22241 NHSQIS Ear Care BPS COV - spitalmures.ro de ingrijiri - ureche.pdf · The aim of this statement is to offer guidance to nursing staff with responsibility for various aspects

Best Practice Statement ~ May 2006

Ear Care

NHS Quality Improvement ScotlandEdinburgh Office Glasgow OfficeElliott House Delta House8-10 Hillside Crescent 50 West Nile StreetEdinburgh EH7 5EA Glasgow G1 2NP

Phone: 0131 623 4300 Phone: 0141 225 6999Textphone: 0131 623 4383 Textphone: 0141 241 6316

Email: [email protected]: www.nhshealthquality.org

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© NHS Quality Improvement Scotland 2005

ISBN 1-84404-403-3

First published May 2006

You can copy or reproduce the information in this document for use withinNHSScotland and for educational purposes. You must not make a profit usinginformation in this document. Commercial organisations must get our writtenpermission before reproducing this document.

www.nhshealthquality.org

Copies of this best practice statement, and other documents produced by NHS QIS,are available in print format and on the website.

Contents

Introduction to best practice statements i

Key stages in the development of best practice statements ii

Best practice statement on ear care iii

Section 1: Educational preparation of healthcare staff undertaking 1ear care

Section 2: Ear care assessment 2

Section 3: Cerumen management 4

Section 4: Instrumentation 5

Section 5: Ear irrigation 6

Section 6: Use of microscope and microsuction 8

Section 7: Infection control 10

Appendix 1: Suggested questions to include in initial ear care 12assessment

Appendix 2: Patient consent 13

Appendix 3: Guidance for ear care physical examination 14

Appendix 4: Guidance for cerumen management 15

Appendix 5: Guidance for instrumentation 17

Appendix 6: Guidance for ear irrigation 18

Appendix 7: Guidance for microsuction 20

Appendix 8: Ear care in children 23

Glossary 25

References 27

Useful websites 29

Working group membership 30

Patient Group Directions

Introduction

NHS Quality Improvement Scotland (NHS QIS) was set up by the ScottishParliament in 2003 to take the lead in improving the quality of care andtreatment delivered by NHSScotland.

The purpose of NHS QIS is to improve the quality of healthcare inScotland by setting standards and monitoring performance, and byproviding NHS Scotland with advice, guidance and support on effectiveclinical practice and service improvements.

A series of best practice statements has been produced within thePractice Development Unit of NHS QIS, designed to offer guidance onbest and achievable practice in a specific area of care. These statementsreflect the current emphasis on delivering care that is patient-centred,cost-effective and fair. They reflect the commitment of NHS QIS tosharing local excellence at a national level.

Best practice statements are produced by a systematic process, outlinedoverleaf, and underpinned by a number of key principles:

• They are intended to guide practice and promote a consistent,cohesive and achievable approach to care. Their aims are realistic but challenging.

• They are primarily intended for use by registered nurses, midwives,allied health professionals, and the staff who support them.

• They are developed where variation in practice exists and seek toestablish an agreed approach for practitioners.

• Responsibility for implementation of these statements rests at locallevel.

Best practice statements are reviewed, and, if necessary, updated after 3 years in order to ensure the statements continue to reflect currentthinking with regard to best practice.

i

ii

Key Stages in the development of best practice statements

Topic selection and Scoping Process.

Establish working group.Review literature on topic.

Source grey literature.

Ascertain current policy and legislation.

Seek information from manufacturers,

voluntary groups and other relevant

sources.

Establish reference group to

advise on consultation drafts.

Determine focus and content

of statement.

Review evidence for

relevance to practice.

Determine process for

incorporating patients’ views.

Draft document sent to

reference group.

Wide consultation process.

Review and update process. Identify

new research/ findings affecting topic.

Consider challenges of using

statement in practice.

Review and revise statement

in light of consultation

comments.

Publish and disseminate

statement.

Feedback on impact

of statement is

sought/impact

evaluation.

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲

Patient Group Directions

Best practice statement on ear care – introduction

The management and delivery of ear care was identified by a network ofnurses working in Ear, Nose and Throat (ENT) departments and inprimary care as an area in which inconsistencies in practice exist.Uncertainties over best practice are compounded by the lack of researchevidence and range of opinion relating to the delivery of care in this area.The aim of this statement is to offer guidance to nursing staff withresponsibility for various aspects of ear care.

The ear is a sensitive and easily damaged sensory organ. The RoyalNational Institute for the Deaf (RNID) estimates that there are 758,000deaf and hard of hearing people in Scotland. As the proportion of olderpeople in Scotland is increasing (General Register Office for Scotland) andsince hearing difficulty increases with age (Davis, 1995), ear care is likelyto become of increasing concern to the NHS in Scotland. In addition tohearing problems, care of the ear may also be related to tinnitus, vertigo,the removal of cerumen, foreign bodies, and the experience of pain. Mostpeople presenting for ear care, however, are likely to have some degreeof hearing loss, which may be temporary or permanent.

Referrals to GPs and secondary care may be reduced if nurses undertakeinitial management of ear care. In most circumstances nurses trained inthe care of ears are well placed to offer a service which is patient-focusedand community-based; the model of service provision for the NHS for thefuture, outlined in the white paper, Delivering for Health. (ScottishExecutive, 2005)

Some ear care procedures are highly specialist and it is particularlyimportant that those undertaking any of these procedures are competentto do so, prepared by appropriate training and continuing professionaldevelopment commensurate with the role. Individuals have a professionalresponsibility to recognise the limits of their own competence; knowledgeof the referral process is a significant aspect of primary ear care. Theworking group identified that initial training and ongoing mentoring isconsidered best practice and should be something to which allpractitioners aspire.

Given that ear care is often associated with hearing difficulty, thoseoffering this care should be highly skilled communicators. It is importantthat the healthcare worker is aware, not only of hearing loss but of otherpotential barriers to communication. The patient’s first language, whichmay not be English, the presence of a learning disability, dementia, or thepresence of other communication problems may all require a response

iii

iv

and certain techniques to promote effective communication and ensurepatient-centred care. The use of an interpreter, signing, maintaining aposition which will allow effective lip-reading and the use of writtenmaterials are all examples of techniques which can assist withcommunication.

The environment in which care is delivered and in which individualspractice will influence ear care services. This statement recognises the factthat while many practitioners work in isolation from support, often inthe community, practitioners working in specialist units have enhancedaccess to support and knowledgeable and skilled colleagues. The bestpractice statement should not limit experienced healthcare workersworking in a specialist environment. Practitioners in the community maybe unable to replicate the conditions which are routine in the clinic orhospital setting. Seating, lighting, and space constraints may all presentcommunity practitioners with specific challenges and any risks associatedwith this should be identified in the local risk register. (eg it may beimpossible for a community nurse to sit at a level with the patient. Therelevant register would record and address this.) In a similaracknowledgement of the isolated practitioner, the working group suggeststhe most conservative timescales recommended in the literature, forexample in performing ear procedures after a perforation. The workinggroup also recognised that there may be vulnerable individuals (forexample a young person with a learning disability who becomesdistressed at the noise of ear irrigation equipment) for whom bestpractice must be tailored to realistic and achievable practice.

The working group acknowledged that the evidence base for much ofthe practice of ear care is still evolving, in particular for ear care inchildren. The working group recognised that professional consensus willitself evolve as more knowledge becomes available. One of the purposesof a best practice statement is to identify variation in practice andstimulate research and it is hoped that a future review of this statementcould draw on a larger body of evidence.

