EAR CARE PROCEDURE FOR COMMUNITY NURSING SERVICES

EAR CARE PROCEDURE
FOR COMMUNITY NURSING SERVICES
(including ear irrigation)
First
Issued
April
2007
Issue
Version
Two
Purpose of Issue/Description of Change
To promote safe and effective ear care across
community nursing services
Planned Review
Date
2012
Named Responsible Officer:- Approved by Date
Service Improvement Team Nursing Policy Group April 09
Policy File:-
Nursing Policy File N o 1
Impact Assessment Screening
Complete
Date: March 2009
Full Impact
Assessment
Required Y/N
UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE PCT WEB SITE
THERE IS NO ASSURANCE THAT THIS IS THE CORRECT VERSION
.

EAR CARE PROCEDURE (including ear irrigation)
INTRODUCTION
Wax (cerumen) is a normal secretion of the ceruminous gland. A small amount of
wax is normally found in the ear canal, and its absence may indicate that excessive
cleaning, dry skin conditions or infection has interferred with the normal production
of wax.
It is only when there is an accumulation of wax that removal may become
necessary. In order to ascertain whether removal by irrigation is necessary, a full
assessment must be undertaked which includes examination of the ear with an
auroscope. The ear care documentation below must be used to undertake
assessment. Registered nurses who have undertaken PCT Ear Care training can
undertake ear irrigation, using the pathway, without prior examination by a general
practitioner.
Community nursing teams will provide the service for housebound pateints.
TARGET GROUP
Ear care must only be undertaken by PCT employed Registered Nurses that have
undergone appropriate Ear Care Training, provided by Rotherham Ear Care Centre.
Assistance with the administration of ear drops may be delegated to Nursing
Auxiliaries provided that the Registered Nurse provides detailed instructions and
assesses the competence of the Nursing Auxiliary to perform the task and monitors
progress.
RELATED POLICIES
• PCT Health Records Policy
• NMC (2008) The NMC code of professional conduct: standards for
conduct,performance and ethics.
• PCT Record Keeping Procedure for Community Nursing
• ICP4 Policy for the Decontamination of Re-usable Medical Devices
• ICP5 Hand Decontamination
• ICP10 Policy on the Use of Personal Protective Equipment
• ICP14 Single Use Equipment Policy
• ICP18 Clinical Waste Policy
• Clinical Waste Policy
• Incident Reporting Policy
• Medical Devices Policy
• Consent Policy
NB Always use most current versions of PCT and NMC policies as may be
superseded at any time.
EAR CARE PROCEDURE
2/13

Documentation
Nursing Management of Ear Wax – Documentation
Propulse electronic ear syringe cleaning procedure
PROCEDURE FOR EAR EXAMINATION
PROCEDURE
Verbally check the identity of the patient by asking
the patients full name and date of birth. Check
with carer/family if not able to confirm identity
Before careful physical examination of the ear,
listen to the patient, elicit symptoms and take a
history. Explain procedure and obtain informed
consent
Establish patient has no known allergies, check in
patients records and also ask patient / family of
any known history
Decontaminate hands
Examine pinna, outer meatus and adjacent scalp
Choose appropriately sized speculum
Pull the pinna upwards and outwards
To confirm identity
RATIONALE
To allow the patient / client to make an
informed decision and gain cooperation
To reduce allergic reactions
To prevent spread of micro-organisms
Evidence of surgical intervention,
infection, discharge, swelling and signs
of skin lesions may be evident
To prevent damage to the ear canal
To straighten the ear canal
If this is painful do not continue, as pain
may indicate infection / inflammation
Hold the otoscope like a pen and rest the small
digit on the patient’s head as a trigger for any
unexpected head movement
Insert the speculum gently into the ear canal
Attempt to view the tympanic membrane,
observing for any abnormalities
Check for presence of a mastoid cavity – if
present, inspect all parts of the cavity and refer
any concerns to General Practitioner. Mastoid
cavities must not be irrigated
Decontaminate hands
Observe condition of skin when withdrawing
otoscope and note the presence, amount and
consistency of any wax present
Document observations on ear care assessment
form (Appendix 1)
Dispose of single use speculum
To undertake visual assessment and
reduce the risk of trauma
Irrigation should not be carried out if
evidence of infection or perforation is
noted
Any intervention with mastoid cavities
must only be undertaken by an ear care
specialist
To prevent spread of micro-organisms
Subsequent advice and treatment is
dependent on condition of wax present
Ensure compliance with NMC and local
record keeping guidelines
To ensure speculum cannot be reused
EAR CARE PROCEDURE
3/13

