Ear Irrigation Module
Contents
1. externa ear canal Ear tympanic membrane pictures html prettyPhoto Accessed 2015 Feb 17 Revised February 2015 Common Education Required Education 2 Page 2 Middle Ear The middle ear tympanic cavity is covered by the tympanic membrane This area holds air and three 3 small bones the malleus hammer the incus anvil and the stapes stirrup The main function of the middle ear is to transfer sound waves from the outer ear to the fluid filled inner ear The small bones are joined so they amplify sound waves received by the tympanic membrane and transmit these waves to the inner ear The eustachian tube connects the middle ear with the nasopharynx equalizing pressure on each sides of the tympanic membrane Stapes attached to oval vvindow D Semicircular Canals Incus Malleus Vestibular Nerve ru AS pied ERST Nerve LZ Cochlea D AM p External Auditory Canal Tym panic Eustachian Tube Membrane Roumd Window Figure 2 Anatomy of the Human Ear Source http en wikipedia org wiki File Anatomy of the Human Ear svg Accessed on 2015 Feb 17 3 Inner Ear The organs for hearing and equilibrium are located in the inner ear labyrinth Components of the inner ear include the cochlea for hearing the semicircular canals for equilibrium and the vestibule which houses the components for sensing changes in gravity In addition to hearing the structures of the middle and i2. Figure 7 Examination Using an Otoscope 9 Figure 8 Examination Using an Otoscope 10 Figure 9 OtoClear Tip and a 60 mL Luer Lock Syringe 11 Figure 10 OtoClear Tip Attached to Syringe 12 Figure 11 OtoClear Inserted into Ear 12 Figure 15 Water Spray 12 Ear Irrigation Module Learning Objectives Following the review of this module you will be able to e Describe normal anatomy and function of the ear e Describe relevant health history questions related to the ear e Explain examination of the ear e Explain an ear irrigation procedure indications and precautions e Successfully demonstrate an ear irrigation procedure to an Educator or designate Anatomy of the Ear The ear is divided into three 3 anatomic sections 1 External Ear The purpose of the external ear is to receive sound waves and direct them to the tympanic membrane The external ear contains the outer projection referred to as the auricle or pinna and the ear canal referred to as the external auditory meatus or external auditory canal The ear canal ends at the tympanic membrane eardrum The outer half of the ear canal is cartilaginous and the inner part of the adult ear is bony The skin that lines the cartilaginous portion of the canal is thick and contains fine hairs large sebaceous glands and the ceruminous glands Cerumen ear wax is the combined secretion of the sebaceous and ceruminous glands i2Health Hype i healthhype com pinna
3. media and retraction suctioned out of the ear pocket formation Figure 6 Myringotomy Tube Treatment entusa com 4 Painful or edematous ear canal or pinna 5 Clients who have previously experienced complications following ear wax removal Revised February 2015 Common Education Required Education 6 Page Examination of the Ear 1 Examine the external ear canal using observation The external ear canal may also show signs of otitis externa swimmer s ear which is a non specific inflammation of the skin and subcutaneous tissues of the ear canal It causes itching and discharge from the ear The infection can also cause narrowing of the canal due to edema of the tissues lining the canal Ear irrigation should not be done while canal or pinna are painful or tender Cook R 1998 2 Examine the external ear canal using an otoscope To examine the ear canal Explain the procedure to the client e Tilt the client s head away from you e Gently pull the pinna upwards and backwards to straighten the ear canal Figure 7 Examination Using an Otoscope Source Grundman J amp Wigton R Examination of the ear http webmedia unmc edu intmed general eye amp ear earexam2 htm Observe for the following 1 Canal o Normally pinkish o Do not irrigate if red bleeding or you note discharge 2 Tympanic membrane o normally a disc at the back which is mother of pearl or white in color o donotirrigate if eardrum has a hole or yo