1

SEC

TIO

N 1

: Ed

ucat

ion

al p

rep

arat

ion

of

hea

lth

care

sta

ff u

nd

erta

kin

g e

ar c

are

Key

Po

ints

~

1H

ealthc

are

sta

ff a

re a

ppro

pri

ate

ly t

rain

ed i

f per

form

ing

ear

care

in

terv

enti

ons.

All

heal

thca

re s

taff

unde

rtak

e a

com

pet

ency

bas

ed e

ar c

are

educ

atio

n p

rogr

amm

e ap

pro

pria

te*

for

the

asp

ects

of

ear

care

and

pro

cedu

res

they

pra

ctic

e.

Ther

e ar

e lo

cal p

roto

cols

whi

ch c

over

the

pro

visi

on o

ftr

aini

ng a

nd s

upp

ort.

Ther

e ar

e re

cord

s of

indi

vidu

al a

chie

vem

ent

in e

duca

tiona

lan

d C

PD a

ctiv

ities

.**

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

To p

rom

ote

safe

and

effe

ctiv

e p

ract

ice

To m

easu

re p

erfo

rman

ce a

gain

st s

tand

ards

To a

llow

con

tinui

ng a

sses

smen

t ag

ains

t co

mp

eten

cyst

atem

ents

for

Con

tinui

ng P

rofe

ssio

nal D

evel

opm

ent

(CPD

)in

the

rol

e.

Key

Ch

alle

ng

es ~

1The

ava

ilabi

lity

of

suit

abl

e ed

uca

tion

al

an

d t

rain

ing

act

ivit

ies

in l

ocal

are

as.

2The

ava

ilabi

lity

of

men

tors

, an

d t

he t

ime

an

d c

omm

itm

ent

requ

ired

for

on

goin

g ass

essm

ent.

3The

req

uir

emen

t of

hea

lthc

are

sta

ff t

o dev

elop

ser

vice

s w

ithi

n t

he p

ara

met

ers

of s

afe

pra

ctic

e as

des

crib

ed b

y re

gula

tory

bod

ies

(Hea

lth

Pro

fess

ion

s Cou

nci

l, N

MC, G

MC).

*The

lev

el o

f ed

uca

tion

req

uir

ed a

nd c

onte

nt

of e

du

cati

onal

pro

gram

mes

is

dep

enden

t on

the

rem

it o

f th

e in

div

idu

al

pra

ctit

ion

er. I

t is

ass

um

edth

at

all h

ealthc

are

sta

ff w

orki

ng

in e

ar

care

an

d/o

r u

nder

taki

ng

spec

ialist

pro

cedu

res

will

fulf

il t

heir

res

pon

sibi

lity

to

acq

uir

e an

d m

ain

tain

pro

fess

ion

al

know

ledge

an

d c

ompet

ence

appro

pri

ate

to

the

leve

l at

whi

ch t

hey

pra

ctic

e an

d t

hat

train

ing

will

be o

ffer

ed w

ithi

n t

he a

ppro

pri

ate

fram

ewor

ks o

f st

aff

gov

ern

an

ce a

nd r

ole

dev

elop

men

t (S

EH

D 2

002b

, SEH

D 2

005)

.

**The

wor

kin

g gr

oup r

ecog

nis

es t

he i

dea

l pro

visi

on o

f tr

ain

ing

wou

ld b

e by

a t

au

ght

cou

rse

suppor

ted b

y an

iden

tifi

ed m

ento

r w

ho w

ould

the

nass

ess

init

ial

com

pet

ence

an

d p

rovi

de

update

s at

agr

eed i

nte

rvals

2

SEC

TIO

N 2

: Ea

r ca

re a

sses

smen

t

Key

Po

ints

~

1Aw

are

nes

s of

the

pos

sibi

lity

of

heari

ng

impa

irm

ent,

an

d o

ther

pot

ential ba

rrie

rs t

o co

mm

un

ication

is

esse

ntial to

pro

mot

e ef

fect

ive

com

mu

nic

ation

with

patien

ts. (

See

best

pra

ctic

e st

ate

men

t, M

axim

isin

g co

mm

un

ication

with

peop

le w

ho h

ave

hea

rin

g dis

abi

lity

, NH

S Q

IS D

ec 2

005)

2 It i

s cr

uci

al

to u

nder

take

a p

hysi

cal

exam

inati

on o

f th

e ea

r an

d t

ake

a h

isto

ry o

f ea

r ca

re a

nd c

urr

ent

sym

pto

ms

in o

rder

to

elic

it i

nfo

rmati

onw

hich

may

con

train

dic

ate

cer

tain

tre

atm

ent

choi

ces.

Initi

al a

sses

smen

t is

car

ried

out

befo

re a

phy

sica

lex

amin

atio

n of

the

ear

. T

his

incl

udes

a h

isto

ry o

fsy

mp

tom

s an

d of

ear

car

e.

(Ap

pen

dix

1)

Phys

ical

exa

min

atio

n of

the

ear

tak

es p

lace

in a

ccor

danc

ew

ith lo

cal p

roto

cols

and

goo

d p

ract

ice.

(A

pp

endi

x 2)

The

findi

ngs

of t

he h

isto

ry-t

akin

g an

d ex

amin

atio

n ar

edo

cum

ente

d fo

llow

ing

guid

elin

es o

n re

cord

kee

pin

g.

All

deci

sion

s ab

out

initi

al a

nd o

ngoi

ng e

ar c

are

invo

lve

the

pat

ient

(an

d ca

rer

whe

re a

pp

rop

riate

).

Patie

nts

have

acc

ess

to in

form

atio

n ab

out

thei

r ca

re a

ndtr

eatm

ent

whi

ch is

:

•p

rese

nted

in a

var

iety

of

form

ats

•su

pp

lem

ente

d w

ith v

erba

l exp

lana

tions

, an

d

•se

nt t

o p

atie

nts

prio

r to

ap

poi

ntm

ents

whe

re p

ossi

ble.

Rele

vant

med

ical

his

tory

, cu

rren

t m

edic

atio

n an

d hi

stor

y of

ear

diso

rder

s or

tre

atm

ent

are

docu

men

ted

in t

he h

ealth

reco

rd.

Find

ings

fro

m t

he p

hysi

cal e

xam

inat

ion

are

docu

men

ted

inth

e he

alth

rec

ord.

Aud

it of

pat

ient

rec

ords

.

This

will

be

refle

cted

in lo

cal p

roto

cols

.

Com

mun

icat

ion

stra

tegi

es r

ecog

nise

and

add

ress

indi

vidu

alp

atie

nt’s

nee

ds.

Hea

lth r

ecor

ds d

ocum

ent

the

spec

ific

com

mun

icat

ion

need

sof

indi

vidu

al p

atie

nts.

A r

ange

of

info

rmat

ion

is a

vaila

ble

in a

var

iety

of

acce

ssib

lefo

rmat

s.

Loca

l pro

toco

ls d

eter

min

e ho

w a

nd w

hen

info

rmat

ion

isis

sued

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

To id

entif

y an

y in

form

atio

n w

hich

may

con

trai

ndic

ate

cert

ain

trea

tmen

t ch

oice

s.

To id

entif

y an

y in

form

atio

n w

hich

may

con

trai

ndic

ate

cert

ain

trea

tmen

t ch

oice

s.

To f

orm

a r

ecor

d of

ass

essm

ent

as e

vide

nce

for

the

deci

sion

on

any

trea

tmen

t re

com

men

datio

ns,

and

tom

aint

ain

a p

erm

anen

t re

cord

of

findi

ngs.

All

pat

ient

s sh

ould

hav

e th

e op

por

tuni

ty t

o as

k q

uest

ions

abou

t th

eir

care

.

