Topic outline

  • General

  • PART I. GENERAL INTRODUCTION

     PART I. GENERAL INTRODUCTION

    1.0 About the teacher’s guide

    This book is a teacher’s guide for Medical Pathologies subject, for senior six in 
    Associate Nursing program. It is designed to accompany student book and intends 
    to help teachers in the implementation of competence-based curriculum specifically 
    Medical Pathologies syllabus.

    As the name says, it is a guide that teachers can refer to when preparing their 
    lessons. Teachers may prefer to adopt the guidance provided but they are also 
    expected to be more creative and consider their specific classes’ contexts and 
    prepare accordingly.

    1.1. The structure of the guide 
    This section presents the overall structure, the unit and sub-heading structure to 
    help teachers to understand the different sections of this guide and what they will 
    find in each section. 
    Overall structure
    The whole guide has three main parts as follows: 

    ♦ Part I: General Introduction. 
    This part provides general guidance on how to develop the generic competences, 
    how to integrate cross cutting issues, how to cater for students with special 
    educational needs, active methods and guidance on assessment. 

    ♦ Part II: Sample lesson plan
    This part provides a sample lesson plan, developed, and designed to help the 
    teacher develop their own lesson plans.

    ♦ Part III: Unit development
    This is the core part of the guide. Each unit is developed following the structure 
    below. The guide ends with references.
    Each unit is made of the following sections:
    • Unit title: from the syllabus
    • Key unit competence: from the syllabus

    • Prerequisites (knowledge, skills, attitudes and values)

    This section indicates knowledge, skills and attitudes required for the success of 
    the unit. The competence-based approach calls for connections between units/
    topics within a subject and interconnections between different subjects. The teacher 
    will find an indication of those prerequisites and guidance on how to establish 
    connections.

    ♦ Cross-cutting issues to be addressed
    This section suggests cross cutting issues that can be addressed depending on 
    the unit content. It provides guidance on how to come up with the integration of 
    the issue. Note that the issue indicated is a suggestion; teachers are free to take 
    another cross-cutting issue taking into consideration the learning environment. 

    ♦ Guidance on the introductory activity
    Each unit starts with an introductory activity in the teacher’s book. This section of 
    the teacher’s guide provides guidance on how to conduct this activity and related 
    answers. Note that students may not be able to find the right solution but they are 
    invited to predict possible solutions or answers. Solutions are provided by students 
    gradually through discovery activities organized at the beginning of lessons or 
    during the lesson. 

    ♦ List of lessons/sub-heading
    This section presents in a table suggestion on the list of lessons, lesson objectives 
    copied or adapted from the syllabus and duration for each lesson. Each lesson /
    subheading is then developed.

    ♦ End of each unit
    At the end of each unit the teacher provides the following sections:

    • Summary of the unit which provides the key points of content developed in 
       the teacher’s book. 
    • Additional information which provides additional content compared to the 
       student book for the teacher to have a deeper understanding of the topic.
    • End unit assessment which provides answers to questions of the end unit 
        assessment in the teacher’s book and suggests additional questions and 
        related answers to assess the key unit competence.
    • Additional activities sad remedial, consolidation and extended activities). The 
      purpose of these activities is to accommodate each student (slow, average, 

      and gifted) based on the end of unit assessment results. 

    Structure of each subheading 

    Each lesson/sub-heading is made of the following sections:

    Lesson /Sub heading title 1: ……………………………..

    ♦ Prerequisites/Revision/Introduction: 

    This section gives a clear instruction to teacher on how to start the lesson.

    ♦ Teaching resources
    This section suggests the teaching aids or other resources needed in line with the 
    activities to achieve the learning objectives. Teachers are encouraged to replace 
    the suggested teaching aids by the available ones in their respective schools and 
    based on learning environment. 

    ♦ Learning activities
    This section provides a short description of the methodology and any important 
    aspect to consider. It provides also answers to learning activities with cross 
    reference to student’s book. 

    ♦ Exercises/application activities
    This provides questions and answers for exercises/ application activities.

    1.2. Methodological guidance

    1.2.1 Developing competences
    Since 2015 Rwanda shifted from a knowledge based to a competence based 
    curriculum for pre-primary, primary and general secondary education. For Secondary 
    Schools, it is in 2019 that the competence based curriculum was embraced. This 
    called for changing the way of learning by shifting from teacher centered to a learner 
    centered approach. Teachers are not only responsible for knowledge transfer but 
    also for fostering teacher’s learning achievement and creating safe and supportive 
    learning environment. It implies also that a student has to demonstrate what he/she 
    is able to do using the knowledge, skills, values and attitude acquired in a new or 
    different or given situation.

    The competence-based curriculum employs an approach of teaching and learning 
    based on discrete skills rather than dwelling on only knowledge or the cognitive 
    domain of learning. It focuses on what learner can do rather than what learners know. 
    Students develop basic competences through specific subject unit competences 

    with specific learning objectives broken down into knowledge, skills and attitudes. 

    These competences are developed through learning activities disseminated in 
    learner-centered rather than the traditional didactic approach. The students are 
    evaluated against set standards to achieve before moving on. 
    In addition to specific subject competences, students also develop generic 
    competences which are transferable throughout a range of learning areas and 
    situations in life. Below are examples of how generic competences can be developed 

    in Medical Pathologies: 

              

     1.2.2. Addressing cross cutting issues
    Among the changes in the competence-based curriculum is the integration of cross 
    cutting issues as an integral part of the teaching learning process-as they relate to
    and must be considered within all subjects to be appropriately addressed. The eight 
    cross cutting issues identified in the national curriculum framework are: genocide 
    studies, environment and sustainability, gender, Comprehensive Sexuality Education 
    (CSE), Peace and Values Education, Financial Education, standardization Culture 
    and Inclusive Education.

    Some cross cutting issues may seem specific to learning areas or subjects, but the 
    teacher needs to address all of them whenever an opportunity arises. In addition, 
    student should always be given an opportunity during the learning process to address 
    these cross-cutting issues both within and out of the classroom to progressively 

    develop related attitudes and values. 

    Below are examples on how crosscutting issues can be addressed in Medical 

    Pathologies:

               

        1.2.3 Attention to special educational needs specific to each 
                    subject
    In the classroom, students learn in different way depending to their learning pace, 
    needs or any other special problem they might have. However, the teacher has 
    the responsibility to know how to adopt his/her methodologies and approaches 
    to meet the learning needs of each student in the classroom. Also, teacher must 
    understand that students with special needs need to be taught differently or need 
    some accommodations to enhance the learning environment. This will be done 
    depending on the subject and the nature of the lesson. 

    To create a well-rounded learning atmosphere, teacher needs to: 
    • Remember that students learn in different ways, so they have to offer a variety 
      of activities (e.g., role-play, music and singing, word games and quizzes, and 
      outdoor activities).
    • Maintain an organized classroom and limits distraction. This will help students 
       with special needs to stay on track during lesson and follow instruction easily. 
    • Vary the pace of teaching to meet the needs of each student-teacher. Some 
       students process information and learn more slowly than others. 
    • Break down instructions into smaller, manageable tasks. Students with 
      special needs often have difficulty understanding long-winded or several 
       instructions at once. It is better to use simple, concrete sentences to facilitate 
       them understand what you are asking. 
    • Use clear consistent language to explain the meaning (and demonstrate or 
       show pictures) if you introduce new words or concepts.
    • Make full use of facial expressions, gestures, and body language.
    • Pair a student who has a disability with a friend. Let them do things together 
       and learn from each other. Make sure the friend is not overprotective and 
       does not do everything for the student-teacher. Both students will benefit from 
        this strategy
    • Use multi-sensory strategies. As all students learn in different ways, it is 
        important to make every lesson as multi-sensory as possible. Students with 
        learning disabilities might have difficulty in one area, while they might excel in 
        another. For example, use both visual and auditory cues.
     
    Below are general strategies related to each main category of disabilities and how 
    to deal with every situation that may arise in the classroom. However, the list is not 
    exhaustive because each student is unique with different needs and that should be 

    handled differently.

    Strategy to help students with developmental impairment:
    • Use simple words and sentences when giving instructions.
    • Use real objects that the student can feel and handle, rather than just working 
       abstractly with pen and paper.
    • Break a task down into small steps or learning objectives. The student should 
       start with an activity that s/he can do already before moving on to something 
       that is more difficult. 
    • Gradually give the student less help.
    • Let the student work in the same group with those without disability.
      Strategy to help students with visual impairment:
    • Help students to use their other senses (hearing, touch, smell and taste) to 
       play and carry out activities that will promote their learning and development.
    • Use simple, clear and consistent language. 
    • Use tactile objects to help explain a concept.
    • If the student has some sight, ask them what they can see. Get information from 
       parents/caregivers on how the student manages their remaining sight at home. 
    • Make sure the student has a group of friends who are helpful and who allow 
       the students to be as independent as possible. 
    • Plan activities so that students work in pairs or groups whenever possible. 
       Strategy to help students with hearing impairment:
    • Strategies to help students with hearing disabilities or communication difficulties
    • Always get the students attention before you begin to speak.
    • Encourage the student to look at your face.
    • Use gestures, body language and facial expressions.
    • Use pictures and objects as much as possible.
    • Ask the parents/caregivers to show you the signs they use at home for 
      communication use the same signs yourself and encourage other students to 
       also use them.
    • Keep background noise to a minimum. 

       Strategies to help children with physical disabilities or mobility 
        difficulties:
    • Adapt activities so that student who use wheelchairs or other mobility aids, or 
        other students who have difficulty moving, can participate. 
    • Ask parents/caregivers to assist with adapting furniture e.g. The height of a 
       table may need to be changed to make it easier for a student to reach it or fit 
       their legs or wheelchair under.
    • Encourage peer support friends can help friends.
    • Get advice from parents or a health professional about assistive devices.

