.
 Hearing Assessment: Auditory Screening

Older Children
• Older children who are at risk for hearing loss are those
who have been exposed to loud noises such as an
explosion or loud music, were of low birth weight, have
congenital anomalies, have a repaired cleft palate, or
have had repeated ear infections.
• During history taking, ask children if they ever worry if
they have difficulty hearing.
• Ask them how they are doing in school.
 Hearing Assessment : Auditory Screening

Older Children
• Some children with a minimal hearing impairment are considered to have
behavioral problems in school because they do not follow directions well or
appear not to be following the teacher’s discussion when in fact they may be
unable to hear what is being said.
• Be certain not to confuse difficulty hearing with shyness or recalcitrance in
answering.
• Children with an ear infection (otitis media) or allergies should be tested after
the fluids in their ears clear because their hearing may be temporarily
affected by these conditions.
• Cerumen in the ear canal is not documented to substantially decrease
hearing.
Principles of Audiometric Assessment Frequency
• Sound is the result of vibration; frequency is the number of
vibrations a sound creates per second.
❖When frequency is increased, the pitch of the sound increases.
• For audiometric testing, frequency is measured in Hertz units.
❖Hearing is measured at various frequencies, such as 500, 1000,
and 2000 cycles/sec, the critical listening speech range
❖Normal speech sounds fall into a narrow range, 500 to 2000 Hz,
so to function adequately and speak effectively, a child must be
able to hear in this range.
❖Children are tested for a wider frequency range than this, from
500 to 6000 Hz, on a routine screening assessment.
Principles of Audiometric Assessment Frequency
• Loudness
• Decibels are an expression of the intensity of loudness of a
sound (or vigor of the vibrations).
• Symptom Severity Hearing impairment is expressed in terms of a
decibel (dB), a unit of loudness.
• A decibel level of 0 dB is the softest sound that can be heard.
• Normal conversation is approximately 50 to 60 dB.
• The sound level at which inner ear damage can occur is about 90
dB.
• Sound levels of 140 dB are so intense they actually cause pain.
• Screening audiometry is done at 25 dB.
Principles of Audiometric Assessment Frequency
Hearing Loss
• A hearing loss greater than 49 dB is sufficient enough to interfere with
hearing normal conversation and developing language.
• The inability of a child to hear sounds softer than 30 dB indicates a child will
have some difficulty hearing normal instructions and questions.
• If a child cannot hear sounds softer than 50 dB, the child misses most normal
conversation and will have difficulty achieving in a regular classroom
environment. Hearing loss at this level is so severe that the child will also be
speech-challenged because normal speech sounds cannot be heard.
• If children can hear all frequencies at the 25-dB level, they have passed an
audiometric screening check.
• If a child fails to hear two or more frequencies at 25 dB, in either or both ears,
the child has failed a screening audiometry test and should be referred to a
physician or an otologist.
Principles of Audiometric Assessment Frequency

• An audiogram is a record of audiometric testing.

• Figure 34.24 shows an audiogram of a child with normal
hearing in the right ear (the child heard all frequencies at
the 20-dB level) but an inability to hear sounds softer than
45 dB in the left ear at frequencies of 1000, 2000, and
4000 Hz.
 Hearing Assessment

Acoustic Impedance Testing

• Acoustic impedance testing is based on the principle that sound entering the
ear canal meets resistance at the tympanic membrane.
• If the middle ear is functioning normally, there will be a symmetric pattern of
resistance on a tympanogram printout.
• If the middle ear is functioning abnormally, the level of resistance will be
greater or less than normal, so the pattern will be abnormal.
• Acoustic impedance testing is performed by audiologists.
• For the assessment, the ear to be tested is plugged with a rubber disc.
Sound is then administered to the ear through the center of the disc. The
resistance met at the eardrum is registered and recorded as a graph.
 Hearing Assessment

• Tympanograms are inaccurate in children younger than

7 months because the tympanic membrane is too
compliant under that age to register normal impedance.