To e

nsur

e th

at p

atie

nts

who

dep

end

on a

ltern

ativ

e m

eans

of c

omm

unic

atio

n, e

g th

ose

with

red

uced

hea

ring

or t

hose

who

sp

eak

com

mun

ity la

ngua

ges

othe

r th

an E

nglis

h, c

anun

ders

tand

info

rmat

ion.

Th

is c

onfo

rms

to t

he C

linic

al G

over

nanc

e &

Ris

kM

anag

emen

t St

anda

rd 2

a6 (

NH

S Q

IS 2

005)

To

pro

mot

e a

cons

iste

nt a

pp

roac

h to

adv

ice

give

n.

Key

Ch

alle

ng

es ~

1En

suri

ng

com

plian

ce w

ith

best

pra

ctic

e w

hen

exam

inin

g an

d c

ari

ng

for

pati

ents

in

the

ir o

wn

hom

es e

g si

ttin

g at

the

sam

e le

vel

as

the

pati

ent.

2D

evel

opin

g lo

cal

pro

toco

ls.

3En

suri

ng

that

healthc

are

sta

ff c

onsi

der

hea

rin

g lo

ss a

s an

im

por

tan

t part

of

the

ass

essm

ent

pro

cess

to

impro

ve p

ati

ent-ce

ntr

ed c

are

.

4En

suri

ng

that

train

ing

pro

gram

mes

in

clu

de

info

rmati

on o

n a

sses

smen

t an

d c

omm

un

icati

on s

trate

gies

for

tho

se w

ith

tem

por

ary

or

per

man

ent

heari

ng

loss

an

d t

hose

wit

h sp

ecia

l n

eeds.

3

Info

rmed

con

sent

is o

btai

ned

prio

r to

any

ear

car

ep

roce

dure

. (A

pp

endi

x 2)

Adv

ice

is s

ough

t fr

om a

n EN

T sp

ecia

list

or m

edic

alp

ract

ition

er if

the

re a

re c

once

rns

abou

t ab

norm

ality

or

app

rop

riate

man

agem

ent.

Hea

ring

loss

not

pre

viou

sly

inve

stig

ated

and

unr

esol

ved

follo

win

g ea

r ca

re is

rep

orte

d to

a m

edic

al p

ract

ition

er.

Ther

e is

doc

umen

ted

evid

ence

in h

ealth

rec

ords

tha

tap

pro

pria

te in

form

atio

n w

as g

iven

to

the

pat

ient

and

info

rmed

con

sent

sou

ght.

Crit

eria

exi

st f

or r

efer

ral t

o sp

ecia

list

serv

ices

.

Crit

eria

exi

st f

or r

efer

ring

pat

ient

s w

ith n

ewly

dia

gnos

edhe

arin

g lo

ss t

o sp

ecia

list

audi

olog

y se

rvic

es.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Patie

nts

shou

ld b

e aw

are

of r

isks

and

hav

e th

e op

por

tuni

tyto

ask

que

stio

ns r

elat

ing

to e

ar c

are

pro

cedu

res.

To e

nsur

e ac

cess

for

pat

ient

s to

ap

pro

pria

te a

sses

smen

tan

d m

anag

emen

t.

Hea

ring

loss

is a

bnor

mal

and

req

uire

s ap

pro

pria

teas

sess

men

t an

d m

anag

emen

t. (

See

best

pra

ctic

est

atem

ent,

Max

imis

ing

com

mun

icat

ion

with

old

er p

eop

lew

ho h

ave

hear

ing

disa

bilit

y, N

HS

QIS

Dec

200

5)

4

SEC

TIO

N 3

: C

erum

en m

anag

emen

t

Key

Po

ints

~

1In

itia

l tr

eatm

ent

shou

ld b

e th

e u

se o

f ea

r dro

ps

as

this

may

redu

ce n

eed f

or f

urt

her

man

age

men

t.

Trea

tmen

t w

ith e

ar d

rop

s is

the

firs

t lin

e tr

eatm

ent

if

•th

e ea

r ca

nal i

s oc

clud

ed w

ith w

ax a

nd

•fo

llow

ing

asse

ssm

ent,

ear

irrig

atio

n is

bei

ng c

onsi

dere

d.

Trea

tmen

t is

pat

ient

-cen

tred

and

in a

ccor

danc

e w

ith lo

cal

pro

toco

ls a

nd b

est

pra

ctic

e. (

See

Ap

pen

dix

4)

If th

e us

e of

dro

ps

has

not

been

effe

ctiv

e,

the

follo

win

gre

mov

al m

etho

ds a

re e

mp

loye

d

•in

stru

men

tatio

n

•irr

igat

ion,

or

•m

icro

suct

ion

[see

rel

evan

t in

divi

dual

sec

tions

on

thes

ep

roce

dure

s]

Hea

lth r

ecor

ds d

ocum

ent

advi

ce g

iven

to

pat

ient

reg

ardi

ngus

e of

ear

dro

ps.

Ther

e ar

e lo

cal p

roto

cols

for

this

tre

atm

ent.

(Se

e be

st p

ract

ice

stat

emen

t, M

axim

isin

g co

mm

unic

atio

n w

ith o

lder

peo

ple

who

hav

e he

arin

g di

sabi

lity,

NH

S Q

IS D

ec 2

005)

Gui

danc

e on

whi

ch d

rop

s to

use

sho

uld

be in

clud

ed in

loca

lp

roto

cols

.

Gui

danc

e is

incl

uded

with

in lo

cal p

roto

cols

/pro

cedu

res.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

This

may

red

uce

the

need

for

ear

irrig

atio

n an

d th

e ris

ksas

soci

ated

with

it.

Dro

ps

have

bee

n sh

own

to b

e ef

fect

ive

in c

erum

enm

anag

emen

t (K

ean

et a

l 199

5).

The

GP

pra

ctic

e is

usu

ally

the

firs

t p

oint

of

cont

act

for

ap

atie

nt a

nd w

ill d

eter

min

e ho

w c

are

and

trea

tmen

t is

offe

red.

Exce

ssiv

e w

ax s

houl

d be

rem

oved

to

pre

vent

/red

uce

hear

ing

loss

, tin

nitu

s, v

ertig

o or

pai

n an

d to

get

a f

ull v

iew

of t

he t

ymp

anic

mem

bran

e, f

or d

iagn

ostic

pur

pos

es.

Key

Ch

alle

ng

es ~

1Edu

cati

ng

the

pu

blic

an

d p

ract

itio

ner

s in

cer

um

en m

an

age

men

t es

pec

ially

thos

e w

ho a

re a

ccu

stom

ed t

o ea

r ir

riga

tion

as

a f

irst

lin

etr

eatm

ent.

Key

Ch

alle

ng

es ~

1 D

evel

opin

g su

itabl

e tr

ain

ing

an

d c

ours

es.

5

SEC

TIO

N 4

: In

stru

men

tati

on

Key

Po

ints

~

1Thi

s pro

cedu

re i

s u

sed t

o cl

ear

the

ear

can

al

of d

ebri

s, dis

charg

e an

d s

oft

wax.

2 R

emov

al

of p

rodu

cts

shou

ld b

e u

nder

take

n o

nly

by

healthc

are

sta

ff w

ho a

re t

rain

ed a

nd c

ompet

ent

in t

his

are

a o

f pra

ctic

e.

3 Tra

inin

g is

req

uir

ed p

rior

to

inst

rum

enta

tion

.

A f

ull e

xam

inat

ion

of t

he e

ar a

nd a

his

tory

is t

aken

.

