ear, eye

OBJECTIVES:

EYE IRRIGATION

After 30 minutes of varied learning activities, the level III students will be able to:

1. define eye irrigation

2. review the anatomy and physiology of the eye

3. discuss eye irrigation to its 3.1 purpose

3.2 indications

3.3 contraindications

3.4 complications

3.5 principles involved

3.6 guidelines

4. explain nursing the responsibilities before, during, and after the procedure

5. demonstrate beginning skills in eye irrigation

EYE INSTILLATION

1. define eye instillation

2. discuss eye instillation to its 2.1 purpose

2.2 indications


2.4 complications

2.5 guidelines


4. enumerate common ophthalmic medications with its classifications, mechanism of action and side effects

5. demonstrate beginning skills in eye irrigation

EAR IRRIGATION

1. define ear irrigation

2. review the anatomy and physiology of the ear

3. discuss ear irrigation to its 3.1 purpose

3.2 indications


3.4 complications


3.6 guidelines


5. demonstrate beginning skills in ear irrigation

EAR INSTILLATION

1. define ear instillation

2. discuss ear instillation to its 2.1 purpose

2.2 indications


2.4 complications

2.5 guidelines


4. enumerate common otic medications with its classifications, mechanism of action and side effects

5. demonstrate beginning skills in ear instillation

NASAL INSTILLATION

1. define nasal instillation

2. review the anatomy and physiology of the nose

3. discuss nose instillation to its 3.1 purpose

3.2 indications


3.4 complications


3.6 guidelines


5. enumerate common nasal medications with its classification, mechanism of action and side effects

6. demonstrate beginning skills in nasal instillation

ORAL CARE/ OFFERING MOUTHWASH

1. define mouthwash

2. review the anatomy and physiology of the mouth

3. discuss mouthwash to its 3.1 purpose

3.2 indications


3.4 complications


3.6 guidelines


5. enumerate common mouthwash solution and its indication

6. demonstrate beginning skills in oral care

EYE

I. DEFINITION

- washing out of the conjunctival sac with a stream of liquid

3. DISCUSS EYE IRRIGATION TO ITS:

3.1 PURPOSE:

to irrigate or remove chemicals or foreign bodies from the eyes

to remove secretions of conjunctival sac

to treat infections

to relieve itching

provide moisture on the surface of the eyes of an unconscious patient

to prepare eye for surgical procedure

place antiseptic or other solutions in contact with conjunctiva

2 INDICATIONS:

ü allergic conjunctivitis

ü bacterial eye infection

ü unconscious patients

ü eye inflammation, draining or crusting in the eyes

3.3 CONTRAINDICATIONS:

× hypersensitivity reactions

× eye surgery

3.4 COMPLICATIONS

abrasion of the cornea or the conjunctiva

local irritation (stinging or burning sensation on the eye)

blurring of vision

3.5 PRINCIPLES INVOLVED:

1. Anatomy and Physiology

-The conjunctiva is a continuous, thin transparent layer of mucous membrane lining the eyelids covering the anterior surface of the eyeball. It has a rich supply of blood vessels and lymphatics. An abundant nerve supply makes the conjunctiva sensitive to minute irritations.

2. Microbiology

-Hand washing deters the spread of microorganisms

-You should not flow down the lacrimal duct to the nose as this might spread infection.

3. Chemistry

-Cleansing the eyes simply involves washing with a clean washed cloth moistened with water or saline solution, soap may cause burning and irritation

-If irrigations are for mechanical cleaning, use NaCl solution which is non-irritating. Irrigations are most comfortable if given or near body temperature. In treatment of inflammatory condition that may be prescribed as hot as the patient can tolerate them.

4. Pharmacology

-Solutions used or eye irrigation are made from sodium bicarbonate, bovic acid or sodium chloride

-Weak solutions are used so that they will not be irritating

-Drugs used in the eyes may be classed or anti anti-septic, astringents, mydriatic and miotic.

-Antiseptic solutions should choose their effect upon the causative organism.

5. Physics

-Function is needed between nurse’s fingers and eyelids in opening them for irrigation

-During the procedure, gravity will aid the flow of solution

6. Psychology

-The eye is a very sensitive part of the body and the patient is often very fearful about the simplest procedure, therefore he or she be treated with kindness and more patience than usual.

