Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies.

Promotes efficient time management and provides an organized approach to the procedure.

2 Prepare irrigating solution at a tepid temperature.

Solution should be body temperature because other temperatures stimulate the inner ear and can cause dizziness and nausea.

3a Raise child’s bed to working height or position the child on an examination table with the head of the bed elevated 45 degrees. The child may also sit in a chair or on the family members lap for the procedure.

Raising the bed prevents back strain for the nurse.

3b Have child sit up or lie with head tilted toward the side of affected ear.

Sitting up allows easier access to the child’s ear and prevents dripping down the side of the face, neck, and back.

3c Place a waterproof pad under the child’s head. Have another towel available to dry the child’s face, neck, and back as needed.

Waterproof pad prevents bed or examination table from becoming wet.

KidKare Have an assistant immobilize the head and extremities as needed. The highly mobile or combative child may need to be further immobilized during the procedure to ensure safety. Use of blankets to apply a mummy restraint to the child can aid in immobilization. (See Chapter 96 on restraint techniques.)

4 Perform hand hygiene and don gloves.

Standard precaution to reduce transmission of microorganisms.

5a Assess child’s ear canal and pinna for redness, lesions, drainage, and pain.

Visual inspection of the ear is so obvious that it is frequently neglected.

5b Use an otoscope to assess the inner canal and integrity of the tympanic membrane. Per institutional policy, this step may need to be completed by a healthcare prescriber.

Large accumulations of cerumen may not allow visualization of the tympanic membrane. Otitis media is present if the tympanic membrane is red and bulging and no light reflex is exhibited.

If a foreign object is visualized in the ear canal or suspected to be in the ear canal, the procedure should not be attempted until the healthcare prescriber has been consulted.

If the tympanic membrane is not intact, do not irrigate the ear. This avoids transmission of fluid into the middle ear. Do not attempt irrigation if a foreign body is suspected or visualized until discussed with supervising provider.

6 Clean outer ear if necessary using cotton swabs or a warm, wet washcloth.

Deters the spread of debris from outer ear into ear canal.

7 Place emesis basin below child’s ear and fill bulb syringe/irrigating tip with solution.

Filling the syringe with fluid decreases the amount of air forced into the ear canal and the amount of noise the child is subjected to; it also provides a steady irrigating stream.

Water-based and oil-based solutions have been identified as being equally effective in facilitating successful cleansing, and are probably more effective than no treatment.

8 Pull the ear auricle down and back in children 3 years of age or younger and the ear auricle up and back in children older than 3 years. Keep the tragus forward in both groups (see Figure 68-1).

This allows for maximum straightening of the ear canal. It also may provide a good view of the eardrum.

9a Place tip of bulb syringe/irrigating tip about 1 cm above opening of ear canal and gently squeeze syringe toward the roof of the ear. Do not “flood” the canal with fluid or occlude the canal with the irrigating nozzle. Allow the solution to flow out unimpeded. Continue slow stream of fluid until canal is cleansed or all solution has been used.

It is important to be gentle with the syringe in the ear because the epithelium lining the bony portion of canal is very thin and sensitive. Directing the solution at the roof prevents injury to the tympanic membrane. Obstructing the outflow fluid may cause the pressure to rise in the canal and on the eardrum, thus causing pain.

9b Some solutions such as baby oil or olive oil work best by tilting the child’s head so that the oil sits in the ear canal for a few minutes before turning the head and allowing the oil to drip out onto a towel.

Baby oil and olive oil help to soften ear cerumen.

10 Manual removal other than irrigation:

10a If a curette is needed to remove the cerumen, use a blunt ear curette size 00 or a wire curette (called a cerumen spoon).

Trauma risk to the eardrum and canal is high in children using this method. The child’s head must be immobilized to avoid nicking or irritating the tympanic membrane and canal.

10b With an otoscope, visualize the ear and advance the curette beyond the point of the cerumen accumulation, resting medial to the occlusion. Pull cerumen toward the examiner.

caREminder

Per institutional policy, use of the curette may need to be completed by a healthcare prescriber.

11 Dry child’s outer ear and insert cotton ball loosely into canal opening. Instruct the child to lie on the affected side for a few minutes to continue the draining of the fluid.

A cotton ball absorbs fluid, and gravity allows the remaining solution in the canal to escape from the ear.

12 Repeat procedure on other ear if ordered.

Do not automatically irrigate both ears; only affected ears should be treated.

13 Clear away equipment and clean up area. Clean and dry the bulb syringe and allow it to air dry.

Decreases transmission of microorganisms.

14a Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.

14b Dispose of equipment and waste in appropriate receptacle.

Standard precautions.

15 Return child to position of comfort and lower bed to lowest position.

Promotes child’s comfort and safety.