Sudden Sensorineural Hearing Loss (SSNHL) Intervention

Sudden Sensorineural Hearing Loss (SSNHL) Intervention Henry Davis Hearing loss is not a common healthcare issue addressed by Nurse Practitioners (NP) and Sudden Sensorineural Hearing Loss (SSNHL) occurs even less frequently. Often the onset of hearing loss (related to aging or noise exposure) is insidious, often spanning months to years and is typically bilateral. Hearing loss that occurs with advanced age is routinely compensated for with the use of electronic devices that amplify sound and this type of hearing loss is typically not cured. SSNHL by contrast has a well-defined acute onset within 3 days and is characteristically unilateral hearing loss. Some cases of SSNHL could be cured if a diagnosis is made and treatment initiated within a short time from onset of the hearing loss (Raghunandhan et al., 2012). Nurse practitioners may often be the first healthcare provider the patient encounters. Because of the early patient contact, nurse practitioners are uniquely poised to initiate the first line treatment after consulting with neurology, but prior to referral for follow-up care and further evaluation. Recent research supports that patients who receive early medical treatment for SSNHL recover hearing more often than those, who received delayed care (Raghunandhan et al., 2012). Epidemiology Current research indicates the morbidity of SSNHL is 2-20/ 100,000 persons annually and the mean age of occurrence is 43-53 years old. Mortality as not reported other than a possible link between SSNHL and strokes. Gender does not appear to influence incidents. Risk factors for SSNHL include; advanced age, concurrent cardiovascular disease and the presence of a positive antinuclear antibody (Weber, 2014). One study indicated â€Å"†¦viral infection being the most common etiological factor† for SSNHL (Raghunandhan et al., 2012, p. 229). Etiology The cause of SSNHL is currently considered idiopathic, however the preponderance of current research is directed at the supposition that the etiology of SSNHL is due to edema of the eighth cranial and subsequent compression of the internal auditory artery to the cochlea and circular apparatus. The likely cause of the compression is edema of the auditory nerve within the confined space of the internal auditory meatus from a viral infection (Mom, Chazal, Gabrillargues, Gilain, Avan, 2005). There is minimal clearance for the nerves and vessels. If any edema occurs, compression of the associated structures can result. This would be similar in nature to the pathology associated with Bell’s palsy or compartment syndrome associated with a casted extremity. The surrounding tissue swells and compresses adjacent structures. Cause of SSNHL is currently identified as idiopathic but current treatment targets a viral infection as the causative agent. Early treatment with steroids and antiviral drugs demonstrated reduction in percentage of patients who experience total hearing loss. The nurse practitioner can begin treatment of the patient and ensure timely neurologic specialty follow-up and magnetic resonance imaging (MRI) to rule out acoustic neuroma (Chen, Halpin, Rauch, 2003). Pathogenesis Initially to understand SSNHL we first should examine the anatomy and function of the inner ear. The ear communicates with the brain via eighth cranial nerve. The eighth cranial nerve divides into two main branches, cochlear and vestibular nerves. The first cochlear nerve travels to the cochlea and the vestibular nerve travels to the semicircular ducts. The Cochlea is the portion of the inner ear responsible for the transformation of sound from a physical force, from the tympanic membrane via the malleus, incus and stapes into a nerve impulse conducted to the brain via the cranial nerve (Copstead Banasik, 2013). The vestibular nerve conducts impulses from the semicircular ducts. Semicircular ducts change the forces of air movement into fluid movement that in turn is changed into nerve impulses that allow for proprioception. Damage to this branch of the vestibular nerve can result in vertigo, nystagmus, vomiting and disruptions of proprioception (Copstead Banasik, 2013). The eighth cranial nerve passes through a relatively small opening, the internal auditory meatus, in the skull(Weber, 2014) (Kim Lee, 2009). This small opening also provides the arterial blood flow for the inner ear via the internal auditory artery (Kim Lee, 2009). Even a small amount of edema in the eighth cranial nerve can result in both compression of the nerve and occlusion of the arterial blood supply to the inner ear. The result of these Sequelae would be rapid hearing loss, nystagmus and