PROCEDURE FOR EAR CARE COMMUNITY NURSING SERVICES (including ear irrigation)

Transcription

1 COMMUNITY NURSING SERVICES (including ear irrigation) First Issued Issue Version One 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 Quality and Governance Service Section: - Ears, Nose, Throat and Eyes ENT N o 01 Clinical Policies and Procedures Group Target Audience Community Nursing August 2010 UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION.

2 INTRODUCTION EAR CARE PROCEDURE (including ear irrigation) 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 undertaken 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 Trust 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 patients. TARGET GROUP Ear care must only be undertaken by Trust employed Registered Nurses that have undergone appropriate Ear Care Training, provided by the Trust. 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 Please refer to related Trust policies and procedures DOCUMENTATION Nursing Management of Ear Wax Documentation Propulse electronic ear syringe cleaning procedure P ROCEDURE FOR EAR EXAMINAT ION Equipment Required Otoscope Disposable speculae 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 To confirm identity RATIONALE To allow the patient / client to make an informed decision and gain co-operation To reduce allergic reactions 2/11

3 PROCEDURE Decontaminate hands prior to procedure Examine pinna, outer meatus and adjacent scalp Choose appropriately sized single use speculum Gently pull the pinna upwards and outwards RATIONALE To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands 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 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, and the external auditory meatus (EAM) observing for any abnormalities. Refer to section Do not use irrigation to remove wax for people with the following Observe condition of skin when withdrawing otoscope and note the presence, amount and consistency of any wax present. Document observations of both ears on the ear care assessment form (Appendix 1) Dispose of single use speculum Decontaminate hands after procedure If this is painful do not continue, as pain may indicate infection / inflammation To undertake visual assessment and reduce the risk of trauma Irrigation should only be carried out to facilitate the removal of cerumen, keratin and debris from the ear canal, in the presence of no abnormalities 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 To prevent spread of micro-organisms. 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 E AR IR R IG AT ION Ear irrigation must only be undertaken using the Propulse electric ear irrigator II or III provided by the Trust. Syringes must not be used to irrigate ears. Do not use irrigation to remove wax for people with the following: N.B. The following list is not exhaustive, clinical decision making is dependant upon taking a thorough assessment of the patient and examination of the ear canal. The patient has previously experienced significant complications following ear irrigation in the past e.g. perforation, severe vertigo. There is a diagnosis of middle ear infection in the past 6 weeks 3/11

4 The patient has undergone any form of ear surgery (this excludes grommets that have extruded at least 18 months ago and the patient has been discharged from Ear, Nose and Throat services) The patient has current perforation (it is acceptable to irrigate the non affected ear if there are no abnormalities). The patient has a cleft palate (whether repaired or not) The patient has acute otitis externa with pain and tenderness around the pinna Patient is currently taking warfarin therapy and their most recent INR is above their target range Acute undiagnosed hearing loss that is not related to the accumulation of ear wax The patient has had mastoid surgery The patient is confused or agitated The patient is unable to cooperate or tolerate the procedure Presence of non hygroscopic matter such as peas, lentils, cotton ear buds Ear irrigation should be used with caution in patients with: Tinnitus Healed perforation Dizziness Equipment Required Otoscope Single use speculae Propulse electric irrigator II or II (cleaned in accordance with this policy see page 12/13) Disposable irrigator tips Jug Bath thermometer Trough / Receiver Tissues Clean towel Single use disposable apron Single use disposable non-sterile gloves PROCEDURE FOR EAR IRRIGATION PROCEDURE Verbally check the identity of the patient by asking for full name and date of birth. Check with carer/family if not able to confirm identity Ask patient occupation or previous occupation/s Obtain valid and informed consent for procedure and document assessment using aural risk assessment form. Inform patient of the risks and benefits of ear irrigation To confirm identity RATIONALE Informs clinical decision making To allow the patient / client to make an informed decision 4/11

5 PROCEDURE Decontaminate hands prior to procedure Apply single use disposable apron Apply single use disposable non-sterile gloves 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 37 C Set pressure of machine to minimum Attach new jet tip applicator to machine Run the machine for 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 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 RATIONALE To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of micro-organisms To protect hands from contamination with organic matter and transfer of microorganisms 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 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) 5/11