• If hard, impacted wax is identified, advise the use of olive oil drops for 5 days
and reassess after this time (avoid extra virgin olive oil). Instill one to two
drops, twice a day for five to seven days and then re-assess
• If soft wax is present and risk assessment (Appendix 1) does not indicate
any contraindications then ear / ears may be irrigated
EAR IRRIGATION
Ear irrigation must only be undertaken using the propulse electric ear irrigator
provided by the PCT. Syringes must not be used to irrigate ears.
Do not irrigate ear if any of the following contraindications are noted:
• The patient has previously experienced complications following ear irrigation
in the past
• There is a history of middle ear infection in the past 6 weeks
• The patient has undergone any ear surgery (excluding grommets that have
extruded at least 18 months previously and the patient has been discharged
from Ear, Nose and Throat services)
• The patient has a perforation or there is a history of a mucous discharge in
the last year
• The patient has a cleft palate (whether repaired or not)
• Acute otitis externa with pain and tenderness of the pinna is noted
• Patient is currently taking anticoagulant therapy
• A patient who has hearing only in one ear if it is the ear to be treated, as
there is a remote chance that irrigation may cause permanent deafness
• Acute undiagnosed hearing loss that is not related to the accumulation of ear
wax
• There is insufficient light
Equipment Required
• Otoscope
• Speculae - single use items only after the 1 st April 2007
Propulse electric irrigator and other equipment (cleaned in
accordance with this policy – see page 12)
• Propulse electronic ear syringe cleaning procedure
• Jug
• Bath thermometer
• Trough / Receiver
• Tissues
• Clean towel
• Protective clothing
PROCEDURE
Verbally check the identity of the patient by
asking for full mane and date of birth.
Check with carer/family if not able to
confirm identity
To confirm identity
RATIONALE
EAR CARE PROCEDURE
4/13

PROCEDURE
Ask patient occupation or previous
occupation/s
Obtain valid and informed consent for
procedure and document assessment
using risk assessment form.
Inform patient that there is slight risk that
ear irrigation may cause infection, injury to
the ear canal and perforation of the ear
drum
Decontaminate hands
Put on protective clothing
Ask patient to sit in chair with head tilted
towards the ear that is to be syringed
Place towel on patient’s shoulder and ask
patient to hold receiver under same ear
Fill the reservoir of the ear irrigator with
water – water temperature must be
checked and should be approximately
40°C
Set pressure of machine to minimum
Attach new jet tip applicator to machine
Run the machine for 10-20 seconds,
directing the tip into the receiver.
Inform patient that procedure is about to
start and encourage patient to indicate if
pain or dizziness is experienced
Pull the pinna upwards and outwards and
insert the tip of the nozzle into the ear
canal
Begin irrigating using the foot control to
operate the machine – the nozzle should
be directed so that the stream of water is
directed along the roof of the ear canal
towards the posterior canal wall at
approximately a 30 o angle
Increase pressure control gradually if wax
is difficult to remove ( Do not use
maximum)
If patient complains of water in the back of
their mouth, stop procedure and refer to
GP
RATIONALE
Informs clinical decision making
To allow the patient / client to make an
informed decision
To prevent spread of micro-organisms
Protect from splashing and potential
contamination during procedure
To encourage water to flow back out of
ear
Collection of water and patient comfort
Water above or below this temperature
may cause discomfort and / or
dizziness
To reduce the potential for trauma
Single use only jet tips
Patient becomes accustomed to the
noise of the machine
Cold water and air locks are removed
Procedure must be stopped if these
symptoms are experienced
Straightens the ear canal
Directs flow of water to encourage best
removal of wax
To help remove wax
Patient may have perforated ear drum
EAR CARE PROCEDURE
5/13