vertigo (Weber, 2014). During the acute period, the first few hours, it would be possible to decrease the edema by administration of steroids thereby decompressing the nerve and re-establishing blood flow to the inner ear (Narozny et al., 2006). Delays in the reduction of this edema may result in tissue necrosis and clot formation due to stasis of blood in the internal auditory artery. Another less researched cause of SSNHL is vertebrobasilar ischemic stroke or a thrombi occlusion of the arterial supply to the inner ear (Kim Lee, 2009). The resultant Sequelae following the occlusion would mirror the presentation of SSNHL from edema however; the key difference would be the response to oral steroids is ineffective. Any negative effects of oral steroids, if an ischemic stroke were diagnosed would be minimal as the follow-up for MRI should be performed immediately after initial treatment. Clinical Manifestations Onset of SSNHL appears as idiopathic and not related to any trauma and patient denies current source of infection. The patient may report having a clogged ear or pressure in ear. There is an absence of signs and symptoms of infection such as fever, drainage and pain. The patient may find it difficult to impossible to determine the direction of the source of a sound, as both ears are needed to identify the direction of a source of a sound. The brain normally uses the auditory input from both ears identify source location of an auditory stimulus. The occlusion of blood flow to the cochlea on one side has resulted in complete hearing loss to that side. SSNHL may present with an acute onset of tinnitus in the affected ear. The patient may describe the sound as a ringing or roaring sound. Initial onset of tinnitus may cause difficulty in concentration. The pathology responsible for tinnitus remains unclear. The onset of SSNHL is rapid and unilateral, proceeding from normal hearing to complete absence of hearing of the effected ear in less than 3 hours(Weber, 2014). SSNHL is often accompanied by nystagmus, tinnitus and vertigo. This may be due to the compression of the internal auditory artery and the resultant occlusion of blood flow to the cochlea and semicircular apparatus. In addition, when we consider the functions of the central nervous system in the perception of proprioception, multiple stimuli typically confirm the position of the body such as the semicircular apparatus and visual stimuli. With the sudden cessation of blood flow to the inner ear, a mismatch of stimuli rapidly occurs. This mismatch of stimuli among various nerves results in the perception of vertigo and often nystagmus. The Performance of a Rinne test and Weber test enables the nurse practitioner to differentiate between bone conduction damage, as is the case with traumatic injury or nerve damage as is the case in both SSNHL and ischemic stroke (Tintinalli, 2010). Also important is the Dix-Hallpike test, to differentiate between central or peripheral vertigo (Furman Barton, 2014). Central vertigo would be those with a site of origin inside the brain, were as peripheral vertigo originates outside the brain. The Dix-Hallpike test differentiates between central and peripheral vertigo. A Dix-Hallpike test is positive if vertigo and nystagmus is elicited when the head is rotated. Dix-Hallpike test also identifies unilateral vertigo, as well as it differentiates between central and peripheral causes of vertigo and nystagmus. Benign positional nystagmus is also evaluated utilizing the Dix-Hallpike test. In (BPN) the result is a delay of onset of nystagmus of >20seconds, nystagmus slowly resolves if head h eld in the same position, and response decreases with repeated testing (Dix-Hallpike Test, 2014). A central cause of vertigo and nystagmus need to be evaluated if the Dix-Hallpike test yields atypical results of nystagmus that occurs without rotation of the head, begins without delay, and does not decrease with retesting(Dix-Hallpike Test, 2014). Treatment The recommended treatment of SSNHL is early administration of oral glucocorticoids (Raghunandhan et al., 2012)(Narozny et al., 2006). This intervention is well within the scope of practice of the Nurse Practitioner. Nurse Practitioners should be encouraged to take the lead in diagnosing and initiating treatment for SSNHL. The risk associated with early treatment of suspected SSNHL is minimal however if treatment is delayed hearing loss may be permanent. The indication for administration of steroids is to decrease edema of the eighth cranial nerve as this edema leads to loss of nerve conduction and ultimately nerve tissue death and possible arterial occlusion (Chen et al., 2003). The result of tissue death of the eighth cranial nerve is hearing loss, nystagmus, tinnitus and impaired balance (Copstead Banasik, 2013). Current treatment of SSNHL aims at the reduction of damage to the eighth cranial nerve. Other medications can be used to treat the after effects of SSNHL such as vertigo. Select antihistamines, which are also classified as vestibular suppressant, are often used to decrease the perception of vertigo. These drugs reduce â€Å"the activity in the vestibular nuclei and cerebellum.