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GUIDELINES FOR EAR IRRIGATION USING THE PROPULSE ELECTRONIC EAR
Prepared by:
Gillian Brearley District Nurse
Approval Information:
Patient Care & Professions Date Approved: COMMITTEE:
Lead Director:
Sheila Dilks
Responsible Area:
Reference to Standards for Better Health Domain
PEC 13th February 2008
Version No. Approved:
Three
Review Date:
February 2010
First Domain : Safety
Core/Development standard
C1a C4b
Performance indicators
1.Incidence of ear infection / complications following ear irrigation 2 Incidence of repeat ear irrigation per patient.
History of Document
Version 1 November 2003 Version 2 December 2005 Version 3 December 2007
Version No: Date Approved:
CONTENTS Section No.
Page No’s
1.
Introduction
1
2. 3.
Principles Authority to proceed
1 2
4.
Indications
2
5.
Contraindications
2
6.
Guidelines / additional information
3
7.
Examination of the ear
4-5
8.
Procedure for ear irrigation
6-8
9. 10.
Cleaning and disinfection of Propulse ear syringing equipment Cleaning and disinfection of accessories
9
11.
References
10
12.
Appendices 1 Ear irrigation assessment tool
11
13.
Appendices 2 Core Care plan (North Documentation) Appendices 3 Core Care plan (South documentation)
12
14.
8
13
NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
Version No: Date Approved:
0
1. INTRODUCTION The need to develop these guidelines has been due to the high number of patients requiring advice and or ear irrigation for removal of earwax in the community setting. Although the ear has natural mechanisms for the removal of ear wax, it is recognised that contributory factors are present; certain people do experience problems with the accumulated wax that necessitates ear irrigation. Ideally, excessive wax should be removed before it becomes impacted, giving rise to tinnitus, hearing loss, vertigo, pain and discharge (Harkin 2000). Ear irrigation is an invasive procedure with the potential to cause discomfort or injury (Cook 1998) and therefore must only be considered when other conservative methods of wax removal have failed (e.g. use of softeners). Risks associated with this procedure include tympanic membrane perforation and otitis externa. Over a five year period, 19% of cases settled by the medical defence union were caused by ear syringing (Coopey 2001), payments to individual patients ranged from £2,500 to £55,000. In over half of the claims settled the procedure had been carried out by a practice nurse(Aung T AND Mulley G 2002) These guidelines only relate to ear irrigation for the purpose of cerumen (wax) removal. Metal syringes should not be used, as their use is now obsolete due to dangers attached to this type of equipment.
2. PRINICIPLES •
Wherever possible patients should be encouraged to attend their local clinic/surgery for ear irrigation. However it is acknowledged that for housebound patients, district nurses may undertake this procedure in the home.
•
Patients requiring ear irrigation should always receive education and advice, which may reduce contributing factors and therefore the need for further ear irrigation (Stubbs 2000). This should be supported by the provision of a patient information leaflet.
•
For the purpose of infection control, it is important that all equipment is cleaned in line with manufacturers recommended guidelines, as any static water present within the equipment may predispose to the development of pseudomonas.
•
Safety precautions are essential when utilising electronic irrigators, Propose 11 electronic irrigator is the recommended choice of equipment. The model is double insulated and therefore the use of a circuit breaker is not necessary. However it may be considered appropriate to use a circuit breaker in the home environment as an added precaution. All Propulse irrigators should be serviced annually. (MDA 1998)
3. AUTHORITY TO PROCEED •
Informed consent must be obtained following Kirklees Consent Policy and supported by the provision of written patient information leaflet prior to undertaken the procedure.
•
The procedure should only be undertaken by staff that have completed theoretical and practical training in ear irrigation and are competent and
confident to perform the procedure. It is individual nurse’s responsibility to ensure their knowledge is maintained.
4. INDICATIONS •
To improve the conduction of sound to the Tympanic membrane when the external meatus is blocked with wax.
