Leeds ENT Guidelines

Action

Rationale

Ensure patient is seated comfortably.
Explain the procedure and discuss with the patient.

To ensure that the patient understands the procedure and gives valid consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.

Wear gloves if appropriate.

To remove dirt and reduce the transfer of infection.
To reduce cross infection.

Position head so that ear is uppermost.
Examine the ear using auriscope /microscope.

To maintain comfort of the patient and correct head position to undergo the procedure.

To confirm anatomy of ear and identify presence of infection or inflammation.

Prepare the dressing by:

• Cutting the required length of ribbon
  gauze.
• Place the ribbon gauze in a gallipot containing the prescribed medication.
• Ensure the dressing is fully impregnated with the medication but remove any excess.

To ensure safe preparation of the ribbon gauze dressing.

To ensure that ribbon gauze reaches deep into ear canal.

Gauze will act as a carrier for medication.

Pull pinna up and back and insert aural speculum. Insert dressing gently into the meatus using light source/microscope and crocodile forceps as described below.

To ensure proper illumination of the ear canal.

To facilitate insertion of dressing.

Put a fold of the dressing into the meatus approximately half way down towards the tympanic membrane. Place two more folds of the dressing into the meatus to ensure that the dressing reaches deep into the ear canal.

To allow correct insertion of dressing without causing trauma to meatus or tympanic membrane.

Gently fill the meatus with the remainder of the dressing.

The dressing needs to be packed securely to be effective.

Leave a small end of the dressing and place a small amount of cotton wool at the meatal opening.

To assist future removal of the dressing.
To absorb any leakage of medication or discharge.

If patient is required to apply drops/medication at home in order to continue the treatment, teach correct application technique to patient. Give ear care advice sheet or further appointment if required.

To ensure compliance with treatment To ensure correct application of prescribed medication.

To ensure that patient is empowered to carry out own care or to return to nurse for further treatment.

Ensure that the patient is comfortable on completion of the procedure.

To avoid any dizziness or pain.

Complete nursing care plan.
If stat dose, document in medical records as well as in nursing care plan.

To maintain accurate record of patient's treatment in accordance with Trust and NMC policies.

To inform clinician and document that prescribed medication has been given and arranged for follow-up review.

Dispose of clinical waste appropriately.

Clean and sterilise all equipment and instruments according to local decontamination policy.

To maintain patient and staff safety.
To prevent cross infection.

Action

Rationale

Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives informed consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.

Wear gloves as appropriate

To remove dirt and reduce the transfer of infection

To reduce transfer of infection

Position the patient to ensure adequate light.

Examine the ear under direct vision working from the pinna to the tympanic membrane

To ensure a clear view of the aural meatus

If discharge/debris is blocking the meatus a small piece of cotton wool on a probe or other suitable applicator should be used. Straighten the meatus by pulling the pinna gently but firmly backwards and upwards. 'Dry mop' the canal using a gentle rotary action.

To ensure complete clearance of discharge debris

Change cotton wool on applicator after each dry mop and re-examine the ear canal using an auriscope.

To prevent cross infection and to gain detailed view of ear canal.

Take ear swab if infection is present. Refer to GP for appropriate medication prescription

To ascertain organisms responsible for infection and to facilitate the prescription of appropriate treatment

Explain findings to patient and give advice as necessary or required. Document in patient's care plan.

To ensure that patient understands the outcome of the procedure and to prevent complications

To provide evidence that procedure has been carried out and to document any findings.

Dispose of clinical waste appropriately

Clean and sterilise all equipment and instruments according to local decontamination policy.

To maintain patient and staff safety

To prevent cross infection

Action

Rationale

Ensure that patient is seated comfortably with appropriate head rest.

Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives informed consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.

Wear gloves if appropriate

To remove dirt and reduce the transfer of infection

To reduce transfer of infection

Examine the ear

To identify where debris or discharge is present.

Use the recommended correct (orange) aural swab to take sample, with the thin applicator rotate swab in the external auditory meatus gently to collect discharge or debris for analysis.

Place the specimen into the appropriate container.

To collect any secretions for analysis for microbiology or mycology pathology To ensure correct aural care treatment is given and acted upon pending investigation results.

To ensure that organisms for investigation are preserved.

Ensure that container is labelled with:

• Correct patient details
• Date of collection
• Which ear swab has been taken from
• Practice details

To avoid error and ensure that specimen matches up with appropriate request form.

Re-examine the ear canal

To ensure no trauma has been caused to the skin of the ear canal.

Ensure that the patient is comfortable following the procedure.

Explain findings to patient and give advice as necessary or required.

To ensure that patient is free of pain and discomfort and that no trauma has been caused.

To ensure that patient understands the outcome of the procedure and to prevent complications.

To provide evidence that procedure has been carried out and to document any findings.

To maintain accurate record of patient's treatment in accordance with Trust policies and NMC guidance.

Ensure that patient is seated comfortably with appropriate head rest.

Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives informed consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy. Wear gloves if appropriate.

To remove dirt and reduce the transfer of infection.

To reduce transfer of infection.

Position the patient to ensure adequate light. Examine the ear under direct vision.

To ensure a clear view of the aural meatus and mastoid cavity.

If wax is blocking the meatus, remove it using a Jobson-Horne probe to loosen the wax and then lift out of the meatus using crocodile forceps.

To ensure proper removal of wax. To provide an alternative to removal via micro suction where patient is unable to tolerate microsuction clearance due to extreme dizziness.

If wax/discharge or debris is blocking the meatus a small piece of cotton wool on a probe or other suitable applicator should be used to 'dry mop' the canal or help assist removal.