PROCEDURE
Irrigation should never cause pain. if the
patient complains of pain - stop
immediately.
Periodically inspect ear with otoscope
during procedure and check irrigated water
for presence of wax
A maximum of one reservoir of water can
be used per ear – stop irrigating after 5
minutes
Dry excess water from external meatus
once irrigation is complete
Re-examine the ear, observing for any
abnormalities – refer to GP if necessary
If wax is removed due to the presenting
complaint of hearing loss, ascertain
whether good hearing is restored after
treatment – refer to GP if hearing is not
restored
Decontaminate hands
Dispose of contents of trough / receiver
and decontaminate equipment
Document all observations and actions
including consent and patient perceptions
RATIONALE
To prevent damage to ear
To identify if irrigation is effective or
complete
Further irrigation is likely to be
ineffective – patient may require a
further course of drops.
(Further irrigation may be attempted 15
minutes after initial irrigation if
appropriate)
Stagnation of water and abrasion of
skin predispose infection
Irrigation can sometimes cause trauma
Wax may hide evidence of
abnormalities
To ensure assessment of cause of
hearing loss and possible referral to an
ENT surgeon or Audiologist.
To prevent spread of micro-organisms
To prevent spread of micro-organisms
Ensure compliance with NMC and local
record keeping guidelines
Provide post-procedure ear care
information leaflet
Ensure patient remains informed and
involved with their care
The information above is adapted from guidance devised by the ‘Action on ENT’
steering board and is endorsed by the Primary Care Ear Centre – Rotherham.
www.earcarecentre.com
EAR CARE PROCEDURE
6/13

NURSING MANAGEMENT OF EAR WAX – DOCUMENTATION
(1/4 pages)
(For patients over 18 years)
Prior to undertaking ear examination the nurse should have a
demonstrable knowledge of the tympanic membrane and auditory canal
and should have attended appropriate training in ear care. Valid
consent to any treatment must be obtained and documented.
Patient Details:
NHS No:
Full Name
Address
Telephone Number:
Date of Assessment:
DOB:
Referred by:
Current & Previous Occupation:
GP:
Current Medication:
Informed Consent ____________________________________________________
Each nurse must be confident they have the clinical competency and the
underpinning knowledge to fulfil this role. Best practice would be for each nurse
that undertakes this role to consider the disease processes that may require caution
and the need for additional information about the patient and their treatment. This
may include:-
MEDICATION
Diuretic Therapy
Anticoagulant Therapy
Long-term use of ototoxic drugs e.g.
streptomycin
RATIONALE
May lead to hearing loss
trauma
hearing loss
EAR CARE PROCEDURE
7/13

AURAL NURSING RISK ASSESSMENT RECORD
Patients Full Name:
DOB:
NHS Number:-
Left Ear Right Ear
YES NO YES NO
History of tympanic perforation
Cleft Palate
Unable to give valid consent
Recent history of otalgia (ear ache) or
middle ear infection [in previous six weeks]
Does the patient have history of hearing loss that
is not related to the excess production of wax
Does the patient have hearing in only one ear
[NB such patients should not have that ear
irrigated as the risk of damage (although minimal)
is unacceptable - refer to GP]
Have there been any significant problems
previously with ear irrigation e.g pain /
perforation / vertigo after procedure / other
Please state:
Mucoid / discharge other than waxy discharge
Is there a recent history of Giddiness, nausea,
vertigo or Ear surgery e.g. mastoid
NB NEVER IRRIGATE A MASTOID CAVITY
Tinnitus or menieres disease
Is patient currently taking anticoagulants
CLINICAL ASSESSMENT
Check for signs for foreign bodies e.g. grommets,
inflammation / discharge, offensive discharge
Otitis media / externa (usually found in both ears)
Left Ear Right Ear
Yes No Yes No
Pain in or about ear when moving pinna Please
state:
Swelling in or around the ear
Evidence of impacted wax
Hearing Aid
Non concordance to treatment /no valid consent
DO NOT IRRIGATE EAR/S IF THE ANSWER IS YES TO ANY OF THE ABOVE –
REFER PATIENT TO MEDICAL PRACTITIONER
EAR CARE PROCEDURE
8/13

Patients Full Name:
NHS Number:-
DOB:
Patient referred to:
Date:
Have Olive oil drops been instilled as
recommended (minimum of 5 days)
Left Ear
Right Ear
Yes No Yes No
If the patient has not undertaken appropriate
preparation then give advice and rebook
appointment for one week
Outcome
If following the assessment there are no identified problems and there is evidence
of wax, then proceed with the ear irrigation in accordance with Trust guidance. If
there are problems, refer to GP.
The recommendation for the use of olive oil ear drops is that some patients may
have a nut allergy. Also, some proprietary preparations containing organic solvents
can cause irritation of the meatal skin. (extract from the BNF 12.1.3) (NPF 1999-
2001)
EAR CARE PROCEDURE
9/13