    1.2.4 Guidance on assessment
    Each unit in the teacher’s guide provides additional activities to help students 
    achieve the key unit competence. Results from assessment inform the teacher 
    which student needs remedial, consolidation or extension activities. These activities 
    are designed to cater for the needs of all categories of students; slow, average and 
    gifted learners respectively. 
    Assessment is an integral part of teaching and learning process. The main purpose 
    of assessment is for improvement. Assessment for learning/ Continuous/ formative 
    assessment intends to improve student-teachers’ learning and teacher’s teaching 
    whereas assessment of learning/summative assessment intends to improve the 
    entire school’s performance and education system in general.

    Continuous/ formative assessment 
    It is an ongoing process that arises out of interaction during teaching and learning 
    process. It includes lesson evaluation and end of subunit assessment. This formative 
    assessment plays a big role in teaching and learning process. The teacher should 
    encourage individual, peer and group evaluation of the work done in the classroom 
    and uses appropriate competence-based assessment approaches and methods. 
    In Year two textbook, formative assessment principle is applied through application 
    activities that are planned in each lesson to ensure that lesson objectives are 
    achieved before moving on. At the end of each unit, the end unit assessment is 
    formative when it is done to give information on the progress of students and from 
    there decide what adjustments need to be done. Assessment standards are taken 
    into consideration when setting tasks.

    Summative assessment
    The assessment done at the end of the term, end of year, is considered as 
    summative. The teacher, school and parents are informed on the achievement of 
    educational objectives and think of improvement strategies. There is also end of 

    level/ cycle assessment in form of national examinations.

    1.2.5. Student teachers’ learning styles and strategies to 

       conduct teaching and learning process

    There are different teaching styles and techniques that should be catered for. The 
    selection of teaching method should be done with the greatest care and some of 
    the factors to be considered are: the uniqueness of subjects, the type of lessons, 
    the particular learning objectives to be achieved, the allocated time to achieve the 
    objective, instructional available materials, the physical/sitting arrangement of the 
    classroom, individual student teachers’ needs, abilities and learning styles.

    There are mainly four different learning styles as explained below:

     a) Active and reflective students
    Active learners tend to retain and understand information best by doing something 
    active with it, discussing or applying it or explaining it to others. Reflective learners 
    prefer to think about it quietly first. 

     b) Sensing and intuitive students
    Sensing learners tend to like learning facts while intuitive learners often prefer 
    discovering possibilities and relationships. Sensors often like solving problems by 
    well-established methods and dislike complications and surprises; intuitive learners 
    like innovation and dislike repetition. 

     c) Visual and verbal students
    Visual students remember best what they see (pictures, diagrams, flow charts, 
    timelines, films, demonstrations, etc); verbal learners get more out of words (written 
    and spoken explanations).

    d) Sequential and global students
    Sequential students tend to gain understanding in linear steps, with each step 
    following logically from the previous one. Global learners tend to learn in large 
    jumps, absorbing material almost randomly without seeing connections, and then 
    suddenly “getting it.” 

    1.2.6. Teaching methods and techniques that promote the active 
    learning
    The different student learning styles mentioned above can be catered for, if the 
    teacher uses active learning whereby students are really engaged in the learning 

    process. 

    What is Active learning? 
    Active learning is a pedagogical approach that engages students in doing things 
    and thinking about the things they are doing. In active learning, students are 
    encouraged to bring their own experience and knowledge into the learning process. 

    The role of the teacher in active learning 
    • The teacher engages students through active learning methods such as 
    inquiry methods, group discussions, research, investigative activities and 
    group and individual work activities. 
    • He/she encourages individual, peer and group evaluation of the work done 
    in the classroom and uses appropriate competence-based assessment 
    approaches and methods. 
    • He provides supervised opportunities for students to develop different 
    competences by giving tasks which enhance critical thinking, problem solving, 
    research, creativity and innovation, communication and cooperation. 
    • Teacher supports and facilitates the learning process by valuing student
       teachers’ contributions in the class activities. 

    The role of students in active learning 
    Learners are key in the active learning process. They are not empty vessels to fill 
    but people with ideas, capacity and skills to build on for effective learning. A learner 
    engaged in active learning:
    • Communicates and shares relevant information with other learners through 
       presentations, discussions, group work and other learner-centred activities 
       (role play, case studies, project work, research and investigation) 
    • Actively participates and takes responsibility for their own learning 
    • Develops knowledge and skills in active ways 
    • Carries out research/investigation by consulting print/online documents and 
       resourceful people, and presents their findings 
    • Ensures the effective contribution of each group member in assigned tasks 
       through clear explanation and arguments, critical thinking, responsibility and 
       confidence in public speaking
    • Draws conclusions based on the findings from the learning activities.

    Some active techniques that can be used in Medical Pathologies
    The teaching methods strongly emphasised in the competence Based Curriculum 
    (CBC) are active methods. Below are some active techniques that apply in Nursing 
    sciences:

    A. Practical work:
    Many of the activities suggested in Associate Nursing curriculum as well as in the 
    teacher’sbook are practical works. 
    Practical work is vital in learning Medical Pathologies; this method gives the student 
    the opportunity to implement a series of activities and leads to the development of 
    both cognitive and hands-on skills. The practical work and questions given should 
    target the development of the following skills in student-teachers: observation, 
    recording and report writing, manipulation, measuring, planning, and designing. 

    A practical lesson is done in three main stages:
    • Preparation of practical work: Checking materials to ensure they are available 
       and at good state; try the demonstration before the lesson; think of safety 
       rules and give instructions to lab technician if you have any.
    • Performance of practical work: Sitting or standing arrangement of student
       teachers; introduction of the demonstration aims and objectives; setting up 
        the apparatus; performing the nursing technique; write and record the data.
    • Discussion: Observations and interpreting data; make generalisations and 
      assignment: writing out the demonstration report and further practice and 
       research.
    In some cases, demonstration by the teacher is recommended when for example 
    the nursing technique requires the use of sophisticated materials or very expensive 
    materials or when safety is a major factor like dangerous practical work, and it 
    needs specific skills to be learnt first. 

    In case your school does not have enough laboratory materials and chemicals, 
    demonstration of nursing techniques can be done in groups but make sure every 
    student participates. You can also make arrangements with the neighbouring 
    science school and take your students there for a number of experiments.

    Each student or group of students is given a research topic. They have to gather 
    information from internet, available books in the library or ask experienced people 
    and then the results are presented in verbal or written form and discussed in class. 

    B. Project work
    Medical pathology teachers are encouraged to sample and prepare project works 
    and engage their students, as many as possible. Students in groups or individually, 
    are engaged in a self-directed work for an extended period of time to investigate 
    and respond to a complex question, problem, or challenge. The work can be 
    presented to classmates or other people beyond the school. Projects are based on 
    real-world problems that capture learners’ interest. This technique develops higher 
    order thinking as the students acquire and apply new knowledge in a problem

    solving context. 

    C. Field trip
    One of the main aims of teaching Fundamentals of Nursing in Rwanda is to apply 
    its knowledge for development. To achieve this aim we need to show to students 
    the relationship between classroom science lessons and applied sciences. This 
    helps them see the link between science principles and technological applications. 
    To be successful, the field visit should be well prepared and well exploited after the visit:
    Before the visit, the teacher and student:
    • agree on aims and objectives
    • gather relevant information prior to visit
    • brainstorm on key questions and share responsibilities
    • discuss materials needed and other logistical and administrative issues
    • discuss and agree on accepted behaviours during the visit 
    • Visit the area before the trip if possible to familiarise yourself with the place

    After the visit
    When students come back from trip, the teacher should plan for follow-up. The 
    follow-up should allow studentsto share experiences and relate them to the prior 
    science knowledge. This can be done in several ways; either: Students write a 
    report individually or in groups and give to the teacher for marking. The teacher 
    then arranges for discussion to explain possible misconceptions and fill gaps. Or 
    students write reports in groups and display them on the class notice board for 
    everyone to read.

    Main steps for a lesson in active learning approach
    All the principles and characteristics of the active learning process highlighted 
    above are reflected in steps of a lesson as displayed below. Generally, the lesson 
    is divided into three main parts whereby each one is divided into smaller steps to 
    make sure that students are involved in the learning process. Below are those main 
    parts and their small steps:

    1) Introduction
    Introduction is a part where the teacher makes connection between the current 
    and previous lesson through appropriate technique. The teacher opens short 
    discussions to encourage students to think about the previous learning experience 
    and connect it with the current instructional objective. The teacher reviews the prior 
    knowledge, skills and attitudes which have a link with the new concepts to create 
    good foundation and logical sequencings.

    2) Development of the new lesson
    The development of a lesson that introduces a new concept will go through the 
    following small steps: discovery activities, presentation of student-teachers’ findings, 
    exploitation, synthesis/summary and exercises/application activities, explained 
    below:
    Discovery activity 

    Step 1 
    • The teacher discusses convincingly with students to take responsibility of 
    their learning
    • He/she distributes the task/activity and gives instructions related to the tasks 
    (working in groups, pairs, or individual to instigate collaborative learning, to 
    discover knowledge to be learned)

    Step 2 
    • The teacher let the students work collaboratively on the task.
    • During this period the teacher refrains to intervene directly on the knowledge
    • He/she then monitors how the students are progressing towards the 
    knowledge to be learned and boost those who are still behind (but without 
    communicating to them the knowledge). 

    Presentation of student-teachers’ productions

    In this episode, the teacher invites representatives of groups to 
    present the student-teachers’ productions/findings.

    • After three/four or an acceptable number of presentations, the teacher decides 
       to engage the class into exploitation of the student-teachers’ productions.

       Exploitation of student-teachers’s productions
    • The teacher asks the students to evaluate the productions: which ones are 
       correct, incomplete or false
    • Then the teacher judges the logic of the student-teachers’ products, corrects 
    those which are false, completes those which are incomplete, and confirms 
    those which correct.
    Institutionalization (summary/conclusion/ and examples)
    • The teacher summarises the learned knowledge and gives examples which 
        illustrate the learned content. 

