Administering Ear Medications

Steps 6-13 in Administering Ear Meds

6. Identify the patient using two identifiers. Ask the patient about allergies. 7. Take the medication to the patient at the correct time (refer to agency policy). 8. Give time-critical medications (e.g., stat and "now" doses) at the exact time ordered. As you proceed, apply the Six Rights of Medication Administration. 9. Label all medications, medication containers, and other solutions, including those on a sterile field. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them. 10. Explain the procedure to the patient and ensure that he or she agrees to treatment. 11. Discuss the purpose of each medication, its action, and possible adverse effects. 12. Allow the patient to ask questions about the drugs. 13. Patients who wish to self-instill medications may be allowed to do so under a nurse's supervision (check agency policy). Assess the patient's ability to grasp and manipulate a dropper.

STEP 14 INSTILL EAR MED

a. Apply clean gloves if drainage is present. b. Position the patient on his or her side (if not contraindicated) with the ear to be treated facing up. Alternately, the patient may sit in a chair or at the bedside. c. Tilt the patient's head toward the unaffected side, and stabilize it with the patient's own hand. d. For an adult or child *older than 3* years of age, straighten the ear canal by pulling the pinna up and back to the 10 o'clock position. e. For a child younger than 3 years of age, pull the pinna down and back to the 6 o'clock or 9 o'clock position. f. If cerumen or drainage occludes the outermost portion of the ear canal, wipe it out gently with a cotton-tipped applicator. Take care not to force cerumen into the canal. g. Instill the prescribed drops by holding the dropper 1 cm (½ inch) above the ear canal. h. Ask the patient to remain in a side-lying position, on the unaffected side, for a few minutes. i. Gently massage or put pressure on the tragus of the ear with your finger. j. If ordered, gently insert a portion of a cotton ball into the outermost part of the ear canal. Do not press cotton into the canal. k. Remove the cotton after 15 minutes.

Supplies

Prescribed medication Clean gloves Cotton-tipped applicator and cotton balls

How far should you hold the dropper above the ear canal?

1 cm (½ inch) above the ear canal.

Recognize and immediately treat signs of a severe anaphylactic reaction.

1. dyspnea 2. wheezing 3. circulatory collapse

When a pt or family member is instilling the med instead of you, ask the patient or a family member to

1. name the ear medication 2. state its action 3. purpose 4. dosage 5. schedule 6. side effects. - Watch the patient or family member instill the next dose of ear medication, providing appropriate reinforcement of technique.

Ensure that the Six Rights of Medication Administration are followed:

1. right medication 2. right dose 3. right patient 4. right route 5. right time 6. right documentation.

EXPECTED OUTCOMEs

Correct medication is administered according to the six rights of medication safety. Patient is comfortable during administration. Ear canal becomes clear, without drainage, excess cerumen, or inflammation, as medication is repeatedly instilled. If applicable, the patient is able to explain steps for instilling eardrops and demonstrates proper technique for self-administration. Patient experiences no adverse reaction or side effects from medication.

o ensure proper distribution of ear medication after instillation, what will the nurse instruct an adult patient to do? A. Have a family member instill the medication. B. Avoid contaminating the medication's applicator tip. C. Instill the medication at the time ordered by the provider. D. Instill the medication after gently pulling the ear up and back.

Instill the medication after gently pulling the ear up and back. Rationale: Pulling the pinna up and back straightens the ear canal in an adult patient. Having a family member instill the medication does not ensure its proper distribution. Avoiding contamination of the applicator tip is appropriate but has no bearing on distribution of the medication. Instilling the medication at the time ordered by the provider is appropriate but has no bearing on distribution of the medication.

Which statement or question best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the instillation of ear medications? A. "Did you let the ear medication warm to room temperature?" B. "Do you think the patient is capable of instilling her own eardrops?" C. "Please tell the patient that the medication may make him dizzy when he stands up." D. "Be sure to keep the patient on her side for a few minutes, because I just administered her eardrops."