6 PROCEDURE 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 Dispose of contents of trough / receiver and decontaminate equipment in line with Trust Cleaning & Disinfection policy using a detergent wipe and pat dry. On completion of the procedure remove and dispose of personal protective equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Document all observations and actions including consent and patient perceptions Provide post-procedure ear care information leaflet RATIONALE 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 cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under the gloves and possible contamination following removal of PPE. Ensure compliance with NMC and local record keeping guidelines 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 ALLERGY 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 ) (NPF ) KNOWLEDGE AND SKILLS 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. Each nurse must be confident they have the clinical competency and the underpinning knowledge to carry out this procedure. Each nurse that undertakes this procedure must consider the disease processes that may indicate caution is required and the need for additional information about the patient and their treatment. 6/11

7 NURSING MANAGEMENT OF EAR WAX DOCUMENTATION (1of 3 pages) (For patients over 18 years) Step One - Complete an Initial Nursing Assessment AURAL NURSING RISK ASSESSMENT RECORD Patients Full Name: Date of Birth: NHS Number: Date of Assessment: Referred by: Any Known Allergies: Current medication that may impact on procedure? Valid Consent Given Yes No History of tympanic perforation in previous 12 months? Cleft Palate? Left Ear Right Ear YES NO YES NO Diagnosed middle ear infection in past six weeks? Does the patient have history of hearing loss that is not related to the excess production of wax? Have there been any significant problems previously with ear irrigation? e.g perforation / severe vertigo after procedure / other? Please state: Mucous discharge other than waxy discharge? Is there a recent history of dizziness, nausea, vertigo or ear surgery e.g. mastoid, grommets? Tinnitus or menieres disease? Is the patient currently taking Warfarin, and is their last INR within range? Unable to cooperate with the procedure? DO NOT IRRIGATE EAR/S IF THE ANSWER IS YES TO ANY OF THE ABOVE DICUSS WITH THE PATIENTS GENERAL PRACTITIONER 7/11

8 Patients Full Name Date of Birth: NHS Number: CLINICAL ASSESSMENT Left Ear Right Ear Yes No Yes No Check for signs for foreign bodies e.g. grommets, inflammation / discharge, offensive discharge Pain in or about ear when moving pinna? Please state: Swelling in or around the ear? Evidence of impacted wax which requires further oiling? 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 EAR IRRIGATED Was wax successfully removed? Left Ear Right Ear Yes No Yes No Leaflet given to patient following procedure and contents discussed Advice given: Is review of treatment requested Yes / No IF yes date of review: Nurses Name Designation EAR IRRIGATION PATHWAY FOR COMMUNITY NURSES Signature 8/11

9 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 valid consent or provide a history to complete aural risk assessment, discuss with the General Practitioner 9/11

10 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 products 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. Apply single use disposable apron and non-sterile gloves 2. Fill the tank ¾ full with the freshly prepared NADCC solution. 3. Run the machine for a few seconds into a sink to ensure all the internal pipe work is filled with the solution. 4. Stop the machine, leave to stand for 10 minutes to disinfect. 5. After 10 minutes empty the tank and refill with fresh tap water. 6. Run this through the machine to thoroughly rinse the system. 7. Discard any remaining NADCC solution, rinse and dry jug. 8. On completion of procedure remove and dispose of PPE to comply with waste management policy 9. Decontaminate hands following removal of PPE The machine is now ready for use Note: It is not advisable to attempt decontamination within a patient s home 10/11

11 DECONTAMINATING THE MACHINE AT THE END OF THE DAY/CLINIC SESSION 1. Apply single use disposable apron and non-sterile gloves 2. Prepare a detergent solution in the Propulse tank, run the machine into a sink for a few minutes to flush pipe work and pump. 3. Discard remaining solution, rinse tank with fresh tap water. 4. Fill tank ¾ full with a freshly prepared solution of 1,000ppm NADCC disinfectant. 5. Run solution through the machine into the sink to fill internal pipe work and pump. 6. Leave for 10 minutes to disinfect. 7. Empty tank and refill with fresh tap water. 8. Run machine for a few minutes into a sink to rinse internal pipe work. 9. Empty tank, rinse and dry with disposable paper towel. 10. Damp clean the exterior of the machine within a disposable cloth soaked in a detergent solution. 11. Discard any remaining NADCC solution, rinse and dry jug. 12. Store the machine and tips in a dust free environment. 13. On completion of procedure remove and dispose of PPE to comply with waste management policy 14. Decontaminate hands following removal of PPE INFECTION CONTROL ADVICE: This guidance has been based on informed infection control principles until more detailed information is available from the manufacturer. C L INIC AL INC IDE NT S Any related incidents arising from carrying out this procedure which may involve a clinical error or near miss must be reported following the Trust Incident Reporting Policy. C ONSULTATION Infection Prevention and Control Team Clinical Policies and Procedures Group Quality and Governance Service REFERENCES The Primary Ear Care Centre 11/11