3.6 GUIDELINES

1. place patient lying toward site to be irrigated to prevent fluid from flowing to other eye

2. a 5cc syringe is used unless very large amounts of fluids are needed

3. direct the irrigating fluid along the conjunctiva from inner to outer canthus

4. avoid directing a forceful stream on the eyeball

5. avoid touching any eye structure with irrigation equipment

6. a piece of gauze may be wrapped around the index finger to raise upper lid for better cleansing of heavy discharges are present

7. place an emesis basin at side of face to collect irrigating fluid

8. light causes pain in many eye conditions, the light should be arranged in a position to provide optimal illumination of the working area without shining directly to patient’s eyes

9. the lids should be gently separated with the thumb and fingers of the left hand to expose the conjuntival sac. Pressure is exerted in the tiny prominences of the cheek and brow, never on the eyeball

10. movement of the eye, when lids are closed, helps moves secretions from upper to lower conjuntival sac; the patient should close his eyes periodically throughout the procedure

11. the patient may have the urge to rub or wipe his eyes with his fingers; to minimize this problem the nurse should dry the eye and surrounding area with a sterile cotton ball on completion of irrigation

4. NURSING RESPONSIBILITIES:

EYE IRRIGATION

Before

1. Verify order for the eye to be irrigated and solution and amount of irrigation.

2. Explain procedure to the patient.

3. Don gloves.

4. Instruct patient to sit or lie in a supine position with head tilted toward the side of the affected eye

5. Let patient hold kidney basin and place on the side of the eye to be irrigation.

During

1. Expose the conjunctival sac and hold upper lid open with non-dominant hand.

2. Instruct patient to look up.

3. Hold the syringe about 1.5cm above the inner canthus.

4. Allow irrigating fluid to flow from the inner canthus to outer along the conjunctival sac.

5. Occasionally have the patient close his eyes.

After

1. Pat eyes dry and dry patient’s face with a cotton ball.

2. Let patient open and close his eyes.

3. Record kind and amount of fluid used as well as its effectiveness

EYE INSTILLATION

1. DEFINITION:

- Is the introduction of ophthalmic fluid or topical ointment into the cavity of the eye for a specific length of time.

2. DISCUSS EYE INSTILLATION TO ITS:

2.1 PURPOSE:

to dilate or constrict the pupil when examining the eye

relieve pain, discomfort, itching and conjunctivitis

to act as an antiseptic in cleansing the eye

to combat infection

to lubricate the eye

2.2 INDICATIONS

ü glaucoma

ü papillary dilation for surgery and examination

ü ophthalmic infections such as keratitis and conjuctivitis

ü patients requiring local anesthesia for tests

ü eye discomforts

2.3 CONTRAINDICATIONS

× hypersensitivity to drug used in instillation

2.4 COMLICATIONS

eye irritation- due to improper application of eyedrops like applying eyedrops on the lens.

stinging and burning sensation- adverse effect of a drug such as sympathomemetics. Such effects are temporary and may subside.

2.5 GUIDELINES

1. In drawing up the solution from the bottle, don’t draw up more than required since excess solution must not be returned to the bottle for fear of contamination.

2. To instill the drops, tilt head of the patient slightly backward.

3. Gently separate the lids draw down to lower lid with the left hand, ask the patient to look up and allow the drop to fall on the center of the everted lower lid.

4. The dropper should never touch the lashes, lids and eyeball.

5. The same dropper should be not be used for two patients or for different solutions.

3. NURSING RESPONSIBILITIES

Before:

1. Check doctor’s order for amount, no. of drops of solution and eye to be treated.


3. Prepare drug to be administered according to the 5R’s of administration.

4. Warm hands.

5. Don gloves.

6. Let patient sit with head tilted backward or to lie in supine position.

During:

1. Pull lower lid down gently.

2. Instruct patient to look up.

3. Drop medication amount into center of lower lid and never in the cornea.

4. If using an ointment, apply from inner to outer canthus.

5. Instruct patient to close eyes and not to squeeze or rub the eyes.

After:

1. Wipe off excess solution with sterile gauze or cotton balls.

2. While closing his eyes, let patient roll his eyes.

3. Record time, type, strength and amount of medication and the eye into which medication was instilled.

NASAL INSTILLATION

I. DEFINITION

-process of administering medications by spray or drops into the nasal cavity to help resolve symptoms of sinus congestion and colds

What are sinuses?