Deb

ris,

disc

harg

e or

wax

is r

emov

ed w

ith a

n EN

Tin

stru

men

t se

lect

ed u

sing

clin

ical

judg

emen

t an

d in

acco

rdan

ce w

ith b

est

pra

ctic

e. (

See

Ap

pen

dix

5)

The

findi

ngs

of t

he h

isto

ry t

akin

g an

d th

e ex

amin

atio

n ar

e do

cum

ente

d in

acc

orda

nce

with

gui

delin

es o

n re

cord

kee

pin

g.

Hea

lth r

ecor

ds d

ocum

ent

the

reas

on f

or t

he p

roce

dure

,p

revi

ous

ear

care

man

agem

ent

and

any

cont

rain

dica

tions

.

Hea

lth r

ecor

ds d

ocum

ent

the

inst

rum

ent

used

.

Hea

lth r

ecor

ds d

ocum

ent

the

outc

ome

of p

roce

dure

and

info

rmat

ion

give

n to

pat

ient

abo

ut f

indi

ngs.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

To a

scer

tain

pat

ient

’s s

uita

bilit

y fo

r au

ral

toile

t/in

stru

men

tatio

n.

Exce

ssiv

e w

ax s

houl

d be

rem

oved

to

get

a fu

ll vi

ew o

f th

ety

mp

anic

mem

bran

e, f

or d

iagn

ostic

pur

pos

es,

and

top

reve

nt/r

educ

e he

arin

g lo

ss,

tinni

tus,

ver

tigo

or p

ain.

To m

inim

ise

risk

of p

erfo

ratio

n or

tra

uma

to e

ar.

To f

orm

a r

ecor

d of

ass

essm

ent

as e

vide

nce

for

deci

sion

on

any

trea

tmen

t re

com

men

datio

ns a

nd t

o m

aint

ain

ap

erm

anen

t re

cord

of

findi

ngs.

6

SEC

TIO

N5:

Ear

irri

gat

ion

Key

Po

ints

~

1

Earw

ax s

hou

ld b

e re

mov

ed o

nly

if

it c

au

ses

sym

pto

ms

or t

o fa

cilita

te e

xam

inati

on o

f th

e ea

r.

2

Ear

irri

gati

on s

hou

ld b

e u

nder

take

n o

nly

by

thos

e w

ho a

re t

rain

ed a

nd c

ompet

ent

in t

his

pro

cedu

re.

3

Irri

gati

on o

f th

e ea

r m

ay

cau

se c

omplica

tion

s an

d m

ust

be

use

d o

nly

fol

low

ing

indiv

idu

al

ass

essm

ent

(see

Sec

tion

3)

wit

h co

nsi

der

ati

on o

fth

e fo

llow

ing

indic

ati

ons

an

d c

ontr

ain

dic

ati

ons

(Hark

in, 2

003)

*

* H

ark

in, H

, (20

03)

, "Ear

Care

Gu

idel

ines

", N

HS

Mod

ern

isati

on A

gen

cy, L

ondon

: page

6ht

tp://

ww

w.w

ise.n

hs.u

k/si

tes/

clin

icalim

pro

vcol

lab/

EN

T/E

NT%

20D

ocu

men

ts/1

/Ear%

20Care

%20

Gu

idan

ce.p

df

Ind

ica

tio

ns:

•Th

e re

mov

al o

f ea

rwax

whe

n tr

eatm

ent

with

ear

dro

ps

alon

e ha

sbe

en in

effe

ctiv

e

•To

cle

ar d

ebris

to

faci

litat

e ex

amin

atio

n of

the

ear

can

al a

ndty

mp

anic

mem

bran

e or

fur

ther

tre

atm

ent

•Re

mov

al o

f no

n hy

gros

cop

ic f

orei

gn b

odie

s (h

ygro

scop

ic m

atte

r,su

ch a

s p

eas,

abs

orb

wat

er a

nd e

xpan

d m

akin

g re

mov

al m

ore

diffi

cult)

.

Co

ntr

ain

dic

ati

on

s :

•hi

stor

y of

pre

viou

s pr

oble

m w

ith e

ar ir

rigat

ion

(eg

pain

, per

fora

tion)

•hi

stor

y of

mid

dle

ear

infe

ctio

n in

the

pre

viou

s 6

wee

ks

•hi

stor

y of

ear

sur

gery

exc

ept

extr

uded

gro

mm

ets

with

in t

he la

st

18 m

onth

s a

nd p

atie

nt d

isch

arge

d fr

om E

NT

•hi

stor

y of

per

fora

tion

or m

ucou

s di

scha

rge

in la

st 1

2 m

onth

s

•cl

eft

pala

te –

whe

ther

rep

aire

d or

not

•ac

ute

otiti

s ex

tern

a w

ith a

n oe

dem

atou

s ea

r ca

nal a

nd p

ainf

ul p

inna

•if

patie

nt c

onfu

sed

and

agita

ted

or u

nabl

e to

sit

still

.

7

A f

ull h

isto

ry is

tak

en w

ith p

artic

ular

att

entio

n to

cont

rain

dica

tions

and

indi

catio

ns f

or t

his

pro

cedu

re a

ndfo

llow

ing

exam

inat

ion

of t

he e

ar.

Syrin

ges

mus

t n

ot

be u

sed

for

the

irrig

atio

n of

the

ear

cana

l.

The

use

of a

n el

ectr

onic

ear

irrig

ator

is r

ecom

men

ded.

This

will

be

sup

plie

d w

ith

•a

pre

ssur

e va

riabl

e co

ntro

l,

•lim

iting

max

imum

pre

ssur

e,

•sp

ecifi

c m

anuf

actu

rer’s

dis

infe

ctin

g in

stru

ctio

ns,

and

•m

aint

enan

ce g

uide

lines

.

Ear

irrig

atio

n m

achi

nes

are

disi

nfec

ted

and

mai

ntai

ned

inco

mp

lianc

e w

ith t

he m

anuf

actu

rer’s

inst

ruct

ions

and

inac

cord

ance

with

loca

l pro

toco

ls.

Rele

vant

clin

ical

his

tory

, fin

ding

s of

the

exa

min

atio

n an

dth

e p

roce

dure

und

erta

ken

are

docu

men

ted

follo

win

ggu

idel

ines

on

reco

rd k

eep

ing.

The

reas

on f

or t

he p

roce

dure

, th

e p

revi

ous

ear

drop

reg

ime

and

any

cont

rain

dica

tions

are

doc

umen

ted

in t

he h

ealth

reco

rd.

The

equi

pm

ent

used

is d

ocum

ente

d in

the

hea

lth r

ecor

d.

Loca

l pro

toco

ls/p

roce

dure

s in

clud

e in

form

atio

n on

the

use

of t

he e

lect

roni

c irr

igat

or.

Ther

e ar

e lo

cal h

ealth

and

saf

ety

pol

ices

, sp

ecifi

cally

tho

seco

ncer

ned

with

dev

ice

man

agem

ent

and

cont

rol o

fin

fect

ion.

Aud

it of

indi

vidu

al p

atie

nt r

ecor

ds.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

To e

nsur

e irr

igat

ion

is n

ot c

ontr

aind

icat

ed a

nd t

he u

se o

fea

r dr

ops

has

been

att

emp

ted

as a

firs

t lin

e re

spon

se.

The

use

of s

yrin

ges,

sp

ecifi

cally

met

al e

ar s

yrin

ges,

in e

arirr

igat

ion

is n

o lo

nger

con

side

red

good

pra

ctic

e.