• Conduction Loss Testing

• Both the Rinne and the Weber tests are helpful
assessments that can be used to help determine the
cause of hearing loss in older children.
Diagnostic evaluation may reveal:

• Structural abnormalities or signs of inflammation on visual

inspection of the external and internal ear
• Quantitative determination of hearing impairment on
audiometric testing
• Impaired acoustic impedance of the tympanic membrane
detected on tympanometry
• Abnormal activation of neural pathways in direct response
to acoustic stimulation through brainstem auditory-evoked
potentials
Diagnostic evaluation may reveal:

• Abnormal infant motor response prior to sound via a crib-

o-gram (a hearing test that anylyzes hearing responses
by comparing the infant’s response before, during, or after
a sound is introduced)
• Abnormal bone or air sound conduction as evaluated by
the Rinne and Weber tests
• Impaired inner equilibrium detected on vestibular testing
 Speech Assessment
• Speech problems are directly related to hearing problems: infants who do not
hear will make preliminary babbling sounds but then will not develop
intelligible speech because they cannot hear and repeat sounds.
❖ Speech difficulties may also be related to:
• Motor development such as when the child cannot control tongue and facial
muscles well enough to form proper words
• Cognitive development such as when the cognitively challenged child cannot
grasp the concept of speech or word use until later than normal, or possibly
not at all
• Cultural influences such as when the parents speak two languages, making it
difficult for a child to accurately learn and articulate either language or when
parents spoke “baby talk” for so long the child mimicked that instead of
pronouncing words clearly
 Speech Assessment

• Speech screening begins by asking children a few simple

questions to determine their language pattern.
• Also ask parents if they have noticed any difficulties with
their child’s pronunciation or comprehension.
 Speech Assessment

Denver Articulation Screening Examination (DASE)

• Standardized tests, such as the Denver Articulation
Screening Examination, may also be administered.
• The DASE is designed to detect significant developmental
delays and normal variations in the acquisition of speech
sounds.
• Because it is a standardized test, its directions must be
followed carefully. The test is useful only with English-
speaking children.
 Speech Assessment

Denver Articulation Screening Examination (DASE)

• Administration
• Before the test, explain that the child will need to repeat some
words she hears. Give enough examples so she will understand
what she is to do: “When I say ‘boat,’ then you say ‘boat.’” When
you are certain the child understands the directions, say each of
the 22 words shown on the DASE form (Fig. 34.25A). Convey the
impression that there is no right or wrong answer. Give the child
approval for responding and following directions correctly, no
matter how inaccurately the child repeats the word.
 Speech Assessment
Denver Articulation Screening Examination (DASE)
• Scoring
• The DASE is designed for use with children between ages 2.5 and 6 years.
• In scoring, consider the child’s age to be the closest previous age shown on
the percentile rank chart (see Fig. 34.25B).
• Score the child’s pronunciation of the underlined sounds or blends in each
word on the test form. A perfect raw score is 30 correctly articulated sounds.
Match this raw score on the percentile rank chart with the column
representing the child’s age. The number at which the raw score line and the
age column meet is the percentile rank of the child (how the child compares
with other children of that age). Percentiles shown above the heavy line are
abnormal; those below the line are normal.
 Speech Assessment
Denver Articulation Screening Examination (DASE)
• Scoring
• For example, a 3-year-old who says only 12 sounds correctly
ranks in the 9th percentile (abnormal ranking), and a 3-year-old
who says 20 sounds correctly ranks in the 58th percentile (normal
ranking).
• In addition to determining the percentile ranking, rate the child’s
spontaneous speech in terms of intelligibility as 1, easy to
understand; 2, understandable half the time; 3, not
understandable; or 4, cannot evaluate (maybe the child did not
speak in sentences or phrases during your contact with the child).
 Speech Assessment
Denver Articulation Screening Examination (DASE)
• Scoring
• Score intelligibility according to the chart in Figure 34.25B.
• For a final score, rate the child’s total test result (normal or
abnormal on the DASE or intelligibility).
• Children who score abnormally on this screening test should be
retested in 2 weeks. If they still score abnormally, they should be
referred for complete speech evaluation.
 Nursing Diagnosis

• Delayed development/ Risk for

• Disturbed sensory perception: hearing
• Ineffective coping
• Impaired hearing
• Impaired social interaction
• Impaired verbal communication
• Sensory and perceptual alterations: auditory
• Social Isolation
 Planning and Implementation

1. Promote communication by encouraging family

participation in the child’s education.
2. Facilitate lip reading by following specific guidelines to
assist the child such as enface positioning, good lighting on
the face, and not moving while speaking.
3. Maximize communication potential by having the child’s
vision assessed to determine whether any visual problems
accompany hearing impairment and thus interfere with
learning patterned speech.
 Planning and Implementation