†(Denner, 2013, para. 6). This class of medication is used as needed for vertigo control. Vestibular suppressant antihistamines are first line medications for vertigo. If Vestibular suppressant antihistamines are not successful in controlling vertigo then an escalation to a low dose benzodiazepine most often resolves vertigo not controlled by first line medications. Benzodiazepines cause central nervous system depression and thereby decrease vertigo. The treatment of choice for chronic vertigo is vestibular rehabilitation. Vestibular Rehabilitation is an exercise-based therapy used to retrain the central nervous system (CNS). Often vestibular rehabilitation is sufficient to control symptoms of vertigo without the need for daily medications. The provider often refers the patient experiencing vertigo to physical therapy (PT) or occupational therapy (OT) for a course of progressive exercises with associated head/eye movements to retraining the CNS (Vestibular Rehabilitation Therapy (VRT), 2014). Vestibular rehabilitation can greatly reduce the need for medications to reduce symptoms of vertigo and improves the quality of life. Vestibular rehabilitation is only the first of many topics that should be addressed by the nurse practitioner to assist the patient in lessening symptoms and coping with functional loss. Patient education is targeted toward identification of limitation and practices to compensate for those limitations. Simple functions such as body position during sleep can cause functional problems for patients. An example would be if patient sleeps on the non-affected ear toward the pillow, they would not hear sounds such as alarm clocks, smoke alarms, or other auditory products. Specialized alarms are available which provide both auditory and tactile stimuli (a strong bed vibrating unit) to awaken non-hearing or limited hearing persons. Also, educate patient that stressful situations and loud environments can exacerbate the experience of tinnitus and vertigo. Family members of the patient would be educated on actions to compensate for patient’s hearing loss. Walking on the non-affected side and not speaking close to affected ear are two examples. Also explaining the emotional stressors for the patient and the family members as both learn to cope with the new limitations. The Nurse Practitioner can also provide a referral to an ear, nose and throat specialist to evaluate the patient for cochlear implant for complete unilateral hearing loss. Current implants consist of a base magnet implant into the mastoid bone on the affected side. An external device is worn over the magnet and conducts sound into the magnet and across to the functional ear via bone conduction. The delay between air and bone conduction allows the patient to regain the ability to directionalize sound stimuli. The negative impacts of this option are cost, some insurances do not cover this surgery or only cover a portion of the total cost and this is a surgical intervention and all invasive procedure have associated risk factors. Conclusion Nurse Practitioners should broaden the scope of examination and treatment when assessing patients with sudden hearing loss. In the face of a presumptive diagnosis of SSNHL, the provider may improve outcomes by beginning treatment prior to conclusive diagnosis. Increased early intervention for SSNHL by Nurse Practitioners and beginning steroid treatment within the first few hours after onset of hearing loss may decrease the incidence of permanent hearing loss. The Nurse Practitioner is able to discriminate between sensorineural and conductive hearing loss. A causative factor is then diagnosed to direct care. SSNHL is an infrequently occurring health problem that can be treated with an early presumptive diagnosis. If the initial diagnosis of SSNHL is delayed for MRI to rule out Acoustic Neuroma, it increases the chance that hearing loss will become irreversible. The initial treatment with oral steroid is relatively low risk, yet this option is often omitted despite the apparent benefit. Although the confirmation of SNNHL requires MRI to rule out a differential diagnosis of acoustic neuroma, steroid treatment could begin as