Administering Ear Drops

Skill 5-17

Administering Ear Drops

Drugs are instilled into the auditory canal for their local effect and are used to soften wax, relieve pain, apply local anesthesia, and treat infections. If the tympanic membrane is ruptured or has been opened by surgical intervention, the middle ear and the inner ear have a direct passage to the external ear. When this occurs, perform instillations with the greatest of care to prevent forcing materials from the outer ear into the middle ear and the inner ear. In this circumstance, use sterile technique to prevent infection.

Delegation Considerations

The administration of medication via drops in the ear is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the administration of ear drop may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Ear drop medication
Tissue
Cotton balls (optional)
Gloves
Additional PPE, as indicated
Disposable washcloth or washcloth (optional)
Normal saline solution or warm water
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess the affected ear for redness, erythema, edema, drainage, or tenderness. Assess the patient's knowledge of the medication and procedure. If the patient has a knowledge deficit about the medication, this may be an appropriate time to begin education about the medication. Assess the patient's ability to participate with the procedure. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Injury risk
Acute pain

Outcome Identification and Planning

The expected outcomes to achieve are that drops are administered successfully, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of the rationale for the ear drop instillation, and the patient does not experience injury.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medication to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the patient's medication drawer or medication supply system.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
10. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
11. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
12. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
13. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
14. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of each medication to the patient.	Assessment is a prerequisite to administration of medications.
17. Scan the bar code on the patient's identification band, if required (The Joint Commission, 2021).	This provides an additional check to ensure that the medication is given to the right patient.
18. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
19. Warm the bottle of medication by rubbing between the palms of your hands, holding the bottle in your hands for 1 to 2 minutes, or by placing it in warm water (American Academy of Pediatrics, 2013; MFMER, 2021c). Put on gloves.	Administration of cold solution in the ear is uncomfortable and could cause the patient to become dizzy (MFMER, 2021c). Gloves protect the nurse from potential contact with mucous membranes and body fluids.
20. Cleanse the external ear of any drainage with a cotton ball or washcloth moistened with normal saline or water (Figure 1).	Debris and drainage may prevent some of the medication from entering the ear canal.
21. Place the patient on their unaffected side in bed, or, if ambulatory, have them sit with their head well tilted to the side so that the affected ear is facing upward (Figure 2).	This positioning prevents the drops from escaping from the ear.
22. Remove the cap from the medication bottle, being careful not to touch the inside of the cap or the tip of the container (Figure 3).	Touching the inside of the cap or tip of container may contaminate the bottle of medication.
23. Straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back for an adult. (See Infant and Child Considerations for correct positioning for this age group.)	Pulling on the pinna as described helps to straighten the canal properly for ear drop instillation.
24. Invert and hold the medication bottle in the ear with its tip above the auditory canal (Figure 4). Do not touch the dropper to the ear.	By holding the medication bottle in the ear, the medication will enter the ear canal. Touching the bottle to the ear contaminates the bottle and medication. The hard tip of the medication bottle can damage the tympanic membrane if it is jabbed into the ear.
25. Squeeze the container and allow drops to fall on the side of the canal. Avoid instilling in the middle of the canal, to avoid instilling directly onto the tympanic membrane.	It is uncomfortable for the patient if the drops fall directly onto the tympanic membrane.
26. Release the pinna after instilling the drops, and have the patient maintain their head position to prevent escape of medication.	The medication should remain in the ear canal for at least 5 minutes.
27. Gently press on the tragus a few times (Figure 5).	Pressing on the tragus causes the medication to move from the canal toward the tympanic membrane.
28. If prescribed, loosely insert a cotton ball into the ear canal (Figure 6).	A cotton ball can help prevent the medication from leaking out of the ear canal.
29. Instruct the patient to remain lying down with the affected ear upward for 5 to 20 minutes, based on specifics for prescribed medication and/or facility policy.	This ensures the medication remains in the ear canal and maximizes medication absorption (Frandsen & Pennington, 2021; MFMER, 2021c).
30. Replace the cap on the medication bottle. Remove gloves and additional PPE, if used. Perform hand hygiene.	Replacing the cap prevents contamination of the tip of the bottle. Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
31. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
32. Evaluate the patient's response to the medication within an appropriate time frame.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the ear drops were administered successfully, the patient has experienced the intended effect of the medication, the patient has verbalized an understanding of and engaged in the medication regimen, and the patient did not experience injury.

Documentation

Guidelines

Document the administration of the medication immediately after administration, including date, time, dose, route of administration, and site of administration, specifically right, left, or both ears, on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. Document pre- and post-administration assessments, characteristics of any drainage, and the patient's response to the treatment, if appropriate. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team as appropriate. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Medication runs from ear into eye: Notify the health care team and check with the pharmacy. Eye irrigation may need to be performed.
Patient reports extreme pain when you press on the tragus: Allow the patient to press on the tragus. If pressure causes too much pain, this part may be deferred.

Special Considerations

General Considerations

If both ears are to be treated, wait 5 to 20 minutes before having the patient turn over to instill drops into the second ear (Frandsen & Pennington, 2021; MFMER, 2021c).
Ongoing assessment is an important part of nursing care to evaluate the patient response to administered treatments and early detection of adverse drug reactions. If an adverse effect is suspected, notify the health care team. Additional intervention is based on type of reaction and patient assessment.

Infant and Child Considerations

Pull the pinna up and back for a child older than age 3 years (Figure 7) and down and back for an infant or a child younger than age 3 years (Figure 8) to straighten the ear canal (American Academy of Pediatrics, 2013; Kyle & Carman, 2021).
Soothe, comfort, and distract the child after administration to keep the child still after administration (Kyle & Carman, 2021).

Community-Based Care Considerations

Teach the patient/family member/caregiver to warm the ear drops before administration by holding the container in the hand or placing it in a pocket for 5 minutes (Bauldoff et al., 2020).
Teach the patient/family member/caregiver to use the nondominant hand to straighten the ear canal and the dominant hand to administer the drops (Bauldoff et al., 2020).
Caution the patient/family member/caregiver to avoid touching the applicator/tip of the bottle to any surface, including the ear, to avoid contamination (MFMER, 2021c).

section name header

Skill 5-17