The

desi

gn o

f th

e m

etal

syr

inge

com

bine

d w

ith t

hein

abili

ty t

o co

ntro

l wat

er p

ress

ure

incr

ease

s th

e ris

k of

ear

dam

age.

The

re a

re a

lso

diffi

culti

es in

dis

infe

ctin

g th

esy

ringe

aft

er e

ach

use.

(Har

kin

2003

)

This

pre

vent

s cr

oss-

infe

ctio

n an

d en

sure

s p

atie

nt a

ndop

erat

or s

afet

y.

To f

orm

a r

ecor

d of

ass

essm

ent

as e

vide

nce

for

deci

sion

on

any

trea

tmen

t re

com

men

datio

ns a

nd t

o m

aint

ain

ap

erm

anen

t re

cord

of

the

pro

cedu

re.

Key

Ch

alle

ng

es ~

1Edu

cati

ng

the

pu

blic

an

d p

ract

itio

ner

s to

con

sider

ear

irri

gati

on o

nly

as

a s

econ

d l

ine

trea

tmen

t fo

r re

mov

al

of e

arw

ax.

2En

suri

ng

acc

ess

to a

tra

inin

g an

d c

ompet

ence

fra

mew

ork

in e

ar

irri

gati

on f

or h

ealthc

are

sta

ff u

nder

taki

ng

this

pro

cedu

re.

8

SEC

TIO

N 6

: M

icro

sco

pic

exa

min

atio

n a

nd

mic

rosu

ctio

n

Key

Po

ints

~

1M

icro

scop

ic e

xam

inati

on i

s co

nsi

der

ed a

n a

dva

nce

d p

ract

ice

an

d s

hou

ld b

e u

sed o

nly

aft

er a

ppro

pri

ate

tra

inin

g.

2Thi

s pro

cedu

re i

s u

sed t

o:•

view

in

det

ail t

he e

ar

can

al/

mast

oid c

avi

ty a

nd t

ympan

ic m

embr

an

e •

make

a d

iagn

osis

, an

d•

if r

equ

ired

, cle

ar

the

can

al

of f

orei

gn b

odie

s, deb

ris,

dis

charg

e an

d c

eru

men

.

3The

pra

ctit

ion

er w

ill

choo

se t

he c

orre

ct i

nst

rum

enta

tion

to

dea

l w

ith

the

com

pla

int.

4The

use

of

suct

ion

un

der

the

mic

rosc

ope

(mic

rosu

ctio

n)

is s

omet

imes

the

in

stru

men

t of

cho

ice. M

icro

suct

ion

is

a n

oisy

, som

etim

esu

nco

mfo

rtabl

e pro

cedu

re.

An

in

div

idu

al

ass

essm

ent

of e

ach

pati

ent

shou

ld b

e m

ade

to e

nsu

re t

he s

uit

abi

lity

for

mic

rosu

ctio

n w

ith

con

sider

ati

on o

f th

e fo

llow

ing

indic

ati

ons

an

d c

ontr

ain

dic

ati

ons:

Ind

ica

tio

ns:

•re

mov

al o

f ce

rum

en if

ear

dro

p t

reat

men

t an

d ot

her

met

hods

hav

efa

iled

•re

mov

al o

f di

scha

rge,

ker

atin

or

debr

is t

o en

able

cor

rect

tre

atm

ent

ofot

itis

exte

rna

and

allo

w e

xam

inat

ion

of e

ar c

anal

/mas

toid

cav

ity a

ndty

mp

anic

mem

bran

e/dr

um r

emna

nt

•re

mov

al o

f fo

reig

n bo

dies

whi

ch a

re h

ygro

scop

ic o

r hy

dros

cop

ic

•re

mov

al o

f ca

nal d

ebris

or

ceru

men

whe

re t

here

is o

cclu

sion

and

akn

own

per

fora

tion.

Co

ntr

ain

dic

ati

on

s:

•if

pat

ient

con

fuse

d an

d ag

itate

d, e

g a

pat

ient

with

a le

arni

ngdi

sabi

lity

may

fin

d th

e no

ise

dist

ress

ing

and

not

be a

ble

to s

it st

ill f

orth

is p

roce

dure

.

9

A f

ull h

isto

ry is

tak

en,

par

ticul

arly

ass

essi

ng f

orco

ntra

indi

catio

ns a

nd in

dica

tions

as

outli

ned

abov

e an

dfo

llow

ing

exam

inat

ion

of t

he e

ar.

A p

hysi

cal e

xam

inat

ion

of t

he e

ar is

und

erta

ken.

The

mic

rosc

ope

and

mic

rosu

ctio

n ar

e us

ed o

nly

follo

win

gtr

aini

ng a

nd in

acc

orda

nce

with

loca

l pro

toco

ls a

nd b

est

pra

ctic

e.

(Ap

pen

dix

7)

The

findi

ngs

of t

he h

isto

ry t

akin

g, e

xam

inat

ion

and

pro

cedu

re u

nder

take

n ar

e do

cum

ente

d fo

llow

ing

guid

elin

es o

n re

cord

kee

pin

g.

Hea

lth r

ecor

ds d

ocum

ent

the

reas

on f

or t

he p

roce

dure

,p

revi

ous

ear

care

man

agem

ent

and

any

cont

rain

dica

tions

.

The

outc

ome

of p

roce

dure

and

info

rmat

ion

give

n to

pat

ient

abou

t th

e fin

ding

s ar

e do

cum

ente

d in

the

hea

lth r

ecor

d.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

To a

scer

tain

tha

t m

icro

suct

ion

is a

n ap

pro

pria

te t

reat

men

tfo

r th

e p

atie

nt.

To f

orm

a r

ecor

d of

ass

essm

ent

as e

vide

nce

for

deci

sion

on

any

trea

tmen

t re

com

men

datio

ns a

nd t

o m

aint

ain

ap

erm

anen

t re

cord

of

the

pro

cedu

re.

Key

Ch

alle

ng

es ~

1 M

ain

tain

ing

mic

rosc

opes

in

com

plian

ce w

ith

the

man

ufa

ctu

rer’s

inst

ruct

ion

s an

d l

ocal

main

ten

an

ce a

rran

gem

ents

.

2 En

suri

ng

pra

ctit

ion

ers

are

fam

ilia

r w

ith

the

mic

rosc

ope

they

are

usi

ng

as

thes

e ca

n v

ary

.

10

SEC

TIO

N 7

: In

fect

ion

co

ntr

ol

Key

Po

ints

~

1A

ll h

ealthc

are

sta

ff s

hou

ld b

e aw

are

of

the

risk

of

healthc

are

ass

ocia

ted i

nfe

ctio

ns

(HA

I).

2 H

ealthc

are

pro

vider

s sh

ould

have

aw

are

nes

s of

the

Gle

nn

ie F

ram

ewor

k an

d S

cottis

h Exec

uti

ve H

ealth

Dep

art

men

t re

com

men

dati

ons.

The

yha

ve r

espon

sibi

liti

es u

nder

the

Hea

lth

& S

afe

ty a

t W

ork

Act

(19

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12

Appendix 1:

Suggested questions to include in initial ear care assessment

The questions suggested below should help the healthcare worker take afull ear history. Awareness of the patient’s wider health needs eg if thepatient is immuno-compromised, or has diabetes, should inform the earhistory taking, and the patient should be referred to an appropriatespecialist if necessary.

• Have you had ear surgery?

• Have you experienced previous ear problems?

• Have you ever had perforated ear drum(s)?

• Do you suffer from tinnitus?

• Do your ears itch?

• Do you use cotton buds in your ears?

• Do you avoid water getting into your ears? If so, how?

• Do you have any allergies?