    Exercises/Application activities
    • Exercises of applying processes and products/objects related to learned unit/
    sub-unit
    • Exercises in real life contexts
    • Teacher guides students to make the connection of what they learnt to real 
    life situations. At this level, the role of teacher is to monitor the fixation of 
    process and product/object being learned.

    3) Assessment
    In this step the teacher asks some questions to assess achievement of instructional 
    objective. During assessment activity, students work individually on the task/activity. 
    The teacher avoids intervening directly. In fact, results from this assessment inform 
    the teacher on next steps for the whole class and individuals. In some cases, the 

    teacher can end with a homework assignment.

        

       

       

      

  • PART II. SAMPLE LESSON PLAN

    Subject: MEDICAL PATHOLOGIES OF EYES

    School Name: ……………………..

    Teacher’s name: …………………………….

      

     

      

     

  • PART III. UNIT DEVELOPMENT

  • UNIT1: MEDICAL PATHOLOGIES OF EYE

     (Blepharitis, Conjunctivitis, Myopia, Hyperopia/Hypermetropia, and 
    Cataract).

    1.1. Key unit competence: 
    Take appropriate decision on different common medical pathologies of the eyes.

    1.2. Prerequisite (knowledge, skills, attitudes, and values)
    To achieve the above competence, the associate nurse student needs the following 
    prerequisites: human body anatomy and physiology, fundamentals of Nursing, 
    pharmacology.

    1.3. Cross-cutting Issues to be addressed 

    1.3.1. Standardization culture
    In health care system, the most case of patients are presented with medical 
    pathology of eye such conjunctivitis, blepharitis, myopia, hypermetropia and 
    cataract. The learners have to learn eye diseases in order to handle and to manage 
    the patients with eye related diseases.

    1.3.2. Inclusive education
    The teacher involves the students in all learning activities concerning the kind of 
    learner or disabilities for example the slow learner should be reinforced in order to 
    catch up others, and the teacher takes into consideration respective disability of 
    learner.

    Grouping students: Students with special educational needs are grouped 
    with others and assigned roles basing on individual student’s abilities.
    Providing earning resources earlier before teaching session so that students get 
    familiar with them. After end lesson assessment, the identified slow learners are 
    exposed to the remedial learning activities.

    Every important point is written and spoken. The written points help students with 
    hearing impairment and speaking aloud helps students with visual impairment.

    Remember to repeat the main points of the lessons.

    1.3.3. Gender education
    Emphasize to learners that anybody irrespective of their gender can have medical 
    career mainly medical sciences. Give role models who are successful medical 
    pathology of eye in the area where the learners come from. Make sure that during 
    classroom teaching and skills lab demonstration both boys and girls shares and 
    participate equally in practices, arranging and proper hygiene after classroom and 
    skills lab teaching session.

    1.4 Guidance on the introductory activity 
    This introductory activity helps you to engage learners in the introduction of medical 
    pathology of eye and invite the learners to follow the next lessons.

    Teacher’s activity:
    • Ask students to read the text and discuss the given questions.
    • Engage students in working collectively the activity

    • Help students with different problems

      

      

     Lesson 1: Introduction of Medical Pathologies of Eyes. (Definition, 
    causes, signs and symptoms, pathophysiology of Blepharitis)

    a) Prerequisites
    This is the first lesson of the first unit on medical pathologies of eyes in sensory 
    system. In this lesson you will be dealing with the common medical pathologies 
    of eyes which are Blepharitis, Conjunctivitis, Myopia, Hypermetropia and Cataract. 
    The first thing to do before starting teaching is to remind learners that they have 
    learnt about structure and function of eyes in biology, health assessment of eyes 
    from fundamentals of nursing, and let them discuss the questions as indicated 
    in introductory activity. In addition, the students will read and try to answer the 
    questions provided in the case study from learning activity 1.1 so that they can 
    prepare themselves for this lesson.

    b) Learning objectives
          • List the common medical pathologies of eyes: Blepharitis, conjunctivitis, 
              myopia, Hypermetropia and cataract.
          • Define the term “blepharitis”
          • Describe causes, risk factors and pathophysiology of Blepharitis
          • Describe the signs and symptoms of Blepharitis.

    c) Teaching resources
    The teacher could avail the Snellen chart, ophthalmoscope and ensure that the 
    students are able to use them. Also, the teacher should present to the students 
    the library textbooks on medical-surgical nursing especially eyes diseases and 
    indicates the pages. All students must have their student’s books. The algorithm or 
    protocols about eyes diseases management must be availed. There is a need of 
    black board and chalks or flipcharts and markers.
    d) Learning activities 1.1

    Teacher ‘activities and methodology:
    • Ask learners to do individually activity 1.1 in their student book and answer 
       the question number 2 and 3.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard, flipchart, and whiteboard the main students’ ideas.
    • Tick the correct responses and correct those ones which are incorrect and try 
       again to complete those which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.

    Student‘s activity
    • The students answer the questions individually in learning activity 1.1 in their 
    student book
    • The students ask the problems that may be raised from the provided activity 
    if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
    following carefully
    • Summarize the content with the teacher and coming up with conclusion.

    Expected answers to introductory activity 1.0
    1. The human eye is an organ of vision. A vital organ of vision it plays a very 
         important role not only in life but also the human body. The human eye is the 
        organ which gives us the sense of sight, allowing us to learn more about the 
        surrounding world than we do with any of the other four senses. The eye allows 
       us to see and interpret the shapes, colors, and dimensions of objects in the 
       world by processing the light they reflect or emit. The eye is able to see in bright 
        light or in dim light, but it cannot see objects when there is no light
    2. Left eye is not normal
    3. The left eye is colored in blue while right eye is black pupil
    4. The left is small then right
    5. Conjunctivitis, cataract, glaucoma, blepharitis, myopia, and hypermetropia .

    Expected Answers to Questions from Learning Activity 1.1
    1. The different external parts of the eye structures that have been affected: Eyelid, 
         iris, pupil, sclara, conjunctiva (palpebral and bulbar)
    2. The signs and symptoms that patient present are discharges, swollen right 
         eyelid, burning sensation causing itching of right eye, itching of right eye

    3. Conjunctivitis, blepharitis, eye infection

    Lesson 2: Description of Blepharitis (investigation diagnosis, treatment 

    plan, evolution and complication)

    a) Revision
    This is the second lesson of the first unit on medical pathologies of eyes in sensory 
    system. In this lesson you will be dealing with the description of blepharitis such its 
    investigation, diagnosis treatment plan evolution and complication. The first thing to 
    do before starting teaching is to remind learners that they have learnt about lesson 
    one of blepharitis

    b) Learning objectives
    After completion of this lesson, the student will be to:
    • Enumerate the investigations requested for patient with Blepharitis 
    • Identify the adequate medical diagnosis of Blepharitis 
    • Develop a treatment plan of patient with Blepharitis
    • Explain the evolution and complications of Blepharitis. 

    c) Teaching resources
    The teacher could avail the Snellen chart and slip lamp and ensure the students are 
    able to use them. In addition, the teacher should present to the students the library 
    textbooks on medical-surgical nursing especially Eyes Diseases and indicates 
    the pages. All students must have their student’s books. There is need of black 
    board and chalks or flipcharts and markers. Algorithms about assessment and 
    management of conjunctivitis must also be displayed

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 1.2 in their student book and answer 
    the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
    knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
      again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
      in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by conforming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 1.2 in their 
      student book
    • The students ask the problems that may be raised from the provided activity 
        if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attempt to answer the self-assessment questions 1.1

    Lesson 3: Description of conjunctivitis (definition, causes, signs and 
                         symptoms, pathophysiology)

    a) Prerequisites
    This is the fourth lesson of the first unit about medical pathologies of the Eyes. In 
    this lesson, you will be dealing with the description of different types of conjunctivitis: 
    viral conjunctivitis, bacterial conjunctivitis, and allergic conjunctivitis. The first thing 
    to do before starting teaching is to remind learners what they have learnt about the 
    anatomy and physiology of the visual system (Eyes), health assessment of visual 
    system from fundamentals of nursing. The students will discuss the questions from 
    the case study from learning activity 1.2 so that they can prepare themselves for 
    this lesson.

    b) Learning objectives:
    After completion of this lesson, the student will be able to:
    • Define the term “conjunctivitis”
    • Describe causes, risk factors and pathophysiology of different types of 
       conjunctivitis.
    • Describe the signs and symptoms of different types of conjunctivitis.

    c) Teaching resources
    The teacher could avail the Snellen chart and Ophthalmoscope and ensure the 
    students are able to use them. In addition, the teacher should present to the students 
    the library textbooks on medical-surgical nursing especially Eyes Diseases and 
    indicates the pages. All students must have their student’s books.
     
    There is need of black board and chalks or flipcharts and markers. Algorithms about 

    assessment and management of conjunctivitis must also be displayed.

          d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 1.2 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by conforming the right responses.
       Student’s activities
    • The students answer the questions individually in learning activity 1.3 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition
    • Attempt to answer the self-assessment questions 1.3

    The expected answers from Questions of learning activity1.2
    1. The signs and symptoms that the patient was presenting are sticky eyelids, 
    watery and green ocular discharge, redness, soreness and slightly blurred vision 
    in both eyes for about 3 weeks. 
    Other additional information you would ask the patient to guide about the medical 
    diagnosis:
    • Is there anyone from the family who had same symptoms?
    • Past medical and surgical history
    2. Conjunctivitis, infection of the eye, inflammation of the eye, eye diseases etc
    3. The risk factors that exposed the patient to develop that medical condition:
    • Other medical condition: flu syndrome
    • Poor hygiene
    • Possible answers for the questions
    • Risk factors include exposure to infected individuals, fomite contact (e.g., 
    towels, napkins, pillow, slit-lamp, chin rests and handles), wear, sinusitis, 
    immunodeficiency states, prior ocular disease, trauma, and exposure to 
    agents of sexually transmitted disease at birth.
    • Poor hygiene
    • Contact lens misuse
    • Contaminated personal articles
    • Crowded living or social conditions (elementary schools, military barracks)
    • History of ocular diseases including dry eye, blepharitis, and anatomic 
    abnormalities of the ocular surface and lids
    • Recent ocular surgery, exposed sutures, or ocular foreign bodies
    • Chronic use of topical medications
    • Immune compromise
    • Winter/Summer months (bacterial conjunctivitis peaks in the winter and viral 
    conjunctivitis peaks in the summer) etc.