To ensure complete clearance of wax discharge or debris.

Change cotton wool on applicator after each dry mop and re-examine the ear canal using an auriscope.

To prevent cross infection and to gain detailed view of ear canal or cavity.

Take ear swab if infection is present. Refer to GP for appropriate medication prescription.

To ascertain organisms responsible for infection and to facilitate the prescription of appropriate treatment.

Explain findings to patient and give advice as necessary or required.

To ensure that patient understands the outcome of the procedure and to prevent complications

Dispose of clinical waste appropriately.

Clean and sterilise all equipment and instruments according to local decontamination policy.

Action

Rationale

Ensure patient is seated comfortably

Explain and discuss the procedure with the patient. Check if any previous surgery has been performed

To ensure patient has full understanding of procedure and gives consent.

To prevent damage to ear canal and promote safe practice

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.

Wear gloves if appropriate

To remove dirt and reduce the transfer of infection

To reduce cross infection

Adjust microscope to correct position and magnification. Insert speculum, attach appropriate suction end to tubing (single use item)

To enable direct vision of ear canal under microscope.

To prevent cross infection

Suction out wax, debris or discharge. Avoid touching wall of meatus, cavity or tympanic membrane.

To facilitate safe removal of wax, debris or discharge from ear. To allow clear inspection and facilitate any treatment given.

Inspect all aspects of ear canal and mastoid cavity.

To ensure complete clearance of canal and mastoid cavity

Ensure that the patient is comfortable on completion of the procedure.

To avoid any dizziness or pain

Inform patient of any relevant ear care

To empower patient in their care and prevent complications.

Document procedure in patient's care plan. Refer to ENT doctor if required and appropriate.

To ensure continuity of care and to facilitate safe practice.

Dispose of clinical waste appropriately Clean and sterilise all equipment and

To maintain patient and staff safety

At end of clinic clean suction machine by suctioning solution of Sodium Dicloroisocynurate 0.1% (2 Presept or HAZ 0.5g tablets in 500mls water) through machine.

Rinse by suctioning sterile water through machine until clear.

Dispose of cleaning solution and rinse water appropriately.

To prevent cross-infection

To ensure proper functioning and maintenance of machine

Action

Rationale

Ensure patient is seated comfortably Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives informed consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.
Wear gloves if appropriate

To remove dirt and reduce the transfer of infection
To reduce transfer of infection

Pull ear gently upwards and backwards (adults) or downwards and backwards (children) with the non-dominant hand.

To straighten external auditory canal.

Hold the otoscope in the dominant hand so that the ulnar surface of the hand is stabilised on the patient's temple (when the otoscope is reversed) or the patient's jaw (when the otoscope is upright).

To prevent scratching of the ear canal with the speculum if the patient moves.

Gently insert the appropriate sized speculum into the ear.
It is important that young patients have their heads held gently but firmly by a trusted carer or skilled practitioner.

To avoid injury to the canal.
To avoid sudden movements and possible injury to the ear.

Examine the tympanic membrane for:

• Light reflex - normally a triangle of light
• Colour - normally shiny, translucent and pearly grey
• Shape - normally slightly concave
• Scarring

If the light is reflected in an uneven way it is abnormal

Otitis media or myringitis may make it red. Serious otitis will make it appear dull
Serious otitis may cause retraction. A bulging drum indicates the presence of exudate in the middle ear.
Indicates previous infections and/or previous perforations.

• Perforations - but normally the drum is intact.

Perforations

Examine the ear canal for:

• Redness
• Scaling
• Swelling
• Discharge
• Foreign bodies

To assess degree/type of infection.

Document findings.

To ensure appropriate recording of information and compliance with NMC guidelines.

Dispose of clinical waste appropriately.

Clean and sterilise all equipment and instruments according to local decontamination policy.

To maintain patient and staff safety.

To prevent cross infection.

Report any abnormality to medical staff for review.

To obtain guidance on further treatment.

Action

Rationale

Ensure patient is seated comfortably Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and is able to give informed consent.

Wash hands using liquid soap and water in accordance with Trust Infection Prevention and Control Standard Precautions Policy.

Wear gloves as appropriate.

To remove dirt and reduce the transfer of infection.

To reduce transfer of infection.

Position the patient so that adequate light is available.

To ensure good illumination for the procedure.

Prepare the pope wick dressing by removing from the package and placing within crocodile forceps ready for use.

To ensure readiness for use.

Wearing a head mirror or direct the microscope light to illuminate the relevant ear, gently pulling the pinna upwards and backwards (adult) or downwards and backwards (child).

To ensure good vision of external auditory canal appropriate request form.

Take the pre-loaded forceps and insert the pope wick into the illuminated canal.

To ensure safe insertion of the pope wick.

Re-examine the ear.

To ensure correct positioning of the pope wick.

When a pope wick is in situ in the external auditory meatus, apply medication as directed on a patients prescribed prescription by an ENT Doctor or nurse practitioner.

To ensure that correct medication is administered.

To ensure patient has been fully instructed how to use medication onto pope wick dressing.

Instil required number of drops on to pope wick and check sufficient expansion of wick.

Give appropriate advice to patient regarding moistening of wick and continuing care of dressing.

Ensure patient has return visit to clinic to reassess the ear and remove dressing.

To ensure adequate administration of medication.

To ensure compliance with medication and facilitate therapy.

To ensure continuing care and appropriate advice.

To provide evidence that procedure has been carried out and to document any findings.

To maintain accurate record of patient's treatment in accordance with Trust policies and NMC guidance.

Dispose of clinical waste appropriately.

Clean and sterilise all equipment and instruments according to local decontamination policy.