•
Other methods of wax removal have been attempted but were unsuccessful (e.g. use of softeners).
•
Contraindications have been ruled out.
5 CONTRAINDICATIONS •
The patient has a history of tympanic membrane perforation both recent and healed. Evidence available to support irrigation following perforation is very controversial, minimal evidence views this procedure as safe; it is therefore a recommendation of these guidelines that the irrigation procedure is not undertaken if the patient has a history of tympanic membrane perforation.
•
A history of mucous discharge in the last year.
•
History of a middle ear infection (Otitis Media) in the last 6 weeks.
•
Presence of grommets or T tubes.
•
NEVER irrigate mastoid cavities.
•
A bulging tympanic membrane is observed.
•
The patient has previously experienced complications following ear irrigation
•
The patient has undergone ANY form of ear surgery (apart from grommets that have extruded at least 18 months previously and the patient has been discharge from the ENT department.
•
The patient has a cleft palate (repaired or not), as they are more prone to middle ear disease due to poor development of the facial bones (Harkin 2000)
•
The presence of acute Otitis Externa with pain and tenderness of the pinna.
N.B. IF IN ANY DOUBT REFER BACK TO THE GENERAL PRACTITIONER
6. GUIDELINES / ADDITIONAL INFORMATION
Use of softeners
Prior to undertaking ear irrigation, wax removal should be attempted by the use of Olive oil as a first line treatment, or alternatively sodium bicarbonate ear drops. These should be instilled for a duration of between 3 – 7 days, depending on the condition of the wax. Patients should be encouraged to purchase olive oil and ear dropper, alternatively these can be prescribed. (See BNF for prescribing details) Patients should be advised how to correctly instil eardrops, supported with a patient information leaflet. The use of cerumenolytic eardrops may cause meatal irritation due to the astringent qualities of these agents, especially in older adults or people with dermatological conditions. If a perforation is suspected behind the wax, advise the patient to use olive oil in small amounts, but to stop using if they experience pain.
Patient Assessment
Recommended after care / advice
Prior to ear irrigation a comprehensive history should be taken, considering the following: 1) Medical History – both general and specific to ear, supported by an examination of the ear, findings to be documented in Kirklees ear care assessment tool. 2) Duration/details of current symptoms. 3) Any contributory factors: • Narrow ear canals • Dusty / noisy environment • Use of cotton buds/ ear plugs/hearing aid moulds. • Allergies • Poor diet / High Lipid levels • Age – elderly people have drier wax and decreased motility in the ear canal • Hereditary factors. Reduce risk of future excessive wax build up by providing advice on reducing any contributory factors and the self – cleaning properties of the ear. Instillation of olive oil, one drop weekly to the affected ear, helps to reduce the build up of excess wax in patients prone to ear blockage Patients with high Lipid levels may require recurrent irrigation. Wax contains a high concentration of fatty acids. Advice on dietary changes may reduce the incidence of blockage (Forage 1996)
The above information was extracted from Guidance Document in Ear Care. Full document available at www.earcarecentre.com and www.entnursing.com
7. EXAMINATION OF THE EAR This procedure should be carried out with both the patient and nurse seated and under direct vision, using a headlight throughout. •
Both ears should be examined with the otoscope, to ascertain the need for irrigation. It is not uncommon for patients with dysfunction of the middle ear to present for “syringing” because their ears feel blocked.
•
Explain each step of the examination procedure and assure yourself that the patient understands and gives consent.
•
First examine the pinna, outer meatus and adjacent scalp by direct light, checking for any previous surgery incision scars, also check for signs of melanoma and other skin defects. Is the ear red and inflamed a sign of possible trauma or infection? Is it deformed due to previous trauma? Look for scaling or cracking of the skin, together with associated scaling of the scalp or eyebrow region, possibly due to seborrhoeic dermatitis. Shingles may also affect the ear region, so look for characteristic blistering eruptions. Is there any discharge from the ear canal? If so is it purulent, bloodstained or offensive?