    Lesson 4: Description of Conjunctivitis (investigation, diagnosis 
    treatment plan, evolution and complication)

    a) Revision
    This is the four lesson of the first unit about medical pathologies of the eyes. In 
    this lesson, you will be dealing with the investigations, diagnosis, treatment plan, 
    evolution and complications of conjunctivitis. The first thing to do before starting 
    teaching is to remind learners what they have learnt in the lesson three.

    b) Learning objectives:
    After completion of this lesson, the student will be able to:
    • Enumerate the investigations requested for patient different types of 
       conjunctivitis.
     Describe the way used for adequate medical diagnosis of different types of 
      conjunctivitis.
    • Develop a treatment plan for patient with different types of conjunctivitis.

    • Explain the evolution and complications of different types of conjunctivitis

    c) Teaching resources
    The teacher could avail the Snellen chart and Ophthalmoscope and ensure the 
    students are able to use them. Also, the teacher should present to the students 
    the library textbooks on medical-surgical nursing especially Eyes Diseases and 
    indicates the pages. All students must have their student’s books. There is need 
    of black board and chalks or flipcharts and markers. Algorithms about assessment 
    and management of conjunctivitis must also be displayed.

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 1.2 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones , which are incorrect and 
        try again to complete those which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
      in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by confirming the right responses.

       Student’s activities
    • The students answer the questions individually in learning activity 1.3 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
        if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition

    • Attempt to answer the self-assessment questions 1.2

    The expected answers from Questions of learning activity1.3
    1. Investigations requested to that patient: Polymerase chain reaction (PCR), 
         Pus/swab culture.
    2. The possible medical diagnosis the patient was having is conjunctivitis that 
         might be bacterial, viral or allergic
    3. Different treatments options to this patients’ medical condition are: Hygiene: 
         washing hands properly (frequent hand washing and keeping hands away 
         from affected eyes), Cleaning the affected eye using warm compresses, 
         Antibiotics and Corticosteroids (ointments or drops).
    4. If not treated well, the complications might be: reduction of visual acuity/
         blindness, ciliary flush, infectious keratitis, iritis, glaucoma, photophobia, 
         severe foreign body sensation that prevents the patient from keeping the 
         eye open, corneal opacity, hyperacute bacterial conjunctivitis or epidemic 
         keratoconjunctivitis, dry eye, pterygium; blepharoconjunctivitis, etc.

    ♦ Answers for Self-Assessment 1.2
    1. Difference between all types of conjunctivitis basing on their causes:
    A. Bacterial conjunctivitis is commonly caused by some microorganisms 
         (staphylococcus aureus, streptococcus pneumoniae, haemophilus influenzae, 
         and moraxella catarrhalis). Staphylococcus aureus infection is more common in 
         adults; the other pathogens are more common in children. It is highly contagious 
          and is spread by direct contact with the patient and their secretions or with 
           contaminated objects and surfaces. 
    B. Hyperacute bacterial conjunctivitis: Neisseria species, particularly Neisseria 
        Gonorrhoeae, is the major cause of a hyperacute bacterial conjunctivitis that is 
        severe and sight-threatening. The microorganism is usually transmitted from the 
         genitalia to the hands and then to the eyes.
    C. Conjunctivitis due to trachoma: most chronic keratoconjunctivitis are caused by 
         recurrent infection with Chlamydia trachomatis.
    D. Adult inclusion conjunctivitis: It is a sexually transmitted infection (STI) caused 
         by certain serotypes of Chlamydia trachomatis. The microorganism is usually 

        transmitted from the genitalia to the hands and then to the eyes.

    E. Viral conjunctivitis: is typically caused by adenovirus, with many serotypes 
        implicated. Viral conjunctivitis is highly contagious; it is spread by direct contact 
        with the patient and their secretions or with contaminated objects and surfaces.
    F. Allergic conjunctivitis: Is caused by airborne allergens contacting the eye 
        that trigger a classic type I immunoglobulin E (IgE)-mediated hypersensitivity 
        response specific to that allergen.
    G. Noninfectious, non-inflammatory conjunctivitis: patients can develop a red eye 
          and discharge that is not related to either an infectious or inflammatory process. 

         Usually the cause is a transient mechanical or chemical insult.

    1) Using a table, here is the difference between bacterial, viral, and 

         allergic conjunctivitis basing on their symptoms:

                        

       2) The rationale of taking swabs from discharges for laboratory 

             analysis among the patients with conjunctivitis is:

    It is important in cases of chronic conjunctivitis or when the condition is not 
    responding/fail to improve or to respond to treatment. It also helps in guiding 
    about the medications that must be taken as sensitive to any specific type of 
    microorganisms. The management guide should come from the results from 

    swabs culture.

       3) The treatments modalities specific to each type of conjunctivitis:
    Bacterial conjunctivitis: antibiotic treatment is required for acute conjunctivitis in 
    contact lens wearers as well as for cases of adult inclusion conjunctivitis or hyper acute 
    bacterial conjunctivitis. Preferred choices include erythromycin, azithromycin, 
    chloramphenicol ophthalmic ointment or trimethoprim-polymyxin B drops. Common 
    alternative therapies include bacitracin ointment and bacitracin-polymyxin B ointment. 
    Fluoroquinolones are not first-line therapy for routine cases of bacterial conjunctivitis 

    because of concerns regarding emerging resistance and cost. 

    Adult inclusion conjunctivitis treatment: Antibiotic treatment for 
    adult inclusion conjunctivitis requires systemic therapy (typically 
    with doxycycline, tetracycline, erythromycin, or azithromycin) to eradicate 
    the Chlamidia trachomatis infection. 

    Viral conjunctivitis: there are no specific topical or systemic antiviral agents for the 
    treatment of viral conjunctivitis. Symptomatic relief may be achieved with: topical 
    antihistamine/decongestants, warm or cool compresses, nonantibiotic lubricating 
    agents such as those used for noninfectious conjunctivitis. 

    Allergic conjunctivitis: The first step is to remove or avoid the irritant, if possible. 
    Cool compresses and artificial tears sometimes relieve discomfort in mild cases. In 
    more severe cases, nonsteroidal anti-inflammatory medications and antihistamines 
    may be prescribed. People with persistent allergic conjunctivitis may also require 
    topical steroid eye drops. Oral antihistamines may also be prescribed.

    Toxic conjunctivitis: the primary approach to toxic conjunctivitis is recognition and 
    removal of the offending agent. Stopping as many topical agents as feasible is a 
    good first step. 

    Noninfectious noninflammatory: Symptoms relief with the use of topical lubricants 
    might be useful.
    Chemical conjunctivitis: careful flushing of the eyes with saline is a standard 
    treatment for chemical conjunctivitis. People with chemical conjunctivitis also may 
    need to use topical steroids. Severe chemical injuries, particularly alkali burns, flush 

    the eye for several minutes with a lot of water before seeing your medical provider.

    Persistent symptoms: patients with acute bacterial conjunctivitis usually respond 
    to treatment within one to two days by showing a decrease in discharge, redness, 
    and irritation. Patients who do not respond should be referred to an ophthalmologist. 
    Some effective behaviour change activities that are needed to prevent seriousness 
    and complications of conjunctivitis:

    • Preventing contagion: Infected individuals should not share handkerchiefs, 
    tissues, towels, cosmetics, linens, or eating utensils. Frequent hand washing 
    and keeping hands away from eyes also can make a difference, even when 
    no problems are present.
    • Avoid allergy triggers as much as possible
    • Need for examination or consultation prior to therapy: Otherwise, the eye 
    examination must be done carefully and rely on findings to decide the 
    management. Complications of conjunctivitis are the major reasons for urgent 
    ophthalmologic referral.

    4) The warning signs and symptoms of eye diseases that must 
    prompt urgent referral to ophthalmologist: 

    ♦ Answers to Application Activity 1.2
    reduction of visual acuity; photophobia; severe foreign body sensation that 
    prevents the patient from keeping the eye open; corneal opacity; fixed pupil; 
    severe headache with nausea; suspicion for hyperacute bacterial conjunctivitis 
    or epidemic keratoconjunctivitis (EKC); dry eye; medicamentosa; pterygium; 

    blepharo conjunctivitis and adult inclusion conjunctivitis; etc.