a protective measure. If an Acoustic Neuroma is diagnosed the steroid therapy could be discontinued. The impact of steroid use associated with Acoustic Neuroma has not been examined in current research. Appendix Figure 1 (Arora, 2012, figure 5) Figure 2 (Kim Lee, 2009, figure 2) References Arora, R. (2012). Vestibular Rehabilitation: An Overview. Int J Otorhinolaryngol Clin, 4, 54-69. Retrieved from http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=3564Type=FREETYP=TOPIN=_eJournals/images/JPLOGO.gifIID=280isPDF=NO Chen, C., Halpin, C., Rauch, S. (2003). Oral Steroid Treatment of Sudden Sensorineural Hearing Loss: A Ten Year Retrospective Analysis. Otology Neurotology, 24, 728–733. Retrieved from http://www.researchgate.net/publication/9088236_Oral_steroid_treatment_of_sudden_sensorineural_hearing_loss_a_ten_year_retrospective_analysis/links/00b7d51c062542efbc000000 Copstead, L., Banasik, J. (2013). Pathophysiogology (5th ed.). St. Louis, MO: Elsevier. Denner, K. (2013). Meclizine – Does it help? Retrieved from http://vestibular.org/news/10-07-2013/meclizine-–-does-it-help Dix-Hallpike test – Quick guide. (2014). Retrieved from http://www.ncuh.nhs.uk/our-services/dix-hallpike-test-quick-guide.pdf FM Jr, B. (1984). Sudden hearing loss: eight years experience and suggested prognostic table. The Laryngoscope, 94, 647-61. Retrieved from http://ezproxy.okcu.edu:2192/ehost/detail/detail?vid=1[emailprotected]hid=4201bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=mnhAN=6325838 Furman, J., Barton, J. (2014). Evaluation of the patient with vertigo. Retrieved from http://www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo?source=machineLearningsearch=Dix-HallpikeselectedTitle=2~5sectionRank=5anchor=H29#H29 Hearing Loss: A Ten Year Retrospective Analysis. Otology Neurotology, 24, 728-733. Retrieved from http://www.tonybaino.com/otorhino/steroidsssnhl.pdf Kim, J., Lee, H. (2009). Inner Ear Dysfunction Due to Vertebrobasilar Ischemic Stroke. SEMINARS IN NEUROLOGY, 29, 534-540. http://dx.doi.org/10.1055/s-0029-1241037 Mom, T., Chazal, J., Gabrillargues, J., Gilain, L., Avan, P. (2005). Cochlear blood supply: an update on anatomy and function. French Ear, Nose Laryngology, 88, 81-88. Retrieved from http://xa.yimg.com/kq/groups/17470070/1437766444/name/KimJS2009 [Inner Ear Dysfunction Due VB Ischemic Stroke].pdf Our Experience. Association of Otolaryngologists of India, 65, 229-233. http://dx.doi.org/10.1007/s12070-012-0506-9 Our Experience and a Review of the Literature. Annals of Otology. Rhinology Laryngology, 115, 554-558. Retrieved from http://ezproxy.okcu.edu:2192/ehost/pdfviewer/[emailprotected]5vid=16hid=4104 Sensorineural Hearing Loss: Prospective Clinical Research. The Journal of Otolaryngology, 36, 32-37. Retrieved from http://ezproxy.okcu.edu:2192/ehost/pdfviewer/[emailprotected]3vid=1hid=4104 Tintinalli, J. (2010). Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York, NY: Mc Graw Hill. Tintinalli, J. (2010). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York, NY: McGraw-Hill. Tintinalli, J. (2010). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York, NY: McGraw-Hill. Vestibular Rehabilitation Therapy (VRT). (2014). Retrieved November 15, 2014, from http://vestibular.org/understanding-vestibular-disorder/treatment/treatment-detail-page Weber, P. (2014). Sudden sensorineural hearing loss. Retrieved from http://www.uptodate.com/contents/sudden-sensorineural-hearing-loss?source=machineLearningsearch=SSNHLselectedTitle=1~6sectionRank=2anchor=H4#H12 Weber, P. (2014). Sudden sensorineural hearing loss. Retrieved from http://www.uptodate.com/contents/sudden-sensorineural-hearing-loss?source=previewsearch=SSNHLlanguage=en-USanchor=H2selectedTitle=1~6#H2 Yuan-Yuan, L., Zhe, J., Bu-Sheng, T., Jian-ming, Y., Ye-Hai, L., Maoli, D. (2008, January 8). A clinical study of microcirculatory disturbance in Chinese patients with sudden deafness. Acta Oto-Laryngologica, 128, 1168-1172. http://dx.doi.org/10.1080/00016480801901626

“Forrest Gump” Film Review Essay