• Have you any underlying skin complaints?

• Do you swim? If so, how frequently?

If there are clinical indications eg the pinna, surrounding skin or externalmeatus are red or excoriated;

• Have you made any changes in shampoo, hair products or detergents?

Ear Care

Appendix 2

Patient Consent

1. Informed patient consent must be obtained before a healthcareintervention is carried out.

2. Consent should be seen as a process, not a single event. Patients canchange their minds and withdraw their consent at any time.

3. Part 5 of The Adults with Incapacity (Scotland) Act 2000 sets out theprinciples that should underpin the assessment of incapacity toconsent to medical treatment or research, and how to proceed wherean individual is incapable of giving informed consent.

4. An important principle of consent is that the patient understands andagrees to the healthcare intervention. The nature of this agreementwill depend on the nature of the proposed intervention and on localpolicies. Agreement does not necessarily need to be in writing buthealth records must document the fact that the patient understandsthe process of the relevant ear care procedure and the need for it, andconsents verbally to the procedure.

5. In Scottish Law, when someone reaches their 16th birthday, the persongains the legal capacity to make decisions for him/herself. However,even under the age of 16, a young person can have the legal capacityto make a decision on a healthcare intervention, provided that theyoung person is capable of understanding its nature and possibleconsequences.

At the time of going to press, a ‘Good practice guide on consent forhealth professionals in NHS Scotland’ was being prepared by the ScottishExecutive for publication in 2006. In addition, guidance on the amendments to Part 5 of the Adults withIncapacity (Scotland) Act 2000, contained within the Smoking, Health andSocial Care (Scotland) Act 2005 will be issued from the Scottish Executivein 2006.

13

14

Appendix 3

Guidance for Ear Care Physical Examination

Standard infection control precautions are used:

• hand washing before and after procedures involving patients, and

• use of gloves and protective clothing when handling instruments and equipment.

Statement

Ensure that the patient is sitting comfortably.Ensure that you are sitting at the same level aspatient.Ensure the light is good.

Conduct the physical examination of the ear,including pinna, ear canal and adjacent scalp.

Undertake the auriscope examination using thelargest speculum that fits comfortably in ear canal. Adjust your head and auriscope to view all oftympanic membrane. If your view hampered by cerumen, see Section3 and Appendix 4 on cerumen management.

If the patient has had mastoid surgery, adjustyour head and auriscope to view as much of thecavity as possible.

Reasons for statement

The patient needs to sit without moving to avoiddamage to ear from instrument. This improves your vision of the ear andpromotes good posture and reduces the risk ofback injury.

To help identify the existence of any scars,discharge, swelling, skin lesions or defects.

The ear cannot be judged to be normal until allareas of the membrane are viewed.

The mastoid cavity cannot be judged to becompletely free of disease until the entire cavityand tympanic membrane or drum remnant hasbeen viewed. It is not always possible, however,to view the whole cavity.

Ear Care

15

Appendix 4

Guidance for cerumen management




Statement

Take a relevant clinical history and perform anear examination.

Obtain informed consent from the patient.

If you advise an ear drop regime, it should betailored to individual needs eg 2-5 drops of waxsoftening ear drops (olive oil or the patient’schoice) twice a day for 3-5 days.

Supplement these instructions with writteninformation advising the use of ear drops andthe technique for instilling drops.

There is no research evidence to recommendone type of ear drop over another.

The following should be remembered:

• some drops may cause irritation in somepatients, and

• some drops contain nut oil and should beavoided by those with nut allergy.


Determine if cerumen management is indicatedand appropriate.

This is a legal requirement and is intended toensure that the patient is aware of what theprocedure involves, the possible complicationsand has agreed to it.

Drops have been shown to be effective incerumen management (Kean et al 1995).

To reduce risk of increased ear damage.

16

Statement

If a perforation behind the wax is suspected,advise the patient to use the drops in very small amounts. (see contraindications to ear irrigation page 6)

Advise the patient to stop using the ear drops if he/she experiences any pain.

Document all aspects of the treatment episode in the patient’s health records.

Provide any further instructions and advice onear care to the patient.


To reduce risk of increased ear damage.

To ensure a full and accurate record of thepatients condition and the treatment provided.

To promote good ear care

Ear Care

17

Appendix 5

Guidance for instrumentation

Only a suitably trained and qualified practitioner should undertake this procedure.




Statement



Select ENT instrument in accordance withclinical judgement .

Gently pull the pinna upwards and outwards (ininfants downwards and backwards) to straightenout the meatus. Remember that the skin liningthe deeper meatus is very delicate and sensitive.

Periodically inspect the ear canal with auriscopeand examine products removed.

Observe the entire canal/ tympanicmembrane/drum remnant/mastoid cavity.

Document all aspects of the treatment episode inthe patient’s health records.



Determine if instrumentation is indicated andappropriate.


This straightens the ear canal enabling betteraccess and view.

To ensure no damage to ear and assess progress.

The ear cannot be judged to be completely freeof ear disease without a complete view.


To promote good ear care.

18

Appendix 6

Guidance for ear irrigation





Statement



Prepare equipment as per local guidelines andmanufacturer’s instructions. This will include afresh speculum and jet tip for each patient.Protect the patient’s clothing with a towel orwaterproof covering. Ask the patient to hold thewater receiver under their affected ear.

Ensure that the patient is sitting comfortably andthat you are sitting at the same level as thepatient. Use a good light source, from a headlamp or head mirror, throughout the procedure.

Ensure that the temperature of water is aroundbody temperature throughout the procedure anddoes not exceed 40ºC at the beginning of theprocedure.

Pull the pinna upwards and outwards(downwards and backwards in children).The jettip should be angled so that the flow of thewater is along the posterior wall superiorlytowards the superior occipital region.


Determine ear irrigation is indicated andappropriate.


To facilitate a safe and successful procedure. To promote patient comfort.

This improves visibility and promotes goodposture of the nurse, reducing risk of backinjury.

This promotes patient comfort and avoidsextremes of temperature. Irrigation with coldwater is very unpleasant and can cause dizziness(the caloric effect).

This straightens the ear canal enabling betteraccess and view. Directing the water this wayreduces the stimulus of the vagal nerve.

Ear Care

19

Statement

Inspect the ear canal periodically with theauriscope and monitor the solution running intothe receiver. The procedure can beuncomfortable but should not cause pain. If the patient reports ear pain the procedure

should be stopped.

Unless this is overridden by clinical judgement,follow the recommendation that a maximum of500ml water is used per ear in any one irrigatingprocedure.

Following irrigation examine the ear with anauriscope.*

Document all aspects of the treatment episode inthe patient’s health records.



This ensures there is no obvious damage to theear and monitors progress in clearing the ear.Prevent complications due to ear irrigation.

There may be an increased risk of complicationsthe longer the procedure continues.

It is important to check the condition of the ear.



*At this point in the procedure some practitioners recommend dry mopping. The research base on drymopping the ear following ear irrigation is still evolving; it may pre-empt a predisposition to infectionfrom the water left in the ear or it may encourage infection. The working group has therefore notincluded dry-mopping in the statement, since it is hoped that, until further research determines theevidence base for the safety and effectiveness of this procedure, professional clinical judgement and localprotocols will guide healthcare staff.

20

Appendix 7

Guidance for microsuction





Statement



Ensure you are familiar with the equipment andmanufacturer’s instructions.

• Suction should be maintained between 80 and120 Hg (18 to 20 cm H2O) during procedure.

Equipment used includes:

• Zollner tip suction catheter

• fine Zollner tip suction extension 18-22 Fg

• Jobson-Horne probe

• crocodile forceps

• gauze.