    ♦ Answers to Application Activity 1.2
    1. The medical condition that this patient was suffering from: Bacterial 
         conjunctivitis or hyperacute bacterial conjunctivitis
    2. The possible risk factors that contributed to the development of such medical 
       condition: lack of water access, possible urinary tract infection (lower abdominal 
        pain and dysuria), foreign body in the eye, flu like syndrome
    3. Why chloramphenicol (0.5%) was stopped until the laboratory results are 
    available: the Laboratory results were needed to guide the antibiogram basing 
    on types of microorganisms identified from culture and the sensitivity test.
    4. The warning signs that show that the patient had complications and different 
         complications she should experience:
    Warning signs: sticky eyelids, pus like discharge, lack of improvement after 
    antibiotic uses, photophobia.
    Complications: hyperacute bacterial conjunctivitis, keratoconjunctivitis, 

    infectious keratitis

    5. The elements that should constitute the management plan of this patient:
    • Health education about frequent hand washing and keeping hands away 
       from the infected eyes 
    • Health education about urinary tract infections screening
    • Health education about pathogenesis and complications of eyes diseases 
    and relationship between eyes diseases with poor hygiene
    • To request all needed investigations (urine culture, eyes swabs culture, 
       complete blood count, renal function tests, liver function tests, and 
    • Antibiotics and other symptoms relief management (cool compresses in 
       cleaning secretions
    6. The interventions you would advise her to do in order to minimize the 
         seriousness of complication and avoid cross-transmission to other family 
         members:
    • Preventing contagion: Practice frequent hand washing and keeping hands 
       away from eyes also can make a difference. Avoid touching the normal eye 
       after touching infected eye.
    • Avoid allergy triggers as much as possible
    • Need for examination or consultation prior to therapy: Otherwise, the eye 
       examination must be done carefully and rely on findings to decide the 
       management. Complications of conjunctivitis are the major reasons for 
       urgent ophthalmologic referral.
    • Effective use of antibiotics prescribed

    • Respect of appointment for follow up

    Lesson 5: Description of Myopia (definition causes, signs and 

    symptoms, pathophysiology)

    This is the fifth lesson in the unit 1 of medical pathologies of eyes, lesson deals with 
    definition of myopia, causes, pathophysiology, clinical manifestation, and medical 
    investigation of myopia.

    a) Prerequisite
    For successful teaching and learning process of this lesson, learners should have 
    enough knowledge of the different parts of the eye and the function of the eye that 
    they have already studied in the previous lessons of biology, in addition the learners 
    should have the overview of physic especially in optic lesson. They should be well 
    skilled in drawing the structure of the eye.
    • Students to recall the main parts of the structure of the eyes and their functions
    • The knowledge and skills about optic principles in physic and eyes function 
       (accommodation of the eyes) 

    b) Learning objectives
    After completion of this lesson, the student will be able to:
    • Define the key concepts of myopia
    • List the common causes and pathophysiology of myopia 
    • List the different signs and symptoms of myopia
    • Describe briefly medical investigations for myopia

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. The teaching materials are white board, flip chart, marker, computer, 
    Snellen chart, tape measure, textbook, and videos. The teaching methods are 
    interactive lecture, Group discussion, course work and trip field or guest teacher. 
    In addition to the teacher’s guide, the learners where they can find the supporting 
    resources such computer lab, Nursing skills lab and Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course 
    and provide experiences that will enable students to engage in practice and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as: taking notes, course work and reading textbook 
    related to the lesson, group assignment and summarize the content, engagement 
    in debate and other clinical learning activities such as case study.

    Teacher’s activity:
    • Ask learners to do individually activity 1.2 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
      in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.

    • Judge the answers from learners by confirming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 1.5 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
      if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition
    • Attempt to answer the self-assessment questions 1.5

    ♦ Answer to activity 1.3
    1. Difficulty reading road signs and seeing distant objects clearly, eye strain and 
    headaches, trouble seeing things that are far away, needing to squint to see 
    clearly, eye strain
    2. Basing on those signs and symptoms, what could be the medical problem of 
         this patient?
    3. The medical problem of this patient could be myopia.
    4. What medical investigations might you expect to be ordered to guide the 
        confirmation of the medical problem?
    • The Snellen eye chart is considered one of the clinical standards for 
       evaluating visual acuity
    • A retinoscopy and pinhole occlude could be performed by an ophthalmologist

    Lesson 6: Description of Myopia (investigation, diagnosis, treatment 
    plan, evolution and complication)

    This is the Sixth lesson in the unit 1 of medical pathologies of eyes, lesson deals 
    with the medical and nursing management of myopia.

    a) Revision 
    This is the fifth lesson of the first unit about medical pathologies of the eyes. In 
    this lesson, you will be dealing with the investigation, diagnosis, treatment plan, 
    evolution and complication of myopia. The first thing to do before starting teaching 

    is to remind learners what they have learnt lesson five.

    b) Learning objectives
    After completion of this lesson, the learner will be able to:
    • Enumerate the investigations requested for patient different types of myopia
    • Describe the way used for adequate medical diagnosis of myopia.
    • Develop a treatment plan of patient with Myopia.
    • Explain the evolution and complications of Myopia.
     
    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. The teaching materials are white board, flip chart, marker, computer, 
    Snellen chart, and library textbook. The teaching methods are interactive lecture, 
    Group discussion, and trip field or guest teacher. In addition to the teacher’s guide, 
    the learners can find the supporting resources such computer lab, Nursing skills 
    lab, Library and clinical placement)

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course 
    and provide experiences that will enable students to engage in practice and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as: taking notes, course work and reading textbook 
    related to the lesson, group assignment and summarize the content, engagement 
    in debate and other clinical learning activities such as case study.

    Teacher’s activity:
    • Ask learners to do individually activity 1.2 in their student book and answer 
    the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
      knowledge.
    • Invite any five students to provide they answers
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones which are incorrect and try 
       again to complete those which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.

    • Judge the answers from learners by confirming the right responses.

    ♦ Answers to activity 1.3
    1) The decision to treat refractive disorders depends on the individual 
          patient’s symptoms and needs. Treatment is aimed to improve visual 
           acuity, visual comfort
    2) First-line treatments include corrective lenses, such as glasses and contact 
         lenses, or refractive surgery, Eyeglasses, Contact lenses, Refractive 
         surgery
    3) Cataract formation, retinal detachment from peripheral retinal tears, retinal 
         detachment, dome-shaped macula, choroidal/scleral thinning, myopic 
         choroidal, limitations in instrumental activities of daily living (IADLs) falls, 
         decreased ability to drive or work, and depression etc.

    ♦ Answers for self-assessment 1.3
    1) The Five signs and symptoms of myopia are:
    • Difficulty seeing distant objects clearly
    • Eye strain 
    • Frontal headaches
    • Trouble seeing things that are far away,
    • Squinting to see clearly
    • Eye strain
    • Being fatigued
    2) The three preventive measures for myopia complications 
        development are:
    • Take breaks when using computers or cell phones. 
    • Prevent myopia from worsening, spend time outside and try to focus on 
      objects that are in the distance.
    • Vision therapy. .
    • The use of progressive or bifocal lenses (spectacles or contact lenses) may 

       yield a slowing of myopia by limiting eye accommodation.

    3) The three cause and risk factors of myopia are:
    • Genetic factors
    • Increased intraocular pressure
    • Prolonged reading or reading at close range
    • Diabetes mellitus
    • Trauma of the retina
    • maternal smoking during pregnancy

    4) The three main medical treatment options to correct 
          nearsightedness are:

    Prescription of eyeglasses, contact lenses or refractive surgery

    Lesson7: Description of Hypermetropia (definition, causes, signs and 

    symptoms, pathophysiology)

    a) Preriquisites
    This is the Seventh lesson of the first unit Medical pathologies of eyes. In this 
    lesson you will be dealing with the meaning of Hypermetropia or Hyperopia. Before 
    to do start thinking is to remind learners that they have learnt about structure and 
    function of the eye in Biology and let the learners discuss the meaning of refractive 
    errors so that they may get prepared for this lesson. Proceed with the lesson by 

    introducing to them the learning activity 3.1 in the students ’books.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Define the term ‘’hypermetropia’’
    • Describe the signs and symptoms of hypermetropia.
    • Describe causes, risk factors and pathophysiology of Hypermetropia
    • Identify the adequate medical diagnosis of Hypermetropia

    • Describe the investigations requested for patient with Hypermetropia

    a) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. The teaching aids are white board, flip chart, markers, computers and 
    projectors, Snellen chart, flipchart, and library textbook. The teaching methods 
    are interactive lecture, Group discussion, and field trip. In addition to the teacher’s 

    guide, the learners can find the supporting resources such computer lab, Nursing 

    skills lab and Library. 

    Teacher’s activity:

    • Guide learners to form groups of five learners

    • Provide learners with textbooks and guide them to brainstorm the concept 

    related to the refractive errors (Hyperopia). 

    • Supervise the work where the learners are grouped in small group of five 

    learners and teacher facilitates them to answer the questions by using the 

    case study.

    • Invite some of the learner’s group members to present their findings.

    • Judge the logic of the learners’ products by correcting those that are false, 

    complete those which are incomplete and confirming those which are correct

    • Engage the learners to the clinical settings (Ophthalmology department)

    • Help learners to summarize what they have learnt.

      Student’s activities
    • The students answer the questions individually in learning activity 1.4 in their 
        student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition

    • Attempt to answer the self-assessment questions 1.3

    Answers for learning activity 1.4
    1. The problem may be hypermetropia (hyperopia or farsightedness)
    2. Headache, blurred vision, eye discomfort, difficult in reading his newspapers 
         as he did before, he states that he could clearly read only the written scripture 
         that are far from him

    3. Eye muscle test and Visual Acute Test using Snellen chart

    Lesson 8: Description of Hypermetropia (investigation diagnosis, 

    treatment plan, evolution and complication)

    a) Revision 
    This is the eight lesson of the first unit about medical pathologies of the eyes. In 
    this lesson, you will be dealing with the investigation, diagnosis, treatment plan, 
    evolution and complication of hypermetropia. The first thing to do before starting 

    teaching is to remind learners what they have learnt lesson five

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Enumerate the investigations requested for patient with Hypermetropia
    • Describe the way used for the adequate medical diagnosis of Hypermetropia 
    • Develop a treatment plan for patient with Hypermetropia

    • Explain the evolution and complications of Hypermetropia. 

    c) Teaching resources

     This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. The teaching materials are white board, flip chart, markers, computers 
    and projectors, Snellen chart, flipchart, and library textbook. The teaching methods 
    are interactive lecture, Group discussion, and field trip. In addition to the teacher’s 
    guide, the learners can find the supporting resources such computer lab, Nursing skills 

    lab and Library. 

    d) Learning activities

    Teacher’s activity:
    • Guide learners to form groups of five learners
    • Provide learners with textbooks and guide them to brainstorm the concept 
       related to the refractive errors (Hyperopia). 
    • Supervise the work where the learners are grouped in small group of five 
       learners and teacher facilitates them to answer the questions by using the 
       case study and textbook from school library.
    • Invite some of the learner’s group members to present their findings.
    • Judge the logic of the learners’ products by correcting those that are false, 
        complete those which are incomplete and confirming those which are correct
    • Engage the learners to the clinical settings (Ophthalmology department)

    • Help learners to summarize what they have learnt.