4. 0 2 Recent or current middle ear infections otitis media as the tympanic membrane may be under pressure from mucous or pus Negative pressure builds up in the middle ear from the eustachian tube dysfunction this tube connects the ear to the back of the nose and normally allows enough air into the middle ear Even short term negative pressure can cause clear fluid to build up behind the eardrum The eardrum is often retracted or pulled into the middle ear Irrigation would cause pain and there is the risk of perforating the membrane Grade 0 Normal appearance or Grade 1 Erythema only No Grade 2 Erythema air fluid level no effusion only No erythema effusion myringitis only opacification meniscus noted Grade 3 Erythema complete effusion Grade 4 Erythema partial Grade 5 Erythema complete effusion no opacification opacification no bulging noted opacification no bulging no may include complete effusion bubbles no meniscus bubbles and or air fluid level Revised February 2015 Common Education Required Education 5 Page Grade 6 Erythema bulging rounded Grade 7 Erythema bulla doughnut appearance of tympanic membrane Figure 5 Serous Otitis Media www entusa com 3 Myringotomy tubes grommets This is a treatment of eustachian tube dysfunction and eardrum retraction pockets by placing an ear tube in the eardrum Pre operative ear with chronic The glue which was Post operative result serous otitis
5. WY Carewest INNOVATIVE HEALTH CARE Ear Irrigation Module For RNs and LPNs TABLE OF CONTENTS EAR IRRIGATION MODULE LEARNING OBJECTIVES eee eee eere eene rene nere nenne re so sn ne 2 ANATOMY OF THE EAR eise pev eV oux axe Feb uER RP EN PESE C ENU ENS ERR gua OY bale m tas Us ex we apuvt e sa o aUP N Cor Vd ss Ve 2 EAR WAX Sois eoo Bess Nv sua Euet m OMS do ix bro NEU DUE ETE VE nese uueebuguseen oU tu E ms EU M C DOXN a 4 HISTORY OF EAR PROBLEMS OR TREATMENTS 4 eee eee eee eene hehehe renes e reso sese sessio son 4 EXAMINATION OF THE EAR veces Cevke qu ver bus vsu eae x v An ruRe epe eeu Se qub ver bue Sue esa enV Gee huv ao FNISU qu ves boe Px eye av s 7 PREPARATION REQUIRED PRIOR TO EAR IRRIGATION cscscscsccscscsccscscsccscscsccscscsccscscees 8 EARJRRIGATHON PROCEDURE eres Sen Pere vuvS EE EvyaE E ove Ege cue prets Ma POR T E Ee NUN DUNS 9 COMPLICATIONS sid atn sia cats utdecssan iet PENES Oe eS dea C NVRRENIUS Que Y eR VN ER Ee EE Uu Pu 10 RE FER EIN CES m 11 EAR IRRIGATION MODULE QUE sassicicjacscccissiuteisnaeacseciwestevstadsscveswietoassasveucdsoevissseaveucvesesleavees 12 Figures Figure 1 External Ear 3 Figure 2 Anatomy of the Human Ear 4 Figure 3 Anatomy of the Inner Ear 4 Figure 4 Eardrum Perforation 6 Figure 5 Serous Otitis Media 7 Figure 6 Myringotomy Tube Treatment 8
6. Y t oan a ior Cure LULA Samm f T LL Bih DN Figure 9 OtoClear tip and a 60 mL Luer Lock syringe Procedure 1 Wash hands 2 Collect all equipment and connect the parts 3 Explain the procedure to the client 4 Drapeatowel around the client s shoulder and if possible have the client lean in the same direction as the ear that is being irrigated This will allow gravity to help drain the water from the ear If the client is able to help they can hold the bowl or basin against the neck beneath the ear 5 Twist a new OtoClear tip to a disposable luer lock syringe 20 mL or larger Figure 10 OtoClear tip attached to a 60 mL syringe Revised February 2015 Common Education Required Education 9 Page 6 Fill the syringe with body temperature water Check the water temperature by squirting water on the inside of your wrist J 7 Begin irrigation e Place plastic tip into the ear canal OtoClear N AM N 1l NS WS W WW tips cannot be over inserted into the ear wi i canal e Straighten the ear canal by pulling the pinna gently upwards and backwards with one hand e Use the other hand to control the stream of Figure 11 OtoClear tip and syringe inserted into external water as you slowly depress the plunger ear canal while the water enters the ear canal e Observe for and stop at signs of pain nausea or dizziness 8 After approximately 15 seconds stop the infus
7. e amount of wax the size of the canal and confirm no visible inflammation Note You may want to practice just examining ears before attempting the actual procedure 5 Ensure that the wax is softened Carewest policy CS 02 04 03 Ear Wax Cerumen Removal Instill 3 4 drops of mineral oil into the affected ear s nightly for 5 7 nights to hopefully flush the ear wax out spontaneously Carewest Policy CS 02 04 03 Revised February 2015 Common Education Required Education 8 Page Ear Irrigation Procedure At Carewest a disposable luer lock syringe 20 mL or larger and OtoClear tip are used for ear irrigation The OtoClear Tip and attached syringe are Single Use only In these pictures we have used a 60 mL syringe however anything from 20 mL 60 mL may be used When a 60 mL syringe is used there may be slightly less pressure Carewest supports starting with less pressure and then increasing it as needed by using a smaller syringe Benefits of this system Flare tip design OtoClear tips cannot be over inserted into the ear canal Safety First Three tiny holes spray the water at a 45 angle virtually eliminating the risk of damage to the tympanic membrane Easy exit for debris Exit portals let the water and debris drain in a controlled manner keeping you and your clients clean and dry Client Comfort Clients experience the sensation of a plastic receptacle 00382303056534 Cnm t HO 0 IW wo dba r