Patients Full Name:
NHS Number:-
EAR IRRIGATED
DOB:
Left Ear
Right Ear
Yes No Yes No
Was wax successfully removed
Advice given:
Details
Is review of treatment requested:
Yes/No
Date of
review:
Yes
No
Leaflet given to patient following procedure and
contents discussed
Understanding checked
Nurse's Name
Signature Designation :-
Contact Number
The information above is adapted from guidance devised by the ‘Action
on ENT’ steering board and is endorsed by the Primary Care Ear
Centre – Rotherham. (See www.earcarecentre.com)
EAR CARE PROCEDURE
10/13

EAR IRRIGATION PATHWAY FOR COMMUNITY NURSES
All patients must have applied 5 days of ear drops to soften wax
(This can be prescribed by a GP or Nurse Prescriber)
Ears examined and Nursing Aural Risk Assessment completed
Outcome of assessment
Soft wax present
and no risk factors
identified
Wax has been
cleared by the
drops
Hard,
impacted wax
present
Risk factors
identified
Proceed to carry
out ear irrigation
If patient
continues to
experience
hearing loss
advise to see
GP
Advise to
continue with
drops for a
further 5
days
Investigate
compliance
issues
Do not
irrigate ears
Refer to GP
May need ENT
/ Audiology
referral
Re-book
appointment
NB In cases where a patient cannot give informed consent or provide a history to
complete aural risk assessment and discuss with the GP
EAR CARE PROCEDURE
11/13

PROPULSE ELECTRONIC EAR SYRINGE
CLEANING PROCEDURE
It is important that this equipment is decontaminated at the end of a session or at the end of
each day and before use to prevent cross infection between patients or cross infection from
inadequately disinfected equipment.
Jet tips are single use only items.
HEALTH AND SAFETY INFORMATION
Before using any cleaning/disinfection product staff must satisfy themselves that
they are aware of safe handling, storage and dilution strengths of the product used.
COSHH data must be read and available to all staff.
CLEANING AGENTS/DISINFECTANTS REQUIRED
General Purpose Detergent
NADCC disinfectant tablets (Antichlor 0.5g)
Dilution strength: 1,000 parts per million
Dissolve 2 x 0.5g tablets in ½ litre of cold water
DISINFECTANT INFORMATION
NADCC is a broad spectrum anti-microbial agent which is effective against bacteria, fungi
and viruses (including HIV, Hepatitis, MRSA, E.coli and pseudomonas). It is more stable
and therefore more effective than liquid forms of sodium hypochlorite. Tablets have a
longer shelf life and are more convenient to use and correctly prepared give an accurate
strength. NADCC is an approved disinfectant in the Trust Disinfection Policy
DECONTAMINATING THE MACHINE BEFORE USE (This need only be once a day)
1. Fill the tank ¾ full with the freshly prepared NADCC solution.
2. Run the machine for a few seconds into a sink to ensure all the internal pipe work is
filled with the solution.
3. Stop the machine, leave to stand for 10 minutes to disinfect.
4. After 10 minutes empty the tank and refill with fresh tap water.
5. Run this through the machine to thoroughly rinse the system.
6. Discard any remaining NADCC solution, rinse and dry jug.
The machine is now ready for use
Note:
It is not advisable to attempt decontamination within a patient’s home.
EAR CARE PROCEDURE
12/13

DECONTAMINATING THE MACHINE AT THE END OF THE DAY/CLINIC SESSION
1. Prepare a detergent solution in the Propulse tank, run the machine into a sink for a
few minutes to flush pipe work and pump.
2. Discard remaining solution, rinse tank with fresh tap water.
3. Fill tank ¾ full with a freshly prepared solution of 1,000ppm NADCC disinfectant.
4. Run solution through the machine into the sink to fill internal pipe work and pump.
5. Leave for 10 minutes to disinfect.
6. Empty tank and refill with fresh tap water.
7. Run machine for a few minutes into a sink to rinse internal pipe work.
8. Empty tank, rinse and dry with disposable paper towel.
9. Damp clean the exterior of the machine within a disposable cloth soaked in a detergent
solution.
10. Discard any remaining NADCC solution, rinse and dry jug.
11. Store the machine and tips in a dust free environment.
INFECTION CONTROL ADVICE:
This guidance has been based on informed infection control principles until more detailed
information is available from the manufacturer.
References
The Primary Ear Care Centre, Rotherham (2006)
EAR CARE PROCEDURE
13/13