•
Gently pull the pinna upwards and backwards to straighten the meatus. Any localised infection or inflammation will cause the procedure to be quite painful. Common causes of pain might be a boil / Furuncle or fungal infection in the meatus, which will need referral to General Practitioner for treatment. Remember the skin lining of the meatus is very delicate and sensitive.
•
Holding the otoscope (similar to holding a pen), insert the specula gently into the meatus. The light from the otoscope needs to be bright.
•
Carefully check the external auditory meatus (Ear canal) and the Tympanic membrane (Ear drum). The normal drum is pearly grey in appearance and you should be able to see the handle of malleous in the middle ear through the ear drum. It is often also possible to make out the long process of the incus and the short process of the Malleous. In a normal ear drum there is a reflection of light, called the cone of light, extending from the handle to the lower part of the ear drum, this area is known as the pars tensa.
•
The ear can not be judged to de completely normal in appearance until the Tympanic membrane has been seen. You may need to ask the patient to move his/her head e.g. lean head towards the shoulder to be able to see the roof of the meatus and the attic region of the Tympanic membrane (Pars flacida) clearly.
•
The normal appearance of the Tympanic membrane varies and can only be learned with practice. Practice will lead to the recognition of abnormalities.
•
Carefully observe the condition of the external auditory meatus as you withdraw the otoscope. Document what you have seen in both ears.
Note: All of the above should be performed prior to, and following irrigation procedure.
8. PROCEDURE FOR EAR IRRIGATION EQUIPMENT Apron Gloves Otoscope / Auroscope- single use specula Disposable Receiver / Noots tank Jug containing tap water (40 degrees centigrade) Propulse 11 electronic ear irrigator Single use jet tip Jobson Horne Probe- single use Cotton wool Henckle Forcep- single use Headlight. Clinic setting – Paper towel Patient’s home – Clean Towel
Read patients notes and ensure a comprehensive patient assessment is taken, utilising the Kirklees record of assessment tool.
Explain procedure to patient and provide patient information leaflet, ensure consent for treatment is obtained.
Decontaminate hands and put on apron and gloves.
Apply headlight and check position to ensure direct vision.
Examine both ears, (Following procedure for ear irrigation)
Prepare equipment, ensuring easy access to power supply and water.
Position patient comfortable in upright position, with head tilted slightly towards the affected side. Position protective cape and towel around shoulders.
Fill Propulse with tap water approximately 40 degrees C and set water pressure at minimum setting initially. Fluid that is too hot or too cold can stimulate the semi circular canals causing vertigo / nausea.
Connect single use jet tip and twist into right position. Direct tip into receiver and switch on the machine for 10 -20 seconds, to remove any static water or air from the system and to allow the patient to become accustomed to the noise.
Ask the patient to hold the receiver under the affected ear.
Gently pull pinna upward and backward to straighten the external auditory meatus.
Place tip of nozzle into external auditory meatus (Rest in Tragus), and inform the patient you are about to start. Ask patient to inform you of any pain or dizziness during the procedure. Note: it is not uncommon for patient to cough during the procedure; this is due to stimulation of the vagus nerve.
Using foot control, direct water along the roof of the meatus, towards the posterior wall.
Increase the water pressure gradually if there is difficulty removing the wax.
Caution: If dizziness occurs during the procedure, stop irrigation and ask the patient to fix gaze on an object for a few minutes until dizziness subsides. Check water temperature is correct. Stop irrigation if patient feels water at the back of throat, as this could indicate a perforation is present.
Note: Ear irrigation should never cause pain. If patient complains of pain stop procedure immediately
Periodically inspect meatus with otoscope and check receiver contents to assess effectiveness of procedure. A maximum of two reservoirs of water should be used in any one procedure for each ear.
Note: If wax is not removed within 5 minutes of irrigating, it is advisable to stop and move on to irrigation of other ear if this is required. Any wax remaining in the original ear may be softened by the irrigated water and irrigation may be retried after a minimum of 15 minutes.