8. e you are able to demonstrate your skills to an educator designate Return the completed quiz to your site educator for marking 1 Ear wax is produced in the a Eustachian tube b Outer region of the auditory canal c Middle ear d Labyrinth 2 The three 3 small bones of the middle ear are a Malleus incus and stapes b Anvil hammer and stapes c Hammer inca and stapes d Malleus anvil and stirrup 3 The ear canal is also referred to as the a External auditory canal b Internal auditory canal c External auditory meatus d aandc 4 Priorto ear irrigation you a Take a history of any ear problems or treatments Review the Carewest policy on Earwax Cerumen Removal Conduct an examination of the ear Ensure the wax is softened to aid removal all of the above ooo 5 When reviewing the history for your client they tell you that they have had mastoid surgery in the past Ear irrigation may be contraindicated because a The eardrum would have been perforated b She may experience nausea with ear irrigation c Water may enter the mastoid cavity d The malleus could be damaged 6 Ear irrigation is contraindicated in which of the following a Perforation of the tympanic membrane Myringotomy tubes grommets are in place Recent history of a middle ear infection Otitis externa or media All of the above o oo0c 7 The OtoClear is for single use only a rue b False Revised February 2015 Common Education Requ
9. ion of water and withdraw the OtoClear tip 9 Check the ear canal using an otoscope to determine if more irrigation is required Repeat as necessary Figure 12 What the spray looks like out of the OtoClear tip 10 Discard the OtoClear tip and syringe These are single use only 12 Wash your hands 13 Document the outcome and response on the Total Team Record e Color texture and size of the cerumen wax and any odor e How the client tolerated the procedure any pain or dizziness If you were unable to dislodge the wax continue to instill oil into the ear s for several 5 7 days Irrigate again and reassess Complications Complications associated with ear irrigation include e Pain or vertigo during the procedure After completing the attached Ear Irrigation e Trauma rupture to the tympanic membrane Module Quiz contact your Site Educator to b H externa arrange a time for you to demonstrate your skills e External auditory meatus damage Revised February 2015 Common Education Required Education 10 Page References Adu Darko S amp Achtemichuk S 2005 Ear Syringing Powerpoint Presentation Alberta Health Services Corrections CNE Group Ear Irrigation Module January 2012 Assessment Made Incredibly Easy 3 ed Ambler PA Lippincott Williams and Wilkins 2005 Aung T amp Mulley G 2002 Removal of ear wax Electronic version British Medical Journal 325 7354 p 27 Carney A How t
10. ired Education 12 Page 8 Acerumen plug can cause a Dizziness Pain Itching Decreased hearing All of the above co290 5 9 Name all of the necessary equipment needed to perform an ear irrigation procedure a Adisposable 20mL or larger Luer lock syringe A disposable OtoClear tip A kidney basin A towel to put over the shoulder All of the above ooog 10 Removal of ear wax by irrigation may be required due to T1 12 13 14 15 a Anarrow ear canal b Awide ear canal c Hearing aid moulds d Age e bandconly f a candd only To examine the ear canal in an adult gently pull the pinna a Upwards and backwards b Downwards and outwards c Downwards and forwards d Upwards and forwards What size of syringe should you attach the OtoClear tip to a 20mL or smaller b 20mLor larger c It does not matter as long at it has a luer lock Name four 4 potential complications with ear syringing a Pain or vertigo during the procedure Trauma rupture of the tympanic membrane Otitis externa External auditory meatus damage All of the above co290 5 Cold water should be used in this procedure a True b False Ear syringing is an advanced competency in nursing and requires learning and following specified procedures and proper training a True b False Revised February 2015 Common Education Required Education 13 Page
11. nner ear play a large role in controlling a person s balance anterior semicircular canal f vestibular ves cochlear nerve Ue posterior ampulla semicircular canal showing cupula oval window Figure 3 Anatomy of the Inner Ear Source http images paraorkut com img health images i inner ear 1732 jpg Accessed on 2015 Feb 17 Revised February 2015 Common Education Required Education 3 Page Ear Wax Cerumen The ear wax is produced only in the outer regions of the auditory canal where the ceruminous glands are found but it may be pushed further back into the canal The color consistency and amount of ear wax vary from individual to individual It is normally honey colored but becomes darker brown in color and gradually hardens as it becomes exposed to air Cerumen is removed by two natural methods e Evaporation e Shedding with dead skin flakes as the skin migrates out of the external auditory canal Removal of the wax by ear irrigation may be required for the following reasons 1 Narrow ear canal Persons with narrow ear canals may find that the wax builds up in the ear canal 2 Cleaning attempts Using Q tips in an attempt to clean out the ear canals is one of the causes of impacted wax Instead of removing the wax this tends to force it down the canal so that it forms a hard dry plug against the tympanic membrane 3 Ear plugs The use of ear plugs to block out noise e g various occu