4. Maximize residual hearing by investigating reliable

hearing devices.
5. Help prevent further hearing loss by encouraging
immunizations, teaching parents signs and symptoms of ear
infections, and teaching parents to question any prescribed
drug that might be ototoxic.
6. Provide opportunities for socialization and play by
encouraging the child to participate in age-related and
developmentally appropriate activities.
 Planning and Implementation

7. Encourage independent development through emphasis

on self-care.
8. Assist family members in adjusting to life with a hearing-
impaired child; refer them to available community support
groups.
9. Promote parent-child attachment by helping parents cue
into their child’s body language, distress signals, and
comfort signs.
 Planning and Implementation

10. Provide patient and family teaching, covering:

a. Goals of rehabilitation; acceptance of the disability and active participation
in the child’s care and education
b. The importance of viewing the child primarily as a child and only secondary
as a child with disability
c. Information on all local and national organizations that assist persons with
hearing impairment
d. Specific behaviors to enhance parent-child attachment, such as using the
enface position when cuddling or talking with an infant.
e. How to operate a hearing aid to reduce ambient noise
f. Hearing aid care
g. Strategies for maximizing the child’s active participation in peer activities
and social events.
 Nursing Care Management
FACILITATE COMMUNICATION
Lipreading
• Even though the child may become an expert at lipreading, only
about 40% of the spoken word is understood, less if the speaker
has an accent, mustache, or beard.
• Exaggerating pronunciation or speaking in an altered rhythm
further reduces comprehension.
• Parents can help the child understand the spoken word by using
the suggestions in the Nursing Care Guidelines box.
 Nursing Care Management
FACILITATE COMMUNICATION
Lipreading
• The child learns to supplement the spoken word with sensitivity to
visual cues, primarily body language and facial expression (e.g.,
tightening the lips, muscle tension, eye contact).
• Health care providers should consider not putting on the surgical
mask if a child with hearing impairment is able to lipread.
• Someone who is able to translate using sign language should
always be with the child.
 Nursing Care Management

FACILITATE COMMUNICATION
Cued Speech
• This method of communication is an adjunct to straight
lipreading.
• It uses hand signals to help the child with a hearing
impairment distinguish between words that look alike
when formed by the lips (e.g., mat, bat).
• It is most often used by children with hearing impairments
who are using speech rather than those who are
nonverbal.
 Nursing Care Management
FACILITATE COMMUNICATION
Sign Language
• Sign language, such as American Sign Language (ASL)
or British Sign Language (BSL), is a visual gestural
language that uses hand signals that roughly correspond
to specific words and concepts in the English language.
• Family members are encouraged to learn signing
because using or watching hands requires much less
concentration than lipreading or talking.
• A symbol method enables some children to learn more
and to learn faster.
ALPHABETS
 Nursing Care Management

FACILITATE COMMUNICATION
Speech Language Therapy
• The most formidable task in the education of a child who
is profoundly hearing impaired is learning to speak.
• Speech is learned through a multisensory approach using
visual, tactile, kinesthetic, and auditory stimulation.
• Parents are encouraged to participate fully in the learning
process.
 Nursing Care Management
FACILITATE COMMUNICATION
Additional Aids
• Everyday activities present problems for older children with hearing
impairment.
• For example, they may not be able to hear the telephone, doorbell, or alarm
clock.
• Several commercial devices are available to help them adjust to these
dilemmas.
• Flashing lights can be attached to a telephone or doorbell to signal its ringing.
• Trained hearing ear dogs can provide great assistance because they alert
the person to sounds, such as someone approaching, a moving car, a signal
to wake up, or a child’s cry.
 Nursing Care Management

FACILITATE COMMUNICATION
Special teletypewriters or telecommunications devices
• Special teletypewriters or telecommunications devices for
the deaf (TDD or TTY) help people with impaired hearing
communicate with each other over the telephone;
• The typed message is conveyed via the telephone lines
and displayed on a small screen
 Nursing Care Management

FACILITATE COMMUNICATION
Closed captioning and subtitles in audiovisual medium
• Any audiovisual medium presents dilemmas for these children, who
can see the picture but cannot hear the message.
• However, with closed captioning a special decoding device is
attached to the television, and the audio portion of a program is
translated into subtitles that appear on the screen.
 Nursing Care Management