Forrest Gump, a movie that not only informs the audience and the people who interact with Forrest, about the life of a very simple man (Forrest Gump, played by Tom Hanks). It also teaches morals and the way life is perceived in the beautiful mind of a simple man. Forrest Gump, throughout the movie narrates the story whilst he is sitting at a bus stop telling the people who sit next to him about his past experiences in his life (the storyline and set up of the movie). Most of the people waiting for their bus aren’t convinced and don’t believe Forrest and his stories, how he met Jenny Curran, his first ever real friend who ends up marrying him, how he met Bubba (played by Mykelti Williamson) and became the richest shrimp operator in America with Lt. Dan Taylor, his Lieutenant in the Vietnam War and how he was the Pin Pong champion for the army. The movie and stories told by Forrest all interact with events which actually occurred and impacted on the American society.The special effects in Forrest Gump are used uniquely and widely throughout the movie. One of the most creative effects used in movies which when used appropriately can have an entire different effect on the movie. There was great use of special effects when Forrest throughout the movie meets several presidents of America which some have been assassinated, with the use of special effects it enables and makes the audience think that Forrest was in that time period and able to meet them in person. A technique that is used to show emotions or reactions of characters which is used throughout Forrest Gump. Close Ups are used to give brief explanations of the way the character thinks, feels, etc. It makes the audience feel the emotions created by the character at the time/place. It also gives them a perspective of the characters character/personality. This technique is used when Forrest is a young boy and he is getting his leg braces on. There is a Close Up of his face showing the pain he is being put through in order for him to have a straight back when he is older. This Close Up makes the audience see and feel the pain Forrest is going through, it also shows that he is not a very physical/strong boy because he is not coping with the pain. A technique that is greatly used to create mood or atmosphere which can have a huge impact on the audiences view of the film. This technique is used greatly in Forrest Gump in order to set the time and place of specific  scenes. It is used in the opening scenes when there is a feather which is floating through the sky and around the city. There is music played while this is occurring, the music is soft, calm, basic and emotional which gives the audience the feel and setting of the movie. A technique which is used to involve the audience in the action of the movie so it gives them the feeling that they are involved in the specific scene. This technique is used throughout the movie especially when Forrest is a young boy and he begins to get chased by the class bullies. There is tracking used when the boys start to chase Forrest and Jenny tells Forrest to run and the camera follows him making it seem you are running with him. It shows the speed of Forrest as he is beating the boys who are on push bikes ands later on in the movie the scene is repeated but they are all older and they are chasing Forrest in a car and he still managers to get away. Bubba Forrest’s best friend, one of which is of the same intelligence as Forrest, both being simple minded people. They met in the army where their friendship formed. A man of his word, true to his family beliefs, growing up to one day own a shrimp boating business. Bubba is a man who has a goal and will do anything to succeed in what he hopes to achieve in, which contributes to the meaning of the film that as long as you stick to your goals you can achieve highly. Mrs GumpA woman who has a strong up bring amongst Forrest, she is very strong on her beliefs and will do anything for her son, which is shown in the movie. A woman of high intelligence, kind heart and willing to help people in need which is also shown throughout the movie. Lt. DanA man from a background of war torn history, which for him is a major thing to live up for. Being very angry with Forrest, who saves his life. Forrest is treated in a unique way, both being through hell and back together, which has built their friendship. Lt Dan is a very wise man and also strong on his beliefs and stands by his word, which is shown when he tells Forrest that he will join him on his shrimp boat. Forrest Gump can be portrayed in many different styles of films but it is mainly showing the beautiful mind of a simple man who is taken advantage of in many aspects of his life due to his simplicity and generosity, during the adventures and achievements he achieves throughout his life. In the movie he is portrayed a simple man who achieves in ways the normal man would not achieve which gives the message that anything is possible as long as you have a dream and continue to work at it. Another message is if you help people hopefully the favour will be returned as long as you stay a good, honest person. The director of the film Robert Zemeckis achieves these messages created by posting that feeling of isolation of society which Forrest receives but still managers to be a successful person.