12. o use an otoscope Retrieved December 5 2005 from http www comdis wisc edu facstaff mrchial howotoscope htm Carewest Care and Service Manual Ear Wax Cerumen Removal CS 02 04 03 July 2014 Cook R 1998 Ear syringing Electronic version Nursing Standard vol 13 13 15 pp 56 61 Accessed on December 05 2005 from http gateway ut ovid com gwl ovidweb cgi Freeman R 1995 Impacted cerumen How to safely remove earwax in an office visit Electronic version Geriatrics vol 50 6 p 52 53 Grundman J amp Wigton R Examination of the ear Accessed on December 05 2005 from http webmedia unmc edu intmed general eye amp ear earexam2 htm Harkin H 2005 A nurse led ear care clinic sharing knowledge and improving patient care Electronic version British Journal of Nursing vol 14 5 p 250 254 Lavan Z 2004 Ear syringing the pros and cons Electronic version Journal of Community Nursing vol 18 9 p 35 39 Lueckenotte A 2000 Gerontologic Nursing 2 ed St Louis Mosby Medical Encyclopedia Accessed on December 05 2005 from http www nim nih gov medlineplus ency imagepages 8771 htm Thompson J McFarland G Hirsch J and Tucker S 2002 Mosby s Clinical Nursing 5 ed St Louis Mosby Revised February 2015 Common Education Required Education 11 Page Ear Irrigation Module Quiz Name Site _ ocu Date You must receive 80 pass grade befor
13. pations require them as mandatory protection etc can also force the wax down the ear canal 4 Hearing aid moulds Hearing aids are designed to fit inside the auditory canal and may be worn for long periods of time They can interfere with the natural ability of the body to shed dead skin and wax which causes a build up in the canal 5 Age With increased age changes in the sebaceous and apocrine glands leads to drier cerumen With this change and stiffer coarse hairs lining the canal impaction can result Symptoms of cerumen impaction may include e hearing loss e earache e feeling of fullness in the ear or a sensation that the ear is plugged e itching e tinnitus History of Ear Problems or Treatments Taking a history of ear problems or treatments is critical prior to ear irrigation The fact that the client has had ear irrigation in the past does not mean that there are no contraindications this time Ear irrigation is CONTRAINDICATED for the following reasons 1 If the tympanic membrane has been perforated in the past or surgery e g mastoid surgery has been done unsterile water may be forced into the middle ear or mastoid cavity Eardrums can develop holes Revised February 2015 Common Education Required Education 4 Page or perforations in them The picture on the far right shows an eardrum with three holes and destruction of the middle ear bones ossicles Figure 4 Eardrum Perforation www entusa com April 201
14. u see myringotomy tubes o donotirrigate if pink or red 3 Wax o lsit present o Describe the location o In canal or against eardrum o Interms of a clock compared to tympanic membrane o Determine color and consistency o Softer if lighter brown or honey colored O Drier and harder is dark brown Do not irrigate without using oil for several days prior Revised February 2015 Common Education Required Education 7 Page Eardrum Figure 8 Examination by Otoscope Source Medical Encyclopedia http www nlm nih gov medlineplus ency imagepages 8771 htm accessed on December 5 2005 Do NOT irrigate if you notice the following Perforation of the tympanic membrane Myringotomy tubes grommets Otitis Media or recent history of a middle ear infection tympanic membrane may be under pressure from mucous or pus Irrigation would cause pain and there is a risk of perforating the membrane Otitis Externa or painful tender edematous ear canal pinna PREPARATION REQUIRED PRIOR TO EAR IRRIGATION Before irrigating the ears it is important to 1 Review the Carewest policy CS 02 04 03 Note Demonstrated competence with this procedure is required This includes reading this training module answering the quiz questions correctly and demonstrating your skills to an Educator or delegate 2 Checkthe client s history of ear problems or treatments 3 Explain the procedure to the client 4 Examine the ear using an otoscope Assess th
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