Be sure to keep the patient on her side for a few minutes, because I just administered her eardrops." Rationale: NAP may provide supportive care to a patient receiving ear medication. No aspect of the instillation of ear medication may be delegated to NAP. Responsibility for patient assessment and patient education may not be delegated to NAP.

GERONTOLOGICAL CONSIDERATIONS

Many older adults accumulate cerumen in the ear. This should be removed by irrigation before administering medication.

UNEXPECTED OUTCOMES

Medication error occurs. Patient experiences discomfort during administration. Ear canal is inflamed, swollen, and tender to palpation. Drainage is present. Cerumen occludes the ear canal. Patient is unable to explain medication information and steps for medication instillation. Patient has difficulty in self-administering eardrops. Patient experiences adverse reaction or side effects from the medication.

DOCUMENTATION: Documentation Guidelines:

Record the 1. time of administration, 2. type and strength of medication applied, 3. number of drops instilled, and 4. application site (right, left, or both ears) in the MAR immediately after administration, not before. 5. Include your initials or signature. 6. Record patient teaching and validation of the patient's understanding. 7. Document objective data related to the ear involved (e.g., redness, drainage, irritation, cerumen) as well as any subjective data (e.g., pain, itching, altered hearing) and the patient's response to the medications, including any adverse reactions. 8. Record the reason any medication was withheld and follow facility policy for noting withheld doses. Record unexpected outcomes and related nursing interventions.

DELEGATION

The skill of administering ear medication *cannot be delegated to NAP*. Be sure to inform NAP of the following: Review the expected therapeutic effects as well as potential side effects of medications that should be reported to the nurse. Discuss the potential for temporary hearing changes after administration of ear medications.

What is the best way to minimize discomfort caused by the instillation of ear medication? A. Warm the eardrops to room temperature before instillation. B. Wear treatment gloves during the application process. C. Ask the patient to sit while introducing the medication. D. Use a cotton-tipped applicator to remove any visible cerumen.

Warm the eardrops to room temperature before instillation. R: Warming the medication to room temperature minimizes the risk of vertigo and/or nausea from instillation of the eardrops. Although it is appropriate to wear gloves if the patient has ear drainage, doing so does not minimize the patient's discomfort. Instilling the medicine with the patient in a sitting position would have little or no effect on his or her postinstillation discomfort. Although it is appropriate to use a cotton-tipped applicator to remove any visible cerumen, doing so will not minimize the patient's discomfort.

If medication is ordered for both ears,

ask the patient to stay in the side-lying position for a few minutes after the first dose before turning to the other side.

Note the patient's response to the medication by

assessing for hearing changes; ask if symptoms have been relieved, and note any side effects.

Do not force any solution into the ear. Do not occlude the ear canal with a medicine dropper; doing so can

cause pressure within the canal during instillation and subsequent injury to the eardrum.

If the patient expresses concern regarding the accuracy of a medication,

do not give the medication. Explore the patient's concern, notify the practitioner, and verify the order

Take steps to eliminate interruptions and distractions during

medication preparation.

Although structures of the outer ear are not sterile,

use sterile drops and solutions in case the eardrum is ruptured.

After instructing a patient in the self-administration of antibiotic eardrops, what must come first in the nurse's assessment? A. The patient's understanding of the medication's purpose B. The patient's hand grasp, strength, coordination, and ability to manipulate the applicator C. The patient's comprehension of the dosage instructions provided with the medication D. The patient's ability to recognize the signs of an allergic reaction to the medication

. The patient's hand grasp, strength, coordination, and ability to manipulate the applicator Rationale: After demonstrating the technique for instilling the ear medication, the nurse must ensure that the patient is physically capable of safely self-administering the medication. Although it is appropriate to assess the patient's understanding of the purpose of the medication, another item takes priority in self-administration. Although it is appropriate to make sure the patient understands the dosage instructions, the nurse's highest priority at this point is to ensure that the patient is physically capable of safely self-administering the medication. Although it is important that the patient be alert for signs of an allergic reaction, the patient's ability to recognize such signs does not pertain to self-administration of the medication—the technique that the nurse has just demonstrated for the patient.

