7.4 Eye and Ear Irrigation, Cast Care, Splints & Slings

Eye Irrigation

Eye irrigation flushes chemicals, foreign material, or discharge from the conjunctival sac. It is a clean procedure, though sterile solution and supplies are used for the eye itself.

Technique

1. Verify the order, identify the patient with two identifiers, and confirm which eye — right, left, or both.
2. Perform hand hygiene and don gloves and eye protection.
3. Position the patient lying or seated with the head tilted toward the affected side, so the solution runs away from the unaffected eye.
4. Place a basin against the cheek below the eye and drape a towel over the shoulder.
5. Clean the eyelid from inner canthus to outer canthus before irrigating.
6. Separate the lids with gloved fingers and direct a steady gentle stream from about one inch above the eye, flowing inner canthus to outer canthus along the conjunctival sac. Do not touch the eye with the irrigation tip and do not direct the stream onto the cornea.
7. Dry the lids from inner to outer canthus and document the eye irrigated, solution and volume, duration, drainage appearance, and the patient's response.

The two rules that carry the tested content

Direction: inner to outer. Irrigating outward keeps contaminated solution from crossing the bridge of the nose into the unaffected eye and from being flushed into the nasolacrimal duct at the inner canthus.

Chemical splash: irrigate first, for 15 to 20 minutes minimum. For a chemical exposure, irrigation begins immediately with copious water or normal saline and continues at least 15 to 20 minutes — before assessment, before charting, and before looking up the substance. Alkali burns (lye, drain cleaner, cement) penetrate more deeply than acids and require the longest irrigation. This mirrors the emergency eyewash station requirement under the OSHA standard.

Ear Irrigation

Ear irrigation removes impacted cerumen, a foreign body, or discharge from the external auditory canal.

Contraindications

Irrigation is contraindicated with a perforated or suspected perforated tympanic membrane, tympanostomy (pressure equalization) tubes, current otitis externa or otitis media, prior ear surgery, or a vegetable-matter foreign body such as a bean or pea, which swells when wetted and worsens the impaction. The tympanic membrane is inspected with an otoscope before irrigation, and the provider makes the decision when the view is obstructed.

Technique

1. Warm the solution to approximately body temperature, 98.6°F (37°C).
2. Seat the patient upright with the head tilted toward the affected side and place the basin under the ear against the neck.
3. Straighten the canal: pull the auricle up and back for adults and children over 3; pull down and back for children under 3.
4. Direct the stream toward the superior (upper) wall of the canal, never straight at the tympanic membrane, so the returning flow carries the cerumen out.
5. Stop for pain, dizziness, or nausea, and document solution, temperature, volume, return appearance, and post-procedure otoscopic findings.

The temperature rule is the most heavily tested point. Solution that is not near body temperature stimulates the semicircular canals — the same physiology used deliberately in caloric vestibular testing — and produces sudden vertigo, nausea, and nystagmus. Warming the solution is not a comfort courtesy; it prevents a genuine adverse event.

Cerumen softening agents such as carbamide peroxide or mineral oil may be instilled for several days beforehand to make removal easier. For ear instillation rather than irrigation, drops are warmed similarly, the canal is straightened the same way, and the patient remains lying on the unaffected side for about 5 minutes afterward.

Cast Care

Types and drying

Plaster casts are heavier, mold precisely, and take 24 to 48 hours to dry fully. Fiberglass casts are lighter, water-resistant, and set within about 30 minutes. A drying plaster cast is handled with the palms, not the fingertips, because fingertip pressure creates indentations that become pressure points, and it is left uncovered to air dry.

Patient instruction

Neurovascular monitoring — the five Ps

Distal neurovascular checks are documented for every casted extremity: Pain, Pallor, Paresthesia, Pulselessness, Paralysis, with poikilothermia (coolness) sometimes added as a sixth. Capillary refill should return within 2 to 3 seconds.

Compartment syndrome is the emergency the five Ps exist to detect. The hallmark is pain out of proportion to the injury, unrelieved by elevation and analgesia, and worsened by passive stretch of the digits — and it appears before pulselessness and paralysis, which are late findings. A patient who telephones reporting escalating pain, numbness, or inability to move the fingers in a casted arm is escalated to the provider immediately, not scheduled for the next available appointment.

Splints and Slings

Splints immobilize without fully encircling the limb, which accommodates the swelling expected in the first days after an acute injury; that is precisely why an acute fracture is often splinted before it is cast. Common types include the volar wrist splint, the ulnar gutter, the thumb spica, and the posterior lower-leg splint. A splint is applied over padding, secured snugly enough to immobilize but loosely enough to admit a finger, and the joint above and below the injury is immobilized.

Slings support the weight of an injured upper extremity and offload the shoulder. Correct application places the elbow at approximately 90 degrees with the hand elevated above the level of the elbow — a hand allowed to hang dependent below the elbow swells. The sling supports the wrist and hand rather than letting them dangle over the edge of the fabric, and the knot or fastener is positioned to the side of the neck rather than over the cervical spine to prevent pressure on the vertebrae. Instruct the patient to remove the sling for range-of-motion exercises only as ordered, and to perform neurovascular checks of the fingers.