Promote socialization and safety

• As children learn to compensate for their lack of hearing,
they become extremely perceptive to visual and vibratory
changes.
• Children often know when another person wants to talk to
them because the person will walk close by but not pass.
• They learn to be alert to other people approaching them
by seeing their shadows or feeling the vibrations of their
footsteps.
 Nursing Care Management

Promote socialization and safety

• They are acutely aware of facial expressions and may comprehend
unspoken messages more quickly than the spoken word.
• Socialization is extremely important to children’s development.
• The toddler will need guidance on how to play with others, and safety issues
must be considered.
• If children attend a special school for the hearing impaired, they are able to
socialize with peers in that setting.
• Classmates become a potential source of close friendships because they
communicate more easily among themselves.
• Encourage parents to promote these relationships whenever possible.
 Nursing Care Management
Provide help with school or social activities
• Children with a hearing impairment may need special help with school or
social activities.
• For children wearing hearing aids, background noise should be kept to a
minimum.
• Because many of these children are able to attend regular classes, the
teacher may need assistance in adapting methods of teaching for the child’s
benefit.
• The school nurse is often in an optimal position to emphasize methods of
facilitated communication, such as lipreading (see Nursing Care Guidelines
box).
 Nursing Care Management
Provide help with school or social activities
• Because group projects and audiovisual teaching aids may hinder the child’s
learning, these educational methods should be carefully evaluated.
• In a group setting, it is helpful for the other members to sit in a semicircle in
front of the child. Because one of the difficulties in following a group
discussion is that the child is unaware of who will speak next, someone
should point out each speaker.
• Speakers can also be given numbers, or their names can be written down as
each person talks.
• If one person writes down the main topic of the discussion, the child is able to
follow lipreading more closely. Such suggestions can increase the child’s
ability to participate in sports, organizations such as Scouts, and group
projects.
 Nursing Care Management

Support Child and Family After the diagnosis of hearing

impairment is made
• Parents need extensive support to adjust to the shock of
learning about their child’s disability and an opportunity to
realize the extent of the hearing loss.
• If the hearing loss occurs during childhood, the child also
requires sensitive, supportive care during the long and
often difficult adjustment to this sensory loss.
• Early rehabilitation is one of the best strategies for
fostering adjustment.
 Nursing Care Management

Support Child and Family After the diagnosis of hearing

impairment is made
❖Emotional support of the child and family
• Progress in learning communication may not always
coincide with emotional adjustment. Depression or anger
is common, and such feelings are a normal part of the
grieving process.
 Nursing Care Management

Care for the Child During Hospitalization

• The needs of the hospitalized child with impaired hearing
are the same as those of any other child, but the disability
presents special challenges to the nurse.
• For example, verbal explanations must be supplemented
by tactile and visual aids, such as books or actual
demonstration and practice.
 Nursing Care Management

Care for the Child During Hospitalization

• Children’s understanding of the explanation needs to be
constantly reassessed.
• If their verbal skills are poorly developed, they can answer
questions through drawing, writing, or gesturing.
• For example, if the nurse is attempting to clarify where a spinal
tap is done, the child is asked to point to where the procedure will
be done on the body.
• Because these children often need more time to grasp the full
meaning of an explanation, the nurse needs to be patient,
allowing ample time for understanding.
 Nursing Care Management

Care for the Child During Hospitalization

• When communicating with the child, the nurse should use
the same principles as those outlined for facilitating
lipreading. Ideally, nurses without foreign accents should
be assigned to the child.
• The child’s hearing aid is checked to ensure that it is
working properly.
• If it is necessary to awaken the child at night, the nurse
should gently shake the child or turn on the hearing aid
before arousing the child.
 Nursing Care Management

Care for the Child During Hospitalization

• The nurse should always make certain that the child can
see him or her before any procedures, even routine ones
such as changing a diaper or regulating an infusion. It is
important to remember that the child may not be aware of
one’s presence until alerted through visual or tactile cues.
 Nursing Care Management

Care for the Child During Hospitalization

• Ideally, parents are encouraged to room with the child.
However, it must be conveyed to them that this is not to
serve as a convenience to the nurse but as a benefit to
the child.
• Although the parents’ aid can be enlisted in familiarizing
the child with the hospital and explaining procedures, the
nurse also talks directly to the youngster, encouraging
expression of feelings about the experience.
 Nursing Care Management