       Student’s activities
    • The students answer the questions individually in learning activity 1.4 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
        if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
        following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition

    • Attempt to answer the self-assessment questions 1.3

    Answers for learning activity 1.3
    1. The current treatment of hyperopia evolves and can be corrected with 
       eyeglasses, contact lenses, bifocal Glasses those includes: 
    • Glasses: This the standard treatment for all children and adult for the 
      majority
    • Contact lens: contacts are great option, you can change the color of the 
       patient eyes and this could be tried during a contact lens examination.
    • Bifocal glasses: This is an excellent and effective treatment for moderate 
       levels of hyperopia in you people as it enhances a young person’s ability to 
       see up and far away
    2. Farsightedness can be associated with several problems, such as: 
    • Crossed eyes: Some children with farsightedness may develop crossed 
      eyes. Specially designed eyeglasses that correct for part or all of the 
      farsightedness may treat this problem’
    • Reduced quality of life: With uncorrected farsightedness, the patient might 
       not be able to perform a task as well as he/she wish. Moreover, the limited 
        vision may detract from the patient enjoyment of day-to-day activities.
    • Eyestrain: Uncorrected farsightedness may cause the patient to squint or 

       strain the eyes to maintain focus. This can lead to eyestrain and headaches.

    ♦ Answers to Self-assessment
    1. The two signs of hypermetropia include blurred vision, the patient may need 
         to squint to see clearly, eyestrain, burning sensation of the eyes and aching in 
         or around the eyes, general eye discomfort or a headache after doing close 
         tasks such as reading, writing, computer work or drawing
    2. The causes of hyperopia include axial shortening of the eyeball. Flattening of 
         the cornea, change in the refractive index of the crystalline lens, malposition 
         or absence of the crystalline lens.
    3. The investigations to confirm hypermetropia includes Visual acute Test, Visual 
         field Test, Slit-lamp examination, ophthalmoscopy or Fundus copy.
    4. The options of hyper metropia treatment are: Eye glasses, Contacts lens, 
         bifocal glasses
    5. The complications of hypermetropia includes Crossed eyes, reduced quality 

         of life, eyestrain, impaired safety, financial burden.

    Lesson 9: Description of Cataract (definition, causes, signs and 

    symptoms, pathophysiology)

    This is the Ninth lesson in the unit 1 of medical pathologies of eyes, lesson deals 
    with definition of cataract, causes, pathophysiology, clinical manifestation, and 
    medical investigation of cataract.

    a) Prerequisite 
    For successful teaching and learning process of this lesson, learners should have 
    enough knowledge of the different parts of the eye and the function of the eye that 
    they have already studied in the previous lessons of biology. They should be well 
    skilled in drawing the structure of the eye.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Define the term “cataract”
    • Describe causes, risk factors and pathophysiology of Cataract. 
    • Describe the signs and symptoms of Cataract.

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. These teaching aids are white board, flip chart, marker, computer, 
    Snellen chart, tape measure textbook, and videos. The teaching methods are 
    interactive lecture, Group discussion, and course work. In addition to the teacher’s 
    guide, the learners where they can find the supporting resources such computer 

    lab, Nursing skills lab and Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as: taking notes, course work and reading textbook 
    related to the lesson, group assignment and summarize the content, engagement 
    in debate and other clinical learning activities such as case study.

    Teacher’s activity:
    • Ask the learners to brainstorm the meaning of myopia, identify the 
              common signs and symptoms of the patient with cataract
    • Teacher guide to use textbook in school library, computer lab.
    • Supervise the work where the learners are grouped in small group of 5 
             learners and teacher facilitates them to find the books which are related 
             the subjects
    • After 30 minutes, ask learners to comeback and to present what they have 
             done in their groups
    • Help learners to summarize what they have learnt.
    • Engage the learners to the clinical settings (Ophthalmology department)

    Student’s activities
    • The students answer the questions individually in learning activity 1.4 in their 
        student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of eye condition

    • Attempt to answer the self-assessment questions 1.4

    ♦ Answer to activity 1.4

    1. Differentiate the normal and abnormal eye on the above observed diagram
    • Right eye is big than left eye,
    • Right eye has black color pupil, and
    • Left eye blue color
    2. Which diseases do you think could affect the abnormal eyes?
     Common Eye Disorders and Diseases
    • Refractive Errors.
    • Age-Related Macular Degeneration.
    • Cataract.
    • Diabetic Retinopathy.
    • Glaucoma.
    • Amblyopia.
    • Strabismus.

    ♦ Answers to self-assessment 1.4
    a) The most common symptoms of cataracts include:
    • Clouded, blurred or dim vision
    • Increasing difficulty with vision at night
    • Sensitivity to light and glare
    • Need for brighter light for reading and other activities
    • Seeing “halos” around lights
    • Frequent changes in eyeglass or contact lens prescription
    • Fading or yellowing of colors
    • Double vision in a single eye

    1) The causes of cataract are:
    Most cataracts develop when aging or injury changes the tissue that makes up the 
    eye’s lens. Proteins and fibers in the lens begin to break down, causing vision to
    become hazy or cloudy.
    Some iherited genetic disorders that cause other health problems can increase 
    your risk of cataracts. Cataracts can also be caused by other eye conditions, past 
    eye surgery or medical conditions such as diabetes. Long-term use of steroid 

    medications, too, can cause cataracts to develop.

    2) The types of cataract are:
         Cataract types include:
             • Cataracts affecting the center of the lens (nuclear cataracts). 
             • Cataracts that affect the edges of the lens (cortical cataracts
             • Cataracts that affect the back of the lens (posterior subcapsular cataracts
             • Cataracts you’re born with (congenital cataracts)

    3) The complications of cataract are:
    Over time, cataracts become worse and start to interfere with vision. Important skills 
    can be affected, such as driving, and loss of vision can affect the overall quality of 
    life in many ways including reading, working, hobbies and sports. If left untreated, 
    cataracts will eventually cause total blindness.

    1.6. Summary of the unit
    Medical pathology is a branch of medical science primarily concerning the diseases 
    affects different human organs such as respiratory tract organs, cardio-vascular 
    organs, digestive organs, urino-genetal organs, sensory organs etc. This unit of 
    medical pathology of the eye described the most common eye conditions that met 
    in Rwanda such conjunctivitis, blepharitis, myopia, hypermetropia, and cataract. 
    This unit describes the eye conditions by providing their definition, clinical features, 
    investigation, treatment plan, evolution and complications. The student who learns 
    this content will be able to take appropriate decision on different common medical 
    pathologies of eyes in terms of diagnosing, treatment and prevent the complication 
    of conjunctivitis, blepharitis, myopia, hypermetropia, and cataract.

        1.7 Additional Information for teachers
        Common additional eye disorders and diseases.
         • Diabetic Retinopathy.
         • Glaucoma.
         • Amblyopia.
         • Strabismus.

    Age-Related Macular Degeneration.

     Definition 
    Age-related macular degeneration (AMD) is a common condition that affects the 
    middle part of your vision. It usually first affects people in their 50s and 60s.

    It does not cause total blindness. However, it can make everyday activities like 
    reading and recognizing faces difficult.

    Without treatment, your vision may get worse. This can happen gradually over 
    several years (“dry AMD”), or quickly over a few weeks or months (“wet AMD”).

    The exact cause is unknown. It has been linked to smoking, high blood pressure, 
    being overweight and having a family history of AMD.

    Symptoms
    The first symptom is often a blurred or distorted area in your vision.

    Other symptoms include:
    • seeing straight lines as wavy or crooked
    • objects looking smaller than normal
    • colors seeming less bright than they used to
    • seeing things that are not there (hallucinations)

       Diagnosis
    • Sometimes the patient may be referred to an eye doctor (ophthalmologist).
    • This is usually only necessary if there is a possibility the patient will need to 
       start treatment quickly within a day.
    • The patient may have more tests, such as a scan of the back of the eyes.

    If the patient is diagnosed with AMD, the specialist will give the information about 
    the type of disease and the treatment options.

    Treatment depends on the type of AMD you have.
    • Dry AMD – there is no treatment, but vision aids can help reduce the effect on 
       the patient life. Read about living with AMD.
    • Wet AMD – you may need regular eye injections and, very occasionally, a 

       light treatment called photodynamic therapy, to stop your vision getting worse.

    1) Glaucoma
    Definition
    Glaucoma is a condition that damages your eye’s optic nerve. It gets worse over 
    time. It’s often linked to a buildup of pressure inside your eye. Glaucoma tends to 
    run in families. You usually don’t get it until later in life.

    The increased pressure in the eye, called intraocular pressure, can damage your 
    optic nerve, which sends images to your brain. If the damage worsens, glaucoma 
    can cause permanent vision loss or even total blindness within a few years..

    If you lose vision, it can’t be brought back. But lowering eye pressure can help you 
    keep the sight you have. Most people with glaucoma who follow their treatment 

    plan and have regular eye exams are able to keep their vision.

    Glaucoma Causes
    The fluid inside your eye, called aqueous humor, usually flows out of your eye 
    through a mesh-like channel. If this channel gets blocked, or the eye is producing 
    too much fluid, the liquid builds up. Sometimes, experts don’t know what causes 
    this blockage. But it can be inherited, meaning it’s passed from parents to children

    Less-common causes of glaucoma include a blunt or chemical injury to your eye, 
    severe eye infection, blocked blood vessels inside your eye, and inflammatory 
    conditions. It’s rare, but eye surgery to correct another condition can sometimes 
    bring it on. It usually affects both eyes, but it may be worse in one than the other.