Steps 1-5 in Administering Ear Meds

1. Verify the health care provider's orders. 2. Gather the necessary equipment and supplies. 3. Perform hand hygiene and don gloves. 4. Provide for the patient's privacy. 5. Introduce yourself to the patient and family, if present.

Sample Documentation:

1300 Patient complains of pain in both ears, rated 6 on 0/10 scale. Redness noted on external ear structures and ear canals bilaterally. Removed scant, yellow drainage with cotton-tipped applicator from R ear. Aurodex ear medication, two drops instilled in each ear as ordered. -K. Morgan, RN, 6/22/13 1330 States relief from c/o bilateral ear pain. Rates pain 2 on 0/10 scale. -K. Morgan, RN, 6/22/13

For a child *younger than 3* years of age

pull the pinna *down and back* to the *6 o'clock or 9 o'clock position*.

Steps 15- of Admin ear med

15. Dispose of your used supplies in the appropriate trash receptacle, remove and dispose of your gloves (if used), and perform hand hygiene. 16. After the drops have been absorbed, help the patient into a comfortable position and place toiletries and personal items within reach. 17. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 18. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed to the lowest position. 19. Leave the patient's room tidy. 20. Document and report the patient's response and expected or unexpected outcomes.

ASSESSMENT AND PREPARATION

Check the accuracy and completeness of each medication administration record (MAR) against the health care provider's medication order. Confirm the patient's name, the drug and dosage, number of drops to instill, ear to be treated (left, right, or both), and the time of administration. Clarify incomplete or unclear orders with the health care provider. Note patient allergies. Read manufacturer's application/administration directions carefully. Observe the Six Rights of Medication Administration: right medication, right dose, right patient, right route, right time, and right documentation. (For details, see the video skill "Ensuring the Six Rights of Medication Administration.") Prepare medications for application. Check label of medication against MAR two times. Check expiration date on container. If ear medication has been refrigerated, hold container in hands for a few minutes to bring to body temperature. Understand drug reference information pertinent to the medication's action, purpose, onset of action and peak action, normal dose, common side effects, and nursing implications, if needed.

PEDIATRIC CONSIDERATIONS

Insert cotton pledgets loosely into ear canal to prevent medication from flowing out. To prevent cotton from absorbing medication, premoisten it with a few drops of medication.1

MONITORING AND CARE

Monitor the patient for adverse or allergic reactions to the medication. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization's practice for emergency response. Ask the patient or a family member to name the ear medication and state its action, purpose, dosage, schedule, and side effects. Note the patient's response to the medication by assessing for hearing changes; ask if symptoms have been relieved, and note any side effects. Watch the patient or family member instill the next dose of ear medication, providing appropriate reinforcement of technique.

Which instruction would help ensure the maximum therapeutic response when a patient self-administers ear medication? A. Remain in the lateral position (unaffected side) for a few minutes after instillation. B. Bring refrigerated ear medication to room temperature before instillation. C. Place a cotton ball firmly into the ear canal for 30 minutes after instillation. D. Apply a warm, damp washcloth to the external ear to remove any crusted discharge.

Remain in the lateral position (unaffected side) for a few minutes after instillation. Rationale: Remaining in the lateral position for a few minutes after instillation allows the medication to remain in contact with the tissues of the ear canal. Although it is appropriate to bring refrigerated ear medication to room temperature before instillation, doing so has no effect on therapeutic response. A cotton ball is inserted gently into the ear canal for 15 minutes, and only when ordered by the provider. Although it is appropriate to remove any crusted discharge from the external ear, or pinna, with a warm, damp washcloth, doing so has no effect on therapeutic response.

Administer eardrops at

room temperature.

For an adult or child *older than 3* years of age,

straighten the ear canal by pulling the pinna *up and back* to the *10 o'clock position*.

Instilling cold drops can cause

vertigo (severe dizziness) or nausea and debilitate a patient for several minutes.