10.1 Eye, Ear, and Integumentary Disorders
Key Takeaways
- Acute angle-closure glaucoma presents with sudden severe eye pain, a fixed mid-dilated pupil, a hard eye, haloes around lights, and vomiting; it is an emergency, and any anticholinergic or mydriatic agent is contraindicated.
- Sudden painless floaters, flashes, and a curtain descending across the visual field indicate retinal detachment; restrict activity, position as instructed, and escalate immediately.
- Instil eye drops into the lower conjunctival sac, never onto the cornea, wait five minutes between different drops, and apply punctal occlusion after drops with systemic effects such as timolol.
- Approach a patient with a hearing impairment from the front in good light, speak at a normal pace in a slightly lowered pitch, and never shout, because shouting distorts speech and raises pitch beyond the impaired range.
- Herpes zoster is infectious to non-immune contacts through vesicle fluid until every lesion has crusted; antiviral therapy is most effective when started within 72 hours of rash onset.
10.1 Eye, Ear, and Integumentary Disorders
These are small topics individually, but together they contribute a steady stream of items — usually as an emergency to recognise, a drop or drop-sequence to administer correctly, or a communication adjustment to make.
Eye Disorders
Glaucoma: the two presentations
| Feature | Primary open-angle | Acute angle-closure |
|---|---|---|
| Onset | Insidious, over years | Sudden, over hours |
| Pain | None | Severe eye and brow pain |
| Vision | Gradual loss of peripheral field; tunnel vision late | Blurred vision, haloes around lights |
| Pupil | Normal | Mid-dilated and fixed |
| Globe | Normal | Hard, stony on palpation |
| Systemic | None | Nausea and vomiting, headache |
| Status | Chronic management | Ophthalmic emergency |
Acute angle-closure glaucoma is the emergency: untreated, it destroys vision within hours. Nursing actions are to escalate immediately, keep the patient in a quiet, dimly lit room, give prescribed analgesia and antiemetic, and administer the ophthalmic agents prescribed to reduce intraocular pressure. Critically, anticholinergic and mydriatic agents are contraindicated — atropine, many antihistamines, some antidepressants, and pre-operative anticholinergics can all dilate the pupil and precipitate or worsen an attack. Vision already lost to glaucoma cannot be recovered, so adherence with chronic drops is the central teaching message.
Cataract
Painless, progressive blurring, glare, haloes, and a loss of colour contrast, with the classic sign of the absent red reflex. Post-operative teaching after extraction and intraocular lens implantation: do not rub or press the eye, wear the protective shield at night as instructed, avoid bending at the waist, heavy lifting, and straining, report sudden pain, a sudden decrease in vision, flashes, or increasing redness or discharge, and use prescribed drops exactly as scheduled. Mild itching and a scratchy sensation are expected; severe pain is not.
Retinal detachment
Sudden painless onset of floaters, flashes of light, and a curtain or shadow advancing across part of the visual field. There is no pain, which is why patients delay. Restrict activity, position the patient as instructed by the ophthalmologist so that the detached area is dependent, avoid sudden head movement, and escalate urgently. After pneumatic retinopexy with a gas bubble, the prescribed head positioning may be required for days and air travel is contraindicated until the bubble has resorbed.
Eye-drop technique
- Wash hands; check the drug, eye, and expiry; never touch the dropper to the eye or lashes.
- Tilt the head back, ask the patient to look up, and gently pull down the lower lid to expose the conjunctival sac.
- Instil the drop into the sac, not onto the cornea, which is exquisitely sensitive and triggers blinking that expels the drop.
- Ask the patient to close the eye gently — not squeeze — for 30 to 60 seconds.
- Apply punctal occlusion (gentle pressure on the inner canthus) for one minute for drops with systemic effects, most importantly beta-blockers such as timolol, which can cause bradycardia and bronchospasm if absorbed.
- Wait 5 minutes between different drops; instil drops before ointments, because ointment blocks absorption of anything that follows.