After removal of wax, or when the maximum length of the procedure is reached, dry mop excess water from external auditory meatus, under direct vision using the Jobson Horne probe and cotton wool. Do not touch the tympanic membrane.
Perform final examination with otoscope and assess need for further treatment.
Dispose of receiver contents. Remove protective cape and towel. Remove apron and decontaminate hands.
Document all care given using Kirklees record of care, including detail of treatment, presenting condition of the ears and the condition of the Tympanic membrane and external auditory meatus following the procedure.
Give advice regarding ear health and arrange follow up visit if needed.
Ensure equipment is cleaned as per Kirklees guidelines.
GUIDANCE FOR MANUAL REMOVAL OF EXCESSIVE EAR WAX •
Recommended for patients who have a history of tympanic perforation. This procedure should only be carried out by a nurse who has received appropriate training, and has developed skills to enable them to undertake the procedure safely.
•
Hard crusty wax can often be gently manoeuvred out of the meatus with a ring probe, using a headlight for illumination.
•
If the procedure becomes painful, do not continue as the meatal lining quickly becomes traumatised, so risking infection.
•
If a perforation is suspected behind the wax, advice the patient to use olive oil in very small amounts, but to stop if they experience any pain.
•
Give advice regarding ear care and provide relevant written information
•
Document what has been seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus and treatment given.
•
If any abnormalities are observed, refer to the General Practitioner.
9. CLEANING AND DISINFECTION OF PROPULSE EAR SYRINGING EQUIPMENT Please note: Numerous agents and cleaning solutions are mentioned within this guidance, as with all COSHH (Care of Substances Hazardous to health) manufacturer’s instructions must be followed, in order to achieve safe practice. Nurses must ensure personal protective equipment is worn for cleaning equipment i.e. Gloves and aprons Do not attempt to clean the jet tip. Use one propulse disposable jet tip per patient treatment and discard to clinical waste after use as this reduces the risk of cross infection between patients. External cleaning should be done by hand, wiping unit with a damp cloth only. Apply liquids to the cloth not the unit. Do not immerse the unit in water. Mild detergents and disinfectants may be used externally.
PRIOR TO USE
The Propulse should be disinfected using a fresh solution of Sodium Dichloroisocyanurate 0.1% (NaDCC) (1000ppm) HAZ 0.5g tablets, in 500mls of warm water or 4 tablets in 1 litre of water. DO NOT USE MILITON
Fill the water tank with NaDCC solution.
Run the Propulse for a few seconds to allow the solution to fill the pump and the flexible tubing.
Leave to stand for 10 minutes
Empty the water tank
Before use Rinse the propulse through with cool boiled tap water, or run cold tap water thoroughly, to flush through the system to ensure no cleaning solution is left.
Dry the machine using disposable paper towels.
DO NOT LEAVE THE SOLUTION IN THE UNIT FOR LONGER THAN STATED At the end of each individual patient’s ear syringing session (In the home)
Drain the water from the Propulse machine
Dry the Propulse with disposable towels.
AT THE END OF EACH SESSION •
Dry the water from the machine
•
Dry the Propulse with disposable towels
10. CLEANING AND DISINFECTION OF ACCESSORIES At the end of each individual ear syringing session accessories should be cleaned following manufacturers guidelines for cleaning. Instruments should always be cleaned in a designated “dirty area” and not in a clinical setting. Jet tip applicator and Speculum for Otoscope These guidelines recommend the use of “single use” disposable jet tips and Specula. Jobson Horne Probe and Henkle Forcep These guidelines recommend the use of “single use” disposable Jobson Horne probes Dispose in sharps bin
NOOTS These guidelines recommend the use of “single use” disposable Noots tank, or similar disposable receptacle i.e. paper cup.
Storage of equipment used in the patients home •
The carrying case used to store the equipment should be made of a washable material.