Care for the Child During Hospitalization

• If the child’s speech is difficult to understand, the nurse makes an
effort to become familiar with his or her pronunciation of words.
• Parents often can be helpful by explaining the child’s usual
speech habits.
• Nonverbal communication devices that use pictures or words that
the child can point to are also available. Such boards can also be
made by drawing pictures or writing the words of common needs
on cardboard, such as parent, food, water, or toilet.
 Nursing Care Management

The nurse as an advocate

• The nurse has a special role as child advocate and is in a
strategic position to alert other health team members and other
patients to the child’s special needs regarding communication.
• For example, the nurse should accompany other practitioners on
visits to the child’s room to ensure that they speak to the child and
that the child understands what is said. Caregivers sometimes
forget that the child has the abilities to perceive and learn despite
a hearing loss, and consequently they communicate only with the
parents. As a result, the child’s needs and feelings remain
unrecognized and unmet.
 Nursing Care Management
The nurse as an advocate
• Because children with impaired hearing may have difficulty
forming social relationships with other children, the child is
introduced to roommates and encouraged to engage in play
activities.
• The hospital setting can provide growth-promoting opportunities
for social relationships. With the assistance of a child life
specialist, the child can learn new recreational activities,
experiment with group games, and engage in therapeutic play.
• The use of puppets, dollhouses, role-playing with dress-up
clothes, building with a hammer and nails, finger painting, and
water play can help the child express feelings that previously were
suppressed.
 Nursing Care Management

Assist in Measures to Prevent Hearing Impairment

• A primary nursing role is prevention of hearing loss.
• Because the most common cause of impaired hearing is
chronic otitis media, it is essential that appropriate
measures be instituted to treat existing infections and
prevent recurrences.
• Children with a history of ear or respiratory infections or
any other condition known to increase the risk of hearing
impairment should receive periodic auditory testing.
 Nursing Care Management

Assist in Measures to Prevent Hearing Impairment

• To prevent the causes of hearing loss that begin
prenatally and perinatally, pregnant women need
counseling regarding the necessity of early prenatal care,
including genetic counseling for known familial disorders;
avoidance of all ototoxic drugs, especially during the first
trimester; tests to rule out syphilis, rubella, or blood
incompatibility; medical management of maternal
diabetes; strict control of alcohol intake; adequate dietary
intake; and avoidance of smoke exposure.
 Nursing Care Management

Assist in Measures to Prevent Hearing Impairment

• The necessity of routine immunization during childhood to
eliminate the possibility of acquired sensorineural hearing
loss from rubella, mumps, or measles (encephalitis) is
stressed.
 Nursing Care Management
Assist in Measures to Prevent Hearing Impairment
• Excessive noise pollution is a well-established cause of
sensorineural hearing loss.
• The nurse should routinely assess the possibility of environmental
noise pollution and advise children and parents of the potential
danger.
• When individuals engage in activities associated with high-
intensity noise, such as flying model airplanes, target shooting, or
snowmobiling, they should wear ear protection such as earmuffs
or earplugs.
• Even common household equipment, such as lawn mowers,
vacuum cleaners, and cordless telephones, can be harmful.
 Evaluation

1. The child does not develop additional hearing loss.

2. Family members provide adequate stimulation and
communication for the child.
3. Persons communicating with the child practice good
technique.
4. The child acquires and uses a hearing aid (when
appropriate).
5. The child interacts appropriately with peers.
 Evaluation

6. The child attends school regularly.

7. The child practices self-care independently as
appropriate
8. Family members express their concerns and feelings
regarding the child’s hearing impairment.
9. Family members verbalize the sighns and symptoms of
ear infection to watch for and report.
10. The family is actively involved in the child’s educational
program.
 References

• Marilyn Hockenberry and David Wilson. Wong’s

Essentials of Pediatric Nursing. 9th ed. Elsevier
• Adele Pillitteri. Maternal and Child Health Nursing:
Care of the childbearing and Childrearing Family. 6th
ed. Lippincott. Williams & Wilkins.
• Lippincott’s Review Series: Pediatric Nursing.
Lippincott.
THANK YOU!