    Glaucoma Risk Factors
    It mostly affects adults over 40, but young adults, children, and even infants 
    can have it. African American people tend to get it more often, when they’re 
    younger, and with more vision loss.
    • Are over 40
    • Have a family history of glaucoma
    • Are nearsighted or farsighted
    • Have poor vision
    • Have diabetes
    • Take certain steroid medications such as prednisone
    • Take certain drugs for bladder control or seizures, or some over-the-counter 
        cold remedies
    • Have had an injury to your eye or eyes
    • Have corneas that are thinner than usual
    • Have high blood pressure, heart disease, diabetes, or sickle cell anemia

    • Have high eye pressure

    Types of Glaucoma

    There are two main kinds:

    Open-angle glaucoma: this is the most common type. The doctor may also call 
    it wide-angle glaucoma. The drain structure in your eye (called the trabecular 
    meshwork) looks fine, but fluid does not flow out, as it should.

    Angle-closure glaucoma: This is more common in Asia. The patient may also hear it 
    called acute or chronic angle-closure or narrow-angle glaucoma. The eye does not 
    drain, as it should because the drain space between iris and cornea becomes too 
    narrow. This can cause a sudden buildup of pressure in your eye. It is also linked to 
    farsightedness and cataracts, a clouding of the lens inside the eye.

    Less common types of glaucoma include:
    Secondary glaucoma. This is when another condition, like cataracts or diabetes, 
    causes added pressure in the eye.

    Normal-tension glaucoma. This is when the patient has blind spots in the vision 
    or the optic nerve is damaged even though the eye pressure is within the average 
    range. Some experts say it is a form of open-angle glaucoma.

    Pigmentary glaucoma. With this form, tiny bits of pigment from your iris, the colored 
    part of your eye, get into the fluid inside your eye and clog the drainage canals.

    Glaucoma Symptoms
    Most people with open-angle glaucoma do not have symptoms. If symptoms do 
    develop, it is usually late in the disease. That is why glaucoma is often called the 
    “sneak thief of vision.” The main sign is usually a loss of side, or peripheral, vision.

    Symptoms of angle-closure glaucoma usually come on faster and are more obvious. 
    Damage can happen quickly. If the patient has any of these symptoms, he/she may 
    get medical care right away:
    • Seeing halos around lights
    • Vision loss
    • Redness in your eye
    • Eye that looks hazy (particularly in infants)
    • Upset stomach or vomiting

    • Eye pain

      Glaucoma Diagnosis
    Glaucoma tests are painless and do not take long. Your eye doctor will test your 
    vision. They will use drops to widen (dilate) your pupils and examine your eyes.
    They will check your optic nerve for signs of glaucoma. They may take photographs 
    so they can spot changes at your next visit. They will do a test called tonometry to 
    check the eye pressure. They may also do a visual field test to see if there is a loss 
    of peripheral vision.
    If the doctor suspects glaucoma, they may order special imaging tests of the optic 
    nerve.
    Glaucoma Treatment
    Your doctor may use prescription eye drops, oral medications, laser surgery, or 
    microsurgery to lower pressure in the eye.

    Eye drops. These either lower the creation of fluid in the eye or increase its flow 
    out, lowering eye pressure. Side effects can include allergies, redness, stinging, 
    blurred vision, and irritated eyes. Some glaucoma drugs may affect the heart and 
    lungs. Because of potential drug interactions, be sure to tell the doctor about any 
    other medical problems. 

    Oral medication. The doctor might also prescribe medication to take by mouth, 
    such as a beta-blocker or a carbonic anhydrase inhibitor. These drugs can improve 
    drainage or slow the creation of fluid in the eye.

    Laser surgery. This procedure can slightly raise the flow of fluid from the eye if the 
    patient has an open-angle glaucoma. It can stop fluid blockage if the patient has an 
    angle-closure glaucoma. Procedures include:
    • Trabeculoplasty. This opens the drainage area.
    • Iridotomy. This makes a tiny hole in the iris to let fluid flow more freely.
    • Cyclophotocoagulation. This treats areas of the middle layer of the eye to 
       lower fluid production.

    2) Trachoma
    Trachoma is an infectious disease caused by bacterium Chlamydia trachomatis.
    [2] The infection causes a roughening of the inner surface of the eyelids.[2] This 
    roughening can lead to pain in the eyes, breakdown of the outer surface or cornea 
    of the eyes, and eventual blindness.[2] Untreated, repeated trachoma infections
    can result in a form of permanent blindness when the eyelids turn inward

    Signs and symptoms of trachoma
    The bacterium has an incubation period of 6 to 12 days, after which the affected 
    individual experiences symptoms of conjunctivitis, or irritation similar to “pink 
    eye”. Blinding endemic trachoma results from multiple episodes of reinfection that 
    maintains the intense inflammation in the conjunctiva. Without reinfection, the 

    inflammation gradually subsides.

    The conjunctival inflammation is called “active trachoma” and usually is seen in 
    children, especially preschool children. It is characterized by white lumps in the 
    undersurface of the upper eyelid (conjunctival follicles or lymphoid germinal centres) 
    and by nonspecific inflammation and thickening often associated with papillae. 
    Follicles may also appear at the junction of the cornea and the sclera (limbal 
    follicles). Active trachoma often can be irritating and have a watery discharge. 
    Bacterial secondary infection may occur and cause a purulent discharge

    Most commonly, children with active trachoma do not present with any symptoms, 
    as the low-grade irritation and ocular discharge is just accepted as normal, but 
    further symptoms may include: 
    • Eye discharge
    • Swollen eyelids
    • Trichiasis (misdirected eyelashes)
    • Swelling of lymph nodes in front of the ears
    • Sensitivity to bright lights
    • Increased heart rate
    • Further ear, nose, and throat complications

    Cause of trachoma
    Trachoma is caused by Chlamydia trachomatis, serotypes (serovars) A, B, 
    and C. It is spread by direct contact with eye, nose, and throat secretions from 
    affected individuals, or contact with fomites (inanimate objects that carry infectious 
    agents), such as towels and/or washcloths, that have had similar contact with 
    these secretions. Flies can also be a route of mechanical transmission. Untreated, 
    repeated trachoma infections result in entropion (the inward turning of the eyelids), 
    which may result in blindness due to damage to the cornea. Children are the most 
    susceptible to infection due to their tendency to get dirty easily, but the blinding 
    effects or more severe symptoms are often not felt until adulthood. 

    Blinding endemic trachoma occurs in areas with poor personal and family hygiene. 
    Many factors are indirectly linked to the presence of trachoma including lack of 
    water, absence of latrines or toilets, poverty in general, flies, close proximity to 
    cattle, and crowding.The final common pathway, though, seems to be the presence 
    of dirty faces in children, facilitating the frequent exchange of infected ocular 
    discharge from one child’s face to another. Most transmission of trachoma occurs 

    within the family.

    Diagnosis

    McCallan’s classification

    Mc Callan in 1908 divided the clinical course of trachoma into four stages: 

       

        WHO classification
    The World Health Organization recommends a simplified grading system for 
    trachoma. The Simplified WHO Grading System is summarized below: 

    Trachomatous inflammation, follicular (TF)—Five or more follicles of >0.5 mm on 
    the upper tarsal conjunctiva 

    Trachomatous inflammation, intense (TI)—Papillary hypertrophy and inflammatory 
    thickening of the upper tarsal conjunctiva obscuring more than half the deep tarsal 
    vessels 

    Trachomatous scarring (TS)—Presence of scarring in tarsal conjunctiva. 
    Trachomatous trichiasis (TT)—At least one ingrown eyelash touching the globe, or 
    evidence of epilation (eyelash removal) 

    Corneal opacity (CO)—Corneal opacity blurring part of the pupil margin
    Management.

    Azithromycin (single oral dose of 20 mg/kg) or topical tetracycline (1% eye ointment 

    twice a day for six weeks). Azithromycin is preferred because it is used as a single 

    Management
    Azithromycin (single oral dose of 20 mg/kg) or topical tetracycline (1% eye ointment 
    twice a day for six weeks). Azithromycin is preferred because it is used as a single 
    oral dose. Although it is expensive, it is generally used as part of the international 
    donation program organized by Pfizer. Azithromycin can be used in children from 
    the age of six months and in pregnancy. As a community-based antibiotic treatment, 
    some evidence suggests that oral azithromycin was more effective than topical 
    tetracycline, but no consistent evidence supported either oral or topical antibiotics 
    as being more effective. Antibiotic treatment reduces the risk of active trachoma in 
    individuals infected with chlamydial trachomatis.

    Surgery
    For individuals with trichiasis, a bilamellar tarsal rotation procedure is warranted to 
    direct the lashes away from the globe. Evidence suggests that use of a lid clamp 
    and absorbable sutures would result in reduced lid contour abnormalities and 
    granuloma formulation after surgery. Early intervention is beneficial as the rate of 
    recurrence is higher in more advanced disease. 

    Lifestyle measures
    The WHO-recommended SAFE strategy includes: 
    • Surgery to correct advanced stages of the disease
    • Antibiotics to treat active infection, using azithromycin
    • Facial cleanliness to reduce disease transmission
    • Environmental change to increase access to clean water and improved 
       sanitation
    Children with visible nasal and eyes discharge, or flies on their faces are at least 
    twice as likely to have active trachoma. The children with clean faces can also 
    have it. Intensive community-based health education programs to promote face 
    washing can reduce the rates of active trachoma, especially intense trachoma. If an 
    individual is already infected, washing one’s face is encouraged, especially a child, 
    to prevent reinfection. Some evidence shows that washing the face combined with 
    topical tetracycline might be more effective in reducing severe trachoma compared 
    to topical tetracycline alone. The same trial found no statistical benefit of eye 
    washing alone or in combination with tetracycline eye drops in reducing follicular 
    trachoma amongst children

    3) Strabismus
    Strabismus is a condition in which the eyes do not properly align with each other 
    when looking at an object the eye that is focused on an object can alternate. The 
    condition may be present occasionally or constantly. If present during a large part 
    of childhood, it may result in amblyopia or lazy eyes and loss of depth perception. If 

    onset is during adulthood, it is more likely to result in double vision.