Check if the patient has had microsuctionpreviously, explain the nature of the noise andassure them that they can ask for a rest if theyexperience any vertigo. If vertigo occurs stop the procedure and ask thepatient to focus their eyes on a fixed object untilthe feeling subsides.


This determines if microsuction is indicated andappropriate. (see section )


This ensures that the patient is prepared for apotential side effect.

Ear Care

21

Statement

Request that the patient position themselvescomfortably in the examination couch or chair.You may need to ask the patient to move theirhead eg lean head towards the opposite shoulderto be able to see more clearly into the cavity.

Adjust the magnification eyepiece and angle ofthe microscope to the appropriate position.

First examine the pinna, outer meatus andadjacent scalp by direct light and check forincision scars and observe for skin defects.

Gently pull the pinna upwards and outwards (ininfants downwards and backwards) to straightenout the meatus. Remember that the skin liningthe deeper meatus is very delicate and sensitive.

Direct the microscope down the ear. Insert thespeculum gently into the cavity – use the largestsize speculum that will fit comfortably into theear. Rotating the speculum gently will helpflatten the hairs in the outer meatus.

Carefully check the cavity, tympanic membraneor drum remnant. Decide the size of suction tipmost appropriate for the procedure and attach itto the suction tubing.

Inform the patient that you are about to turn thesuction machine on. Apply the suction tip to theareas requiring debris removal. Use anappropriate solution to wash through the suctiontubing if it becomes blocked.

Avoid touching the wall of the meatus, cavity ordrum/drum remnant.

You may need to ask the patient once again tomove their head to gain a full view of theexternal auditory meatus, drum or drumremnant.


To facilitate a safe and successful procedure. Topromote patient comfort.

To obtain maximum benefit from the use of theequipment.

To obtain any relevant information fromobservation.

This straightens the ear canal enabling betteraccess and view.

This gives a clear view.

The most appropriate equipment for theprocedure enables the procedure to be donewith maximum safety and effectiveness.

Touching only the debris helps to minimisediscomfort for the patient.

22

Statement

Vary the angle of the microscope to gain a fullview of the cavity, tympanic membrane or drumremnant.

The normal appearance of the cavity varies.Seek specialist advice to confirm findings ifrequired.

Carefully check the condition of the externalauditory meatus as you withdraw the speculum.

Document all aspects of the treatment episode inthe patient’s health records in accordance withappropriate guidance.



The ear cannot be judged to be completely freeof debris until the entire cavity and tympanicmembrane or drum remnant has been seen.



Ear Care

Appendix 8

Children and ear care

The process of producing a best practice statement often identifies areasfor potential research. The working group identified differences in thepractice of ear care in children across Scotland and noted that theevidence base for procedures is still evolving. The group consequentlysought professional consensus by identifying significant principles forhealthcare practitioners in ear care for children and recommendsadherence to professional judgement and local protocols, noting that thisstatement will be reviewed in three years time.

The working group acknowledged that it requires particular skill to elicitco-operation in children and that the majority of ear care procedurescarried out on children will take place not in primary care but inspecialist paediatric units. Referral to a more highly skilled practitionermay reduce the need for anaesthetic if the child becomes very agitated.

As with the care of adults, practitioners need to refer any concernsidentified before, during or after a procedure to an appropriateconsultant. The working group noted that children become unsettledquickly; if this is the case the group advises that the procedure should bestopped immediately.

The working group also identified the need for careful considerationprior to ear care procedures dependent on a risk-benefit analysis whichwould include the following factors:

• the need for the procedure,

• the risks of the procedure eg of anaesthesia,

• age and developmental stage of child,

• co-operation of child, and

• consent of child/person with parental rights and responsibilities.

23

24

In addition the following principles were identified:

• Education, training, competence and confidence are of paramountimportance. There should be no attempt to undertake urgent ear care(eg the removal of a foreign body in the ear cavity) if there is anydoubt of success at the first attempt.

• Local protocols may determine which interventions take place and inwhat circumstances eg there may be special arrangements for childrenwith a learning disability.

• No healthcare practitioner should be required to undertake anintervention without appropriate support and training. Healthcarepractitioners should consider that they are fully competent andsupported before undertaking an intervention. (NMC Code ofProfessional Conduct, 2004)

• Professional consensus suggests that no intervention, including suctionor instrumentation, is undertaken without a specialist role.

• Professional practice in Scotland suggests that a policy of no irrigationof the ear of anyone under the age of 16 is predominant.

Ear Care

Glossary

aural toilet Cleaning of the ear usually done mechanically by hand

by a skilled specialist. The procedure is usually

performed in a secondary (specialist) setting and can

include dry mopping of the ear canal or suction. This

can be performed with the assistance of a head light or

microscope which allows cleaning of the more medial

areas of the ear canal.

auriscope A medical instrument consisting of a magnifying lens

and light and used for examining the ear. Also known

as an otoscope.

cerumen Commonly known as earwax, is a yellowish, waxy

substance secreted in the ear canal. It plays a vital role

in the human ear canal, assisting in cleaning and

lubrication, and also provides a degree of protection

from bacteria, fungus, and insects.

ear drum See tympanic membrane.

drum remnant What remains of a damaged ear drum, usually the

edge running round the ear canal where the outer ear

meets the middle ear.

ear canal The tube running from the outer ear to the middle ear.

It ends at the ear drum.

grommets A flanged metal or plastic tube that is inserted in the

eardrum in cases of glue ear. It allows air to enter the

middle ear, bypassing the patient’s own non-

functioning Eustachian tube.

instrumentation The use of a range of medical instruments appropriate

to ear care procedures, such as wax scoops,

microscopes, magnifiers and lights.

irrigation The process of washing out a wound or hollow organ

with a continuous flow of water or medicated solution.

keratin A protein that is a primary constituent of hair, nails

and skin.

malleus The outermost of three tiny bones, connecting the

eardrum to the vibration-sensitive structures of the

inner ear and thereby amplifying and transmitting

sound waves.

25

26

mastoid Hard, boney structure behind the ear which is well

developed in adults but not in children.

meatus The auditory meatus is the passage or tube leading

from the oval shaped external ear (pinna) to the

eardrum. (See ear canal.)

membrane Structure or material that separates two environments,

for example the ‘ear drum’ placed between the inner

and outer ear.

microsuction The use of a microscope and suction to remove wax,

debris or foreign bodies from the ear. ‘Micro’ refers to

the gentle level of suction and small-scale specialist

equipment used.

dry mopping Drying the ear canal with ear probe and cotton wool.

oedematous Swelling due to excessive fluid in the tissues.

otitis externa An inflammation of the skin of the ear canal.

perforation A hole in an organ, tissue or tube.

pinna (auricle) The oval flap of skin and cartilage that projects from

the head at the opening of the ear canal. The ‘ear’ as

normally seen.

speculum An instrument for inserting into and holding open a

cavity of the body.

tinnitus A ringing, roaring, buzzing, or other noise that is ‘heard’

but is not actual sound.

tympanic The membrane at the inner end of the external

membrane auditory canal (ear canal), which separates the outer

and middle ear. Sound waves cause the membrane to

vibrate and transmit sound to the malleus within the

middle ear. (See malleus.)

vagus nerve The tenth cranial nerve. The vagus nerve supplies

fibres to, and helps control the function of, the

pharynx, larynx, trachea, lungs, heart, oesophagus and

most of the intestinal tract. The nerve also brings

sensory information back from the ear, tongue,

pharynx and larynx.

vertigo Disabling sensation in which affected individuals feel

that either they themselves or their surroundings are in

a state of constant movement. Vertigo is usually due to

a problem with the inner ear, but can also be caused

by visual problems.