The sinuses are cavities, or air-filled pockets, near the nasal passage. As in the nasal passage, the sinuses are lined with mucous membranes. There are four different types of sinuses:

•ethmoid sinus - located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow.

•maxillary sinus - located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow.

•frontal sinus - located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age.

•sphenoid sinus - located deep in the face, behind the nose. This sinus does not develop until adolescence.

3. DISCUSS NASAL INSTILLATION TO ITS:

3.1 PURPOSE:

to shrink swollen nasal mucous membrane

to loosen secretions and facilitate drainage

to treat infections of nasal cavity sinuses

to reduce blood flow by using tampons containing vasoconstrictors such as epinephrine

3.2 INDICATIONS:

ü nasal problems

ü sinus congestion


× neck and spine injury

× increase ICP


1. Anatomy and Physiology - The head of the patient is positioned slightly tilted backward. The medication is instilled into the nostrils onto the nasal membranes where it is absorbed by the body.

2. Microbiology – Avoid touching the tip of the medicine dropper to the nose to prevent contamination of the drug.

3. Physics – To treat the opening of the Eustachian tube, have the patient assume a back lying position, the drops will flow into the nasal pharynx, where the Eustachian tube opens. To treat the ethmoid and sphenoid sinuses, place patient in a back lying position with the head over the edge of the bed on pillow under the shoulders so that the head is turned backward. To treat the maxillary and frontal sinuses, position patient to back lying position with the head turned toward the side.

4. Psychology – Explain the procedure to the patient to relieve anxiety and gain cooperation of the patient

3.6 GUIDELINES:

-nasal instillation of therapeutic agents maybe administered to shrink edematous tissues, to prevent or control bleeding, provide topical anesthesia or treat infectious process

-administration of nasal drops requires hyperextension of the neck. Because this position places strain on the neck muscles, the client’s comfort should be assured

-although the nose is considered clean (not sterile) cavity because its connection to the sinus, the nurses uses medical asepsis when performing nasal instillation

-protect dropper with a piece of soft tubing when the client is an infant or young child

-avoid touching the nose with the dropper because it may cause the client to sneeze

-the patients should be positioned over a pivot on the edge of the bed during nasal instillation; if the head is only tilted back, the medication will run into the throat and be swallowed, making the medication ineffective

-nasal instillation preparations should be fro single patients only

-before giving any new medications, assess patient for allergies

-clients must be cautioned to avoid abuse of medications because overuse can lead to a rebound effect in which the nasal congestion worsens

-having the client remain in a supine position for 5 minutes; after insertion of the nose drops prevents drainage of the drug and facilitates its action Position types according to affected area:1.Ethmoid or sphenoid sinuses- place patient in a flat position (supine) with shoulders supported with a pillow to hyperextend the neck

2. Maxillary and frontal sinuses- place patient in a flat position (supine) with shoulders supported with a pillow and head hyper extended and turned toward affected side3.Eustachian tube- flat position (supine) with head tilted slightly to the affected side


Before:

1. Check the doctor’s order.

2. Assemble all materials needed.

3. Explain the procedure to the patient and instruct patient to avoid movement during the procedure to facilitate instillation

4. Do medical hand washing.

5. Assume patient in supine position.

During:

1. Instruct patient to blow nose. Provide patent with a disposable tissue.

2. Elevate nares slightly.

3. Withdraw the appropriate amount of prescribed medication into the dropper and instill the medication by counting the drops toward the midline to the superior of the ethmoid bone

4. Instruct patient to breath through the mouth and maintain position for 5 minutes to prevent the escape of medication

5. Absorb the excess medication with disposable tissue but instruct patient that nose blowing should be avoided

After:

1. Assist patient in a comfortable position.

2. Return the medication and the dropper to its designate container.

3. Document the procedure done, type, dosage and route of administration of medication instilled as well as patient’s reaction

ORAL CARE/ OFFERING MOUTHWASH

1. 1. DEFINITION

- it is an antiseptic which is fluoride compound added to drinking water to prevent dental carries.

l Mouth - defined in front and at the sides by the lips, jawbone, teeth, and gums; in the rear it merges with the throat; roof is composed of the hard and soft palates and the floor is formed by the tongue