Recruitment schedule and preparation for interview

Describe about yourself† – Identify synopsis about the applicant, specifically their Unique Selling Proposition, describe the applicants who they are and the major benefit that a company will drive from this person. Q. â€Å"Why have you applied for this Job? Or â€Å"Why are you leaving the current position? † – These are very critical questions. The interviewer will consider the reason why the applicants make a change. Is that problem with their previous employer or co-workers? Or do they want to promote? Q. What do you consider your most significant accomplishment in your previous Jobs? † – To find out their experiences/roles/responsibilities that the company can derive from that accomplishments Q. â€Å"What excites you most about this position and what do you think would be stretch for you? † – Evaluate and test the applicant to make sure they understand this Job description and what motivates them to take this Job. Intervie w questions about applicant's skills and experiences: Q. â€Å"Why do you believe you are qualified for this position? – To identify what qualifications or skills that the applicants need to adapt this Job. The applicant need to mention technical skills, a management skill or personal success story Q. What do you like/dislike most about your previous Job? † – Try to determine compatibility with the open position. Can discuss about challenges, pressure situations, deadlines Q. â€Å"What tasks do you find the hardest in the last Jobs? What weaknesses do you have and want to improve? † – Understand the limit of the applicants and identify their weakness.Does the weakness affect to the company? Or could the weaknesses be improved? Q. â€Å"Describe a difficult work situation/ project and how would you handle it? † Q. â€Å"Describe the time that you didn't work well with supervisor or co-worker? What was the outcome and how would you have chan ged the outcome? † CIO. â€Å"Have you worked with someone you didn't like? If so, how you handle it? † – These case-study questions to determine how the applicants dealt with their Jobs under the difficult situations such as pressure, technical problems, confliction with co-workers†¦IQ 1 . â€Å"Do you prefer to work independently or on a team? † – Want to know if they are team's players or would rather work on their own. IQ 2. â€Å"Give some examples of teamwork that you involved. † – Determine the applicant's roles/responsibilities in the team and how heir contribution to make the project successfully Interview Questions about Technical Skills IQ 3. â€Å"What do you do to maintain your technical certifications? † IQ 4. â€Å"How do you keep current on this industry? – Want to know if the applicant still update their knowledge in IT field and â€Å"could they be trained if required? † IQ 5. â€Å"How do you troubleshoot IT issues? † Q. â€Å"What development tools have you used? † – To find out their experience how to troubleshoot computer's hardware and software; maybe which tools they used to fix it or what programming language they used†¦ IQ 7. â€Å"Tell me about a time that you work conveying technical information to a unintentional audience† – Examine applicant's communication skills, and how they delivered their Job to unintentional audience.How quickly are they response for the problems? IQ 8. â€Å"Tell me about the IT's project you are most proud of, and what your contribution was. † IQ 9. â€Å"Give an example of where you have applied your technical knowledge in a practical way' – A deeper look in terms of technical skills to make sure the candidates are suitable for this Job. The interviewer maybe look at the software, management tools or development tools they used, are these tools used in our company? Q. What are you salary requirements – both short-terms and long- terms? Would you take a Job for less money? † – To identify the salary that satisfy the applicant and also consider the budget that company can afford it Interview Guide l. Prepare Create comfortable environment Introduce the purpose of this interview Spend some time introducing yourself to the applicants, and ask the applicants to do the same II. Core interview Focus on open questions to draw out candidates and their opinions.The questions would follow interview questions above: General questions: Ask about the applicant's personality, passion, hobbies Opinions about work and life Work independently or team Their ability Experienced in problems and how deal with it Deal with deadlines, stress Technical questions: Their roles/responsibilities in previous project/Job Ability to pick up new product/technology quickly Technical skills Technical training courses Career and company questions: Salary requirements Opi nions about this position/company Future career plan Ill. After the interview – Tell the applicants how can you reach them or send the results.Write a checklist all the questions you as

Tips On Controlling Diabetes With Diet And Exercise Essay

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