Ear Care

References

Andaz C and Whittet H. 1993. An in Vitro Study to Determine Efficacy ofDifferent Wax-Dispersing Agents. Journal of Oto-Rhino-Laryngology andits Related Specialties, 55 (2): 97-99.

Aung T and Mulley G. 2002. Removal of Ear Wax. British MedicalJournal, 325 (7354): 27.

Campos A, Arias A, Betancor L, et al. 1998. Study of Common AerobicFlora of Human Cerumen. Journal of Laryngology and Otology, 112 (7): 613-616.

Campos A, Betancor L, Arias A, et al. 2000. Influence of Human WetCerumen on the Growth of Common and Pathogenic Bacteria of the Ear.The Journal of Laryngology and Otology, 114 (12): 925-929.

Ernst A, Takakuwa K, Letner C, et al. 1999. Warmed Versus RoomTemperature Saline Solution for Ear Irrigation: a Randomized ControlledClinical Trial. Annals of Emergency Medicine, 34 (3): 347-350.

Harkin H. 2003 [produced for the Action on ENT Steering Board]. Ear Care Guidance. London: NHS Modernisation Agency.www.modern.nhs.uk/serviceimprovement/1339/1989/7670/Ear%20care%20Guidance%20combined.pdf URL accessed 14/02/06.

Kamien M. 1999. Which Cerumenolytic? Australian Family Physician, 28 (8): 817, 828.

Keane E, Wilson H, McGrane D, et al. 1995. Use of Solvents to Disperse EarWax. The British Journal of Clinical Practice, 49 (2): 71-72.

NHS Quality Improvement Scotland. 2005. Maximising Communicationwith Older People Who Have Hearing Disability: Best Practice Statement.Edinburgh: NHS Quality Improvement Scotland.www.nhshealthquality.org/nhsqis/qis_display_findings.jsp;jsessionid=39C08EAD7F255F6E8E9418100CFE3F4E URL accessed 14/02/06.

NHS Quality Improvement Scotland (NHS QIS). 2005. Standards forClinical Governance & Risk Management: Achieving Safe, Effective,Patient-Focused Care and Services. Edinburgh: NHS Quality ImprovementScotland. www.nhshealthquality.org/nhsqis/files/CGRM_CSF_Oct05.pdfURL accessed 14/02/06.

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NHSScotland. 2005. Framework for Developing Nursing Roles. Edinburgh:Scottish Executive.www.scotland.gov.uk/Publications/2005/07/08144857/48584 URL accessed14/02/06.

NHSScotland. 2005. Framework for Role Development in the Allied HealthProfessions. Edinburgh: Scottish Executive.www.scotland.gov.uk/Publications/2005/07/08145006/50083 URL accessed14/02/06.

Nursing and Midwifery Council (NMC). 2005. Guidelines for Records and Record Keeping. London: Nursing & Midwifery Council. www.nmc-uk.org/(rge0fy3v5jaszk2jkzcbsr55)/aFrameDisplay.aspx?DocumentID=516 URL accessed 14/02/06.

Nursing and Midwifery Council (NMC). 2004. The NMC Code ofProfessional Conduct: Standards for Conduct, Performance and Ethics.London: Nursing and Midwifery Council. www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=201 URL accessed 14/02/06.

Price J. 1997. Problems of Ear Syringing (Avoiding Mistakes Leading toNegligence Claims). Practice Nurse, 14 (2): 126-128.

Primary Ear Care Centre. Rotherham-based centre for ear care workingwithin local primary care trust. Informative website.www.earcarecentre.com URL accessed 14/02/06.

Spiro S. 1997. A Cost-Effectiveness Analysis of Earwax Softeners. The Nurse Practitioner, 22 (8): 28, 30-21, 166.

Staff Governance Standard Working Group. 2002. Staff GovernanceStandard for NHSScotland Employees. Edinburgh: Scottish Executive.www.show.scot.nhs.uk/sehd/publications/dc20020208sgss.pdf URL accessed14/02/06.

UK Parliament. 2002. The Control of Substances Hazardous to HealthRegulations 2002. London: HMSO.www.opsi.gov.uk/si/si2002/20022677.htm#1 URL accessed 14/02/06.

UK Parliament. 1974. Health and Safety at Work Act. London: HMSO.

United Kingdom Central Council for Nursing Midwifery and Health Visiting(UKCC). 1998. Guideline for Records and Record Keeping. London.

United Kingdom Central Council for Nursing Midwifery and HealthVisiting (UKCC). 1992. The Scope of Professional Practice. London: UKCC.

Ear Care

Useful Websites

Royal National Institute for Deaf www.rnid.org.uk

Deafblind UK www.deafblind.org.uk

Deafblind Scotland www.deafblindscotland.org.uk

Scottish Council on Deafness www.scod.org.uk

British Deaf Association http://www.signcommunity.org.uk/

National Deaf Children’s Society www.ndcs.org.uk

Sense www.sense.org.uk

British Tinnitus Association www.tinnitus.org.uk

Tinnitus Information www.tinnitus.org

Primary Ear Care Centre www.earcarecentre.com

ENT Nursing www.entnursing.com

Patient UK (Leaflets) www.patient.co.uk

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Who was Involved in Developing the Statement?

Working Group

Jenny Barclay NHS Grampian

Beverley Boler NHS Tayside

Shirley Brader NHS Fife

Kate Danskin NHS Tayside

Elaine Duncan NHS Grampian

Gillian Fenton NHS Tayside

Elsie Green NHS Grampian

Janice Jamieson NHS Grampian

Helen Kearney NHS Dumfries & Galloway

Kate Lambie NHS Lothian

Fiona McCabe NHS Ayrshire & Arran

Tricia Mackie NHS Fife

Angela MacLeod NHS Highland

Graeme McGibbon NHS Lanarkshire

Linda Mitchell NHS Tayside

Sheila Wheeler NHS Grampian

Karen Sheridan NHS Lanarkshire

Ruth Wilson NHS Argyll & Clyde

Reference Group

The working group acknowledges the support of members of amultidisciplinary group, drawn from across Scotland and beyond, whocontributed to the improvement of the document by commenting on theinitial draft.

Ear Care

Other groups consulted

NHS Quality Improvement Scotland Practice Development LinkNurse/Midwife Network Members, individual link nurses/midwives fromevery NHS Board in Scotland, representatives from academic departmentsof Nursing/Midwifery in Scotland, and the Nursing, Midwifery & AlliedHealth Professions Research Initiative for Scotland (NMAHPRU) alsocontributed by commenting on the first draft of the statement.

NHS Quality Improvement Scotland Support Team

Penny Bond Professional Practice DevelopmentOfficer

Rosemary Hector Project Co-ordinator

31

© NHS Quality Improvement Scotland 2005

ISBN 1-84404-403-3

First published May 2006

You can copy or reproduce the information in this document for use withinNHSScotland and for educational purposes. You must not make a profit usinginformation in this document. Commercial organisations must get our writtenpermission before reproducing this document.

www.nhshealthquality.org

Copies of this best practice statement, and other documents produced by NHS QIS,are available in print format and on the website.

Best Practice Statement ~ May 2006

Ear Care

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Phone: 0131 623 4300 Phone: 0141 225 6999Textphone: 0131 623 4383 Textphone: 0141 241 6316

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Documents

22241 NHSQIS Ear Care BPS COV - spitalmures.ro de ingrijiri - ureche.pdf · The aim of this statement is to offer guidance to nursing staff with responsibility for various aspects