Disorders: leukoplakia, hairy leukoplakia, lichen planus, candidiasis, aphthous stomatitis, nicotine stomatitis, krythoplakia, kaposi’s sarcoma

o Lips - visible organ at the mouth; soft, protruding, movable and serve primarily for food intake, as a tactile sensory organ and in articulation of speech

Disorders: actinic cheilitis, herpes simplex 1, chancre, contact dermatitis

o Tongue - a muscular structure that contains the organs of taste (taste buds).

o Uvula - the small piece of soft tissue that can be seen dangling down from the soft palate over the back of the tongue

o Gingiva- part of the soft tissue lining of the mouth; surround the teeth and provide a seal around them

Disorders: gingivitis, necrotizing gingivitis, herpetic gingivostomatitis, peridontitis

o Salivary glands-: parotid; submandibular and sublingual; deliver the secretions to the mouth via ducts

Disorder: sialolithiasis, sialadenitis, parotitis

o Buccal glands - located in the mucosa that lines the mouth

3. DISCUSS MOUTHWASH TO ITS:

3.1 PURPOSE:

gives fresh feeling in the mouth

increases a person’s confidence

prevents halitosis and dental carries in children

3.2 INDICATIONS

ü Halitosis

ü stomatitis

ü gingivitis

ü glossitis

ü parotitis

ü periodontal disease

3.3 CONTRAINDICATIONS

× allergies to mouthwash

3.4 Complication

irritation of the mucosa

3.5 Principles involved in Mouthwash:

3. 1. Anatomy and Physiology

- plaque is formed when bacteria in the mouth feed on food residue particularly sugar residue and dead epithelial tissues.

4. 2. Physics

- position the patient in side lying position with pillow under his head so he could spit or rinse in sitting position.

5. 3. Microbiology

- place a towel under the chin to protect the patient’s clothes. Using separate applications for each area of the mouth prevents the transfer of microorganisms from one area to another.

6. 4. Psychology

- explain the procedure to the patient to relieve anxiety and gain cooperation of the patient.

7. 5. Pharmacology

- right solutions in which patient is not allergic to, should be used.

4. GUIDELINES

8. Have the patient assume a sitting or recumbent posture, according to their condition and preference.

9. Protect the clothing or bedding with suitable materials such as rubber sheet.10. Support the irrigating so that the level of the solution is approximately 30 cm above the level of the

mouth.11. Use dental hygiene products of patient’s choice whenever possible.

5. If the treatment is new to patients, allow the solution to flow for a very short time, remove the tip form of the mouth.


Before

- Explain and discuss the procedure to the client.

- Prepare solutions required.

- Wash hands with bactericidal soap and water.

During

- Inspect the patient’s mouth with the aid of the torch and spatula.

- Using a soft, small toothbrush, brush the patient’s natural teeth, gums, and tongue.

- Hold the toothbrush against the teeth with the bristles at 45-degree angle.

- Encourage patient to rinse mouth vigorously.

After

- Discard remaining mouthwash solutions.

- Clean and thoroughly dry the toothbrush.

- Wash hands with soap and water

EAR INSTILLATION

1. DEFINITION

- introduction of otic medication into the ear

2. DISCUSS EAR INSTILLATION TO ITS:

2.1 PURPOSE:

soften earwax so that it can be readily removed at a later time

provide local therapy to reduce inflammation or destroy infective organisms in external ear canal which can cause intolerable discomfort

-Ear instillation serves as prophylaxis or remedy to infections or infestations of the ear preventing further complications.

relieve pain

- Some ear instillation have analgesic effects

2.2 INDICATIONS:

ü Accumulation of cerumen in ear canal

- Instillation of a few drops to soften the cerumen before its removal. Ear obstruction in cases of insects entering the canal, instilling of mineral oil can kill the insect and allow its removal.

ü External Otitis Media

- Inflammation of the external auditory canal. The patient usually reports pain and discharges. Discharges may be yellow or green, or foul-smelling, antibiotic preparations are introduced usually combined with corticosteroid agents to sooth the inflamed tissue.

ü Ear Obstruction

Eardrops may soften the impacted cerumen which causes the obstruction the ear.