Ear Disorders and Hearing
Otitis externa ("swimmer's ear") produces pain on moving the tragus or pinna, with discharge and canal oedema; keep the ear dry, and instil drops after warming them to body temperature to avoid triggering vertigo. Otitis media produces deep ear pain, fever, and a bulging erythematous tympanic membrane, and is far more common in children because the eustachian tube is shorter, wider, and more horizontal.
When instilling ear drops, the canal is straightened differently by age: pull the pinna up and back in adults and children over 3 years, and down and back in children under 3. Have the patient lie with the affected ear uppermost for several minutes afterwards.
Meniere disease is an inner-ear disorder of endolymphatic pressure causing the triad of episodic vertigo, low-frequency sensorineural hearing loss, and tinnitus, often with aural fullness. Management includes a low-sodium diet, diuretics, avoidance of caffeine, alcohol, and nicotine, and — during an attack — safety first: lie still in a quiet darkened room, avoid sudden head movement, and stay in bed with the side rails up until the vertigo settles. Fall prevention is the central nursing diagnosis.
Communicating with a hearing-impaired patient is a favourite exam item because the intuitive answer is wrong. Do not shout: shouting raises pitch and distorts articulation, and most age-related loss is worst at high frequencies. Instead, face the patient at eye level in good light so lip-reading and facial cues are available, gain their attention before speaking, speak at a normal pace in a slightly lowered pitch, use short clear sentences, rephrase rather than repeat the same words, reduce background noise, and confirm that hearing aids are in place and switched on.
Integumentary Disorders
Cellulitis presents as a spreading, warm, erythematous, tender area with indistinct margins, often with fever. Mark the border of the erythema with a skin pen and time it, so progression or regression can be judged objectively; elevate the limb, give prescribed antibiotics, and watch for the streaking lymphangitis and systemic features that signal progression. Distinguish it from necrotising fasciitis, where pain is grossly out of proportion to the visible findings, there is rapid progression, skin crepitus or bullae, and systemic toxicity — a surgical emergency.
Herpes zoster (shingles) is a reactivation of varicella-zoster virus in a single dermatome, producing a unilateral band of grouped vesicles that does not cross the midline, usually preceded by burning pain. Key nursing points: the patient is infectious to non-immune people through vesicle fluid until every lesion has crusted; use standard precautions with covered lesions, adding airborne and contact precautions for disseminated disease or immunocompromised patients; keep non-immune pregnant women, neonates, and immunocompromised people away; start antivirals within 72 hours of rash onset for maximum benefit; and manage post-herpetic neuralgia, which may persist for months. Ophthalmic zoster, suggested by lesions on the tip of the nose, threatens sight and needs urgent ophthalmology review.
Psoriasis produces well-demarcated plaques with silvery scale over extensor surfaces; teach that it is not contagious, apply emollients liberally, use prescribed topical agents, and protect the skin from trauma, which provokes new lesions.
Sun damage and skin cancer deserve emphasis in a Gulf climate. Teach the ABCDE rule for a suspicious pigmented lesion: Asymmetry, Border irregularity, Colour variation, Diameter over 6 mm, Evolution or change. Advise broad-spectrum sunscreen reapplied every two hours and after swimming, protective clothing, avoidance of peak-intensity midday sun, and self-examination. Photosensitising medications — tetracyclines, sulfonamides, amiodarone, thiazides, and some non-steroidal anti-inflammatory drugs — warrant specific counselling, and outdoor workers require heat-illness as well as ultraviolet advice.
A 68-year-old patient attends the emergency department with sudden severe right eye pain, blurred vision with haloes around lights, nausea, and vomiting. On examination the right pupil is mid-dilated and non-reactive and the globe feels hard. Which prescription should the nurse question?
A nurse is preparing to administer two different ophthalmic preparations to the same eye: timolol drops and an antibiotic ointment. Which sequence and technique are correct?
A nurse is admitting an older adult with significant age-related hearing loss who does not have hearing aids available. Which approach best supports effective communication?