The administration of an irrigation of 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 irrigation of the ear 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.

• Prescribed irrigating solution (warmed to 98.6°F [37°C]) (Schumann et al., 2021)
• Irrigation set (container and irrigation syringe, tubing and ear tip, or pulsating water device)
• Waterproof pad
• Emesis basin
• Gloves
• Additional PPE, as indicated
• Cotton balls, disposable washcloth, or washcloth
• Normal saline or water
• Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assess the appropriateness of the irrigation solution/medication and procedure for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check expiration dates. Assess for the presence of conditions that indicate irrigation is contraindicated, such as complications from a previous ear irrigation; ear surgery; suspected or actual tympanic puncture or perforation; cleft palate (Harkin, 2015; Hayter, 2016; Schumann et al., 2021). Assess for the presence of conditions that indicate the need for increased caution when performing an ear irrigation, including patients with anticoagulant use, diabetes, immunocompromised, dizziness and tinnitus or patients who had radiation therapy to the ear (Schwartz et al., 2017). Assess the affected ear for redness, erythema, edema, drainage, or tenderness. Assess the patient's ability to hear. 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.

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 computer 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 medication supply system or the patient's medication drawer.	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 the medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
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. Assemble equipment at the patient's bedside.	This provides for an organized approach to the task.
20. Put on gloves.	Gloves protect the nurse from potential contact with contaminants and body fluids.
21. Assist the patient to sit up or lie with their head tilted slightly toward the side of the affected ear. Protect the patient and the bed with a waterproof pad. If the patient is able, have them support the basin under the ear to receive the irrigating solution.	Gravity causes the irrigating solution to flow from the ear to the basin.
22. Cleanse the external ear of any drainage with a cotton ball or washcloth moistened with normal saline or water.	Debris and drainage on the external ear may be washed into the ear and/or may prevent some of the medication from entering the ear canal.
23. Pretreat the ear with 2 to 4 drops of warm water or irrigating solution (refer to Skill 5-17) and wait 15 minutes.	Pretreating softens any cerumen that may be present and enhances the effectiveness of the ear irrigation (Schumann et al., 2021; Schwartz et al., 2017).
24. Fill the irrigating or bulb syringe with the warmed solution. If an irrigating container is used, prime the tubing.	Priming the tubing allows air to escape from the tubing. Air forced into the ear canal is noisy and therefore unpleasant for the patient.
25. Straighten the auditory canal by pulling the cartilaginous portion of pinna up and back for an adult (Figure 1). (See Infant and Child Considerations for correct positioning for this age group.)	Straightening the ear canal allows the solution to reach all areas of the canal easily.
26. Point the syringe tip superiorly and posteriorly toward the upper back to the ear canal wall. Use a gentle squirting motion to direct a steady, slow stream of solution against the roof of the auditory canal, using only enough force to remove secretions (Figure 2). Do not occlude the auditory canal with the irrigating nozzle. Allow the solution to flow out unimpeded.	Use of a gentle squirting motion and directing the solution at the roof of the canal help separate cerumen from the ear canal and prevent tympanic membrane injury or perforation (Schumann et al., 2021). Continuous in-and-out flow of the irrigating solution helps to prevent pressure in the canal.
27. When irrigation is complete, place a cotton ball loosely in the auditory meatus (Figure 3) and have the patient lie on the side of the affected ear on a towel or absorbent pad.	The cotton ball absorbs excess fluid, and gravity allows the remaining solution in the canal to escape from the ear.
28. Remove gloves and any additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
29. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
30. Evaluate the patient's response to the procedure. Return in 10 to 15 minutes. Put on gloves, remove the cotton ball, and assess drainage.	The patient needs to be evaluated for any adverse effects from the procedure. Drainage or pain may indicate injury to the tympanic membrane.
31. Remove gloves and perform hand hygiene. Assist the patient to a position of comfort.	Removing gloves and performing hand hygiene reduces the risk of contamination of other items and the spread of microorganisms. Assisting the patient to a position of comfort promotes patient comfort.
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.