× hypersensitivity to the solution

× Tympanic membrane perforation

- Perforation of the tympanic membrane is usually caused by infection or trauma. Sources of trauma include skull fracture, explosive injury, or severe blow to the ear. Water can easily enter the middle ear with this condition.

× Tympanic membrane injury

-If the eardrum behind the impaction is injured, water can enter the middle ear, producing acute vertigo and infection.

2.4 COMPLICATIONS:

allergic reaction

permanent hearing loss

worsening of pain

2.5 GUIDELINES

1. Assist the client to a side lying position with the ear being treated uppermost.

2. Straighten the ear canal. For an infant, gently pull the pinna downward. For an adult, pull the pinna upward and backward.

3. Press gently but firmly a few times in the tragus of the ear.

4. Have the client remain in the side lying position for about 5 minutes.

5. Insert a small piece of cotton fluff loosely at the meatus of the auditory canal for 15 – 15 minutes. Don’t press it into the canal.

6. Assess the character and amount of discharge, appearance of the canal, discomfort, etc. after the instillation.


Before:

1. Check doctors’ order

2. Wash hands

3. Gather needed equipments.

4. Check medication and compare label with the medication chart.

5. Before preparing the medication for administration, warm the medication bottle to body temperature.

6. Take medication to the patient’s room and check patient’s identification band and ask patient to state hisname.


8. Warm the medication in your hand or place it in a warm water for a short time.

During:

1. Assist the client to a side lying position with ear being treated uppermost.

2. Clean the pinna of the ear and meatus of the ear canal.

3. Fill the medication dropper with prescribed amount of medication.

4. Straighten the auditory meatus For infants: pulling pinna down and backFor adults: pulling pinna up and back

5. Press gently but firmly a few times in the tragus of the ear.

After:

1. Ask patient to remain in side lying position for about 5 minutes.

2. Insert a small piece of cotton loosely at the meatus of the auditory canal for 20 minutes. Do not press it intothe canal.

3. Assess client’s response.

4. Document all relevant information

EAR IRRIGATION

I. DEFINITION

a procedure done by flushing warm sterile water or warm sterile solution in the external ear canal to remove a foreign body or impacted cerumen

EXTERNAL EAR STRUCTURES

The external ear consists of the auricle (pinna) and the external auditory canal. The mastoid process isn’t part of the external ear but is an important body landmark behind the lower part of the auricle.

MIDDLE EAR STRUCTURES

The middle ear is also called the tympanic cavity. It’s an air-filled cavity within the hard portion of the temporal bone. The tympanic cavity is lined with mucosa. It’s bound distally by the tympanic membrane and medially by the round windows.

o TYMPANIC MEMBRANE

® The tympanic membrane consists of layers of skin, fibrous tissue, and a mucous membrane. It transmits sound vibrations to the internal ear.

o EUSTACHIAN TUBE

- The Eustachian, or auditory, tube extends downward, forward, and inward from the middle ear cavity to the nasopharynx. It has a useful function: it allows the pressure against inner and outer surfaces of the tympanic membrane to equalize, preventing rupture.

o OVAL WINDOW

- The oval window (fenestra ovalis) is an opening in the wall between the middle and inner ears into which part of the stapes (a tiny bone of the middle ear) fits. It transmits vibrations to the inner ear.

o ROUND WINDOW

- The round window (fenestra cochleae) is another opening in the same wall. It’s enclosed by the secondary tympanic membrane. Like the oval window, the round window transmits vibrations to the inner ear.

o SMALL BONES

- The middle ear contains three small bones, called ossicles, that conduct vibratory motion of the tympanum to the oval window.

o The osssicles are: The malleus (hammer) – which attaches to the tympanic membrane and transfers sound to the incus. The incus (anvil) – which articulates the malleus and the stapes and carries vibration to the stapes. The stapes (stirrup) – which connects vibratory motion from the incus to the oval window.