At the end of the ear syringing session •
Wipe down the inside of the case using a neutral detergent, warm water and a dry with a disposable cleaning cloth.
•
Dry the case thoroughly with a disposable paper towel
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Return the cleaned propulse machine and equipment to the case
•
Clean the outside of the case only when visibly contaminated, using the same procedure as the inside.
REFERENCES Coopey S (2000) Ear syringing – A case for clinical governance Journal of community nursing Jan Vol. 15 issue1 Cook R (1998) Ear syringing. Nursing standard No 13 –15 pg. 56-61 Guidance document in ear care (2004) The Primary ear care centre website. www.earcarecentre.com and at www.entnursing.com Good practice in infection control - Guidance for nurses working in general practice (2000) RCN Guideline compiled in collaboration with the Infection Control Nurse specialist. Harkin H (2000) Evidence based ear care. Primary Health care Journal. Vol. 10. No8 MDA (1998) Medical defence safety notice MDA SN 9807 February 1998, Ear irrigator, (Pulsed water syringe) - Propulse Stubbs G (2000) Ear Syringing and Aural care. Nursing Times Vol. 96 No 43 pg, 35-37 National Institute of clinical excellence (2003) Prevention of Healthcare – associated infections in Primary and Community care. NICE London NPF (2003 – 2005) Nurse prescriber’s formulary
KIRKLEES PRIMARY CARE TRUST EAR IRRIGATION ASSESSMENT NAME_________________________DOB_________________DATE______________ Relevant past medical history:
Ear History Previous ear irrigation
Right ear Y/N
Left ear Y/N
Any complications due to irrigation Tympanic membrane perforation Ear Surgery
Y/N
Y/N
Y/N
Y/N
Grommets / T tubes
Y/N
Y/N
History of middle ear infection in last 6 weeks Acute otitis externa
Y/N
Y/N
Y/N
Y/N
Cleft Palate
Y/N
Y/N
Tinnitus
Y/N
Y/N
Vertigo
Y/N
Y/N
Hearing Loss
Y/N
Y/N
Ear examination Tympanic membrane visible Tympanic membrane perforated Dryness and scaling Pain Foreign body Oedema / swelling Discharge Itching Inflammation Mastoid tenderness Cerumen amount and colour
Details
Right ear Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Left ear Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Use of softeners Type: Amount/ frequency Date commenced: Date completed: Nurse signature:_____________________ Date________Time___________________
KIRKLEES PRIMARY CARE TRUST EAR IRRIGATION / RECORD OF CARE NAME_____________________DOB____________________DATE______________ EAR IRRIGATION
Consent obtained Yes / No
Right ear Date of initial irrigation: Date of repeat irrigation: Examination:
Left ear Date of initial irrigation Date of repeat irrigation: Examination:
Outcome:
Outcome:
AFTER CARE / DISCHARGE ADVICE Advice on softeners: Advice on reducing contributory factors: Patient information leaflet provided:
Yes / No Yes / No
Referral to others please state:
Nurse signature________________________________Date________Time__________
NAME OF CLIENT DATE
TIME
PATIENTS PROBLEM (Full signature after each entry)
Signature
Patient requires removal of excessive ear wax from Ear canal.
DATE
TIME
AGREED PATIENT CENTRED GOAL (Full signature after each entry)
Signature
To remove ear wax, with minimal discomfort and to Minimise the risk of complications DATE
TIME
CARE PLAN (Full signature after each entry) Registered Nurse to undertake the procedure Complete ear irrigation assessment tool Explain contraindications to patient. Gain verbal consent prior to procedure Ensure wax softening agent has been instilled prior to irrigation Irrigate ear canal following Kirklees guidelines / procedure Dry mop ear canal to minimise risk of infection Re-examine ear canal following procedure Document in ear irrigation record of care. Document any complications or reactions observed Refer any adverse complications to General Practitioner. Give verbal and written ear health advice.
Signature