INNER EAR STRUCTURES

In the inner ear, vibration excites receptor nerve endings. A bony labyrinth and a membranous labyrinth combine to form the inner ear. The inner ear contains the vestibule, cochlea, and semicircular canals.

o VESTIBULE

® The vestibule is located posterior to the cochlea and anterior to the semicircular canals. It serves as the entrance to the inner ear. It houses two membranous sacs, the saccule and utricle. Suspended in a fluid called perilymph, the saccule and utricle sense gravity changes and linear angular acceleration.

o COCHLEA

® The cochlea, a bony, spiraling cone, extends from the anterior part of the vestibule. Within it lies the cochlear duct, a triangular, membranous structure that houses the organ of Corti. The receptor organ for hearing, the organ of Corti transmits sound to the cochlear branch of the acoustic nerve (CN VIII).

o SEMICIRCULAR CANALS

® The three semicircular canals project from the posterior aspect of the vestibule. Each canal is oriented in one of three planes: superior, posterior, and lateral. The semicircular duct transverses the canals and connects with the utricle anteriorly. The crista ampullaris sits at the end of each canal and contains hair cells and support cells. It’s stimulated by sudden movements or changes in the rate or direction of movement.

3. DISCUSS EAR IRRIGATION TO ITS:

3.1 PURPOSE:

soften earwax so that it can be readily removed at a later time

provide local therapy to reduce inflammation or destroy infective organisms in external ear canal

relieve pain

3.2 INDICATIONS:

ü Cerumen impaction - Cerumen accumulated in the external ear occasionally occurs to geriatric population that causes hearing deficit.

ü Ear obstruction - Removing of foreign body from the external auditory canal can be quite challenging. Therefore it must be irrigated to avoid any infection and to clear the auditory canal.

ü Local inflammation of canal.

ü Presence of dust particles inside the ear - To remove any dirt and dust inside the ear so that your hearing becomes less obstructed and better.


× Ruptured eardrum - Ear irrigation may worsen the case.

× Patients with ear pain

× Patient who has previously experienced complications following this procedure in the past

× Presence of acute otitis externa - An edematous ear canal combined with pain and tenderness of the pinna.


o Anatomy and Physiology

- Be able to know the structures and physiological functions of the ear canal. Straightening the auditory canal by pulling the pinna down and back for an infant and up and back for an adult.

o PHYSICS

- Ear irrigation should be given with minimal force to prevent the danger of driving the infectious material into the mastoid cells. The temperature of irrigating solution should be 35 Celsius to 40.6 Celsius degrees, if the temperature is below or above this can cause vertigo and nausea. Gravity allows the remaining solution in the canal to escape from the ear. place a cotton ball loosely in the auditory meatus and have the client lie on the side of the affected ear on a towel or pad.

o MICROBIOLOGY

- There should be a proper handling of drainage to avoid contamination and do medical handwashing before and after the procedure

o PSYCHOLOGY

- Carefully explain the treatment to the patient before starting. Relieve their anxiety and gain patient's cooperation.

o CHEMISTRY

- A 1 % solution of bicarbonate softens and breaks up the wax plug, clean the pinna and the meatus at the auditory canal as necessary with the normal saline or the irrigating solution

3.6 GUIDELINES

1. If their condition permits, seat them comfortably in a chair or support them in an upright position. The dorsal recumbent position also may be used with the ear brought to the edge of the pillow.

2. Protect bedding and clothing with waterproof material.

3. When straightening the canal, take firm but gentle hold of the cartilaginous part of the auricle.

4. Don’t grasp or pull on tip of the ear, this is useless and uncomfortable.

5. Place the tip of the syringe at the opening of the canal or barely within, so as not to block the passage of the return flow.

6. Use a gentle, steady stream of the solution.

7. Remove air from the bulb so that bubbles will not be forced in the ear.


Before:

15. Check doctor's order.16. Explain the procedure to the patient.17. Do medical handwashing.18. Prepare the necessary materials.19. Wear with the prescribed irrigating solution.20. Check the medication and compare with the medication ticket.21. Have the patient support the basin under the ear to be irrigated.22. Place a moisture resistant towel around the patient's shoulder.

During:

23. 1. Position the patient in a sitting or supine position with the head tun towards the unaffected ear

24. Have patient support the basin under the ear to receive the irrigating solution.25. Use moisture tip applicators or cotton ball and solution to clean the pinna an auditor meatus.26. Straighten the ear canal by pulling down and back (for infants), up and back (for adults).

After:

27. Assist the patient in a side lying position of the affected ear 10-15 minutes.28. Dry the outside of the ear with absorbent cotton ball.29. Place dry cotton ball in the auditory meatus.30. Note patient's reaction.31. Do after care.

Do documentation.

ear, eye

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