    Signs and symptoms
    When observing a person with strabismus, the misalignment of the eyes may be 
    quite apparent. A person with a constant eye turn of significant magnitude is very 
    easy to notice. However, a small magnitude or intermittent strabismus can easily be 
    missed upon casual observation. In any case, an eye care professional can conduct 
    various tests, such as cover testing, to determine the full extent of the strabismus. 

    Symptoms of strabismus include double vision and eye strain. To avoid double 
    vision, the brain may adapt by ignoring one eye. In this case, often no noticeable 
    symptoms are seen other than a minor loss of depth perception. This deficit may not 
    be noticeable in someone who has had strabismus since birth or early childhood, 
    as they have likely learned to judge depth and distances using monocular cues. 
    However, a constant unilateral strabismus causing constant suppression is a risk 
    for amblyopia in children. Small-angle and intermittent strabismus are more likely 
    to cause disruptive visual symptoms. In addition to headaches and eye strain, 
    symptoms may include an inability to read comfortably, fatigue when reading, and 
    unstable or “jittery” vision. 

    The extraocular muscles control the position of the eyes. Thus, a problem with 
    the muscles or the nerves controlling them can cause paralytic strabismus. The 
    extraocular muscles are controlled by cranial nerves III, IV, and VI. An impairment 
    of cranial nerve III causes the associated eye to deviate down and out and may or 
    may not affect the size of the pupil. Impairment of cranial nerve IV, which can be 
    congenital, causes the eye to drift up and perhaps slightly inward. Sixth nerve palsy 
    causes the eyes to deviate inward and has many causes due to the relatively long 
    path of the nerve. Increased cranial pressure can compress the nerve as it runs 
    between the clivus and brain stem. In addition, if the doctor is not careful, twisting 
    of the baby’s neck during forceps delivery can damage cranial nerve VI.

    Pathophysiology
    Evidence indicates a cause for strabismus may lie with the input provided to the 
    visual cortex. This allows for strabismus to occur without the direct impairment of 
    any cranial nerves or extraocular muscles.
     
    Strabismus may cause amblyopia due to the brain ignoring one eye. Amblyopia is the 
    failure of one or both eyes to achieve normal visual acuity despite normal structural 
    health. During the first seven to eight years of life, the brain learns how to interpret 
    the signals that come from an eye through a process called visual development. 
    Development may be interrupted by strabismus if the child always fixates with one 
    eye and rarely or never fixates with the other. To avoid double vision, the signal 
    from the deviated eye is suppressed, and the constant suppression of one eye 

    causes a failure of the visual development in that eye.

    In addition, amblyopia may cause strabismus. If a great difference in clarity occurs 
    between the images from the right and left eyes, input may be insufficient to correctly 
    reposition the eyes. Other causes of a visual difference between right and left eyes, 
    such as asymmetrical cataracts, refractive error, or other eye disease, can also 
    cause or worsen strabismus. 

    Accommodative esotropia is a form of strabismus caused by refractive error in 
    one or both eyes. Due to the near triad, when a person engages accommodation to 
    focus on a near object, an increase in the signal sent by cranial nerve III to the medial 
    rectus muscles results, drawing the eyes inward; this is called the accommodation 
    reflex. If the accommodation needed is more than the usual amount, such as with 
    people with significant hyperopia, the extra convergence can cause the eyes to 
    cross.

    Diagnosis
    During an eye examination, a test such as cover testing or the Hirschberg test is 
    used in the diagnosis and measurement of strabismus and its impact on vision. 
    Retinal birefringence scanning can be used for screening of young children for eye 
    misalignment. A Cochrane review to examine different types of diagnosis test found 
    only one study. This study used a photoscreener which was found to have high 
    specificity (accurate in identifying those without the condition) but low sensitivity 
    (inaccurate in identifying those with the condition)

    Management
    Strabismus is usually treated with a combination of eyeglasses, vision therapy, and 
    surgery, depending on the underlying reason for the misalignment. As with other 
    binocular vision disorders, the primary goal is comfortable, single, clear, normal 
    binocular vision at all distances and directions of gaze.

    Whereas amblyopia (lazy eye), if minor and detected early, can often be corrected 
    with use of an eye patch on the dominant eye or vision therapy, the use of eye 
    patches is unlikely to change the angle of strabismus. 

    Glasses
    In cases of accommodative esotropia, the eyes turn inward due to the effort of 
    focusing far-sighted eyes, and the treatment of this type of strabismus necessarily 
    involves refractive correction, which is usually done via corrective glasses or contact 
    lenses, and in these cases surgical alignment is considered only if such correction 

    does not resolve the eye turn.

    In case of strong anisometropia, contact lenses may be preferable to spectacles 
    because they avoid the problem of visual disparities due to size differences 
    (aniseikonia) which is otherwise caused by spectacles in which the refractive 
    power is very different for the two eyes. In a few cases of strabismic children with 
    anisometropic amblyopia, a balancing of the refractive error eyes via refractive 
    surgery has been performed before strabismus surgery was undertaken. 

    Early treatment of strabismus when the person is a baby may reduce the chance 
    of developing amblyopia and depth perception problems. However, a review of 
    randomized controlled trials concluded that the use of corrective glasses to prevent 
    strabismus is not supported by existing research. Most children eventually recover 
    from amblyopia if they have had the benefit of patches and corrective glasses. 
    Amblyopia has long been considered to remain permanent if not treated within 
    a critical period, namely before the age of about seven years; however, recent 
    discoveries give reason to challenge this view and to adapt the earlier notion of a 
    critical period to account for stereopsis recovery in adults.
     
    Eyes that remain misaligned can still develop visual problems. Although not a cure 
    for strabismus, prism lenses can also be used to provide some temporary comfort 
    and to prevent double vision from occurring. 

    Glasses affect the position by changing the person’s reaction to focusing. Prisms 
    change the way light, and therefore images, strike the eye, simulating a change in 
    the eye position.

    Surgery
    Strabismus surgery does not remove the need for a child to wear glasses. Currently 
    it is unknown whether there are any differences for completing strabismus surgery 
    before or after amblyopia therapy in children.

    Strabismus surgery attempts to align the eyes by shortening, lengthening, or 
    changing the position of one or more of the extraocular eye muscles. The procedure 
    can typically be performed in about an hour, and requires about six to eight weeks 
    for recovery. Adjustable sutures may be used to permit refinement of the eye 
    alignment in the early postoperative period. It is unclear if there are differences 
    between adjustable versus non-adjustable sutures as it has not been sufficiently 
    studied. An alternative to the classical procedure is minimally invasive strabismus 

    surgery (MISS) that uses smaller incisions than usual.

    1.8 Answers to end unit 1 assessment 

    Section A: Short Answer Questions

    1. BLEPHARITIS
    2. CONJUNCTIVITIS
    3. KERATITIS
    4. CATARACT
    5. CONVEX

    Section B: Multiple Choice Questions

                                  

    1.9 Additional activities

    1.9.1 Remedial activities

    a. Using different literature define the following medical pathology eye 
           condition
          • Conjunctivitis
          • Blepharitis
          • Myopia
          • Hypermetropia
          • Cataract

    b. Complete the following table

        

         

          1.9.2 Consolidation activities

          1. Label the following diagrammed of eye

                    

         Answers

          

           2. What are the functions of human eye?
    The human eyes are the most complicated sense organs in the human body. From 
    the muscles and tissues to nerves and blood vessels, every part of the human eye 
    is responsible for a certain action. Furthermore, contrary to popular belief, the eye 
    is not perfectly spherical; instead, it is two separate segments fused together. It 
    is made up of several muscles and tissues that come together to form a roughly 
    spherical structure. From an anatomical perspective, the human eye can be broadly 

    classified into external structure and internal structure.

        The External Structure of an Eye
    The parts of the eye that are visible externally include the following:

    Sclera: It is a white visible portion. It is made up of dense connective tissue and 
    protects the inner parts.

    Conjunctiva: It lines the sclera and is made up of stratified squamous epithelium. 
    It keeps our eyes moist and clear and provides lubrication by secreting mucus and 
    tears.

    Cornea: It is the transparent, anterior or front part of our eye, which covers the pupil 
    and the iris. The main function is to refract the light along with the lens.
    Iris: It is the pigmented, coloured portion of the eye, visible externally. The main 
    function of the iris is to control the diameter of the pupil according to the light source.
    Pupil: It is the small aperture located in the centre of the Iris. It allows light to enter 
    and focus on the retina

    The Internal Structure of an Eye
    The internal components of an eye are:
    Lens: It is a transparent, biconvex, lens of an eye. The lens is attached to the ciliary 
    body by ligaments. The lens along with the cornea refracts light so that it focuses 
    on the retina.
    Retina: It is the innermost layer of the eye. It is light sensitive and acts as a film of a 
    camera. Three layers of neural cells are present in them, they are ganglion, bipolar 
    and photoreceptor cells. It converts the image into electrical nerve impulses for the 
    visual perception by the brain.
    Optic nerve: It is located at the posterior portion of the eyes. The optic nerves carry 
    all the nerve impulses from the retina to the human brain for perception.
    Aqueous Humour: It is a watery fluid present between the cornea and the lens. It 
    nourishes the eye and keeps it inflated.
    Vitreous Humour: it is a transparent, jelly-like substance present between the lens 
    and the retina. It contains water (99%), collage, proteins, etc. The main function of 
    vitreous humour is to protect the eyes and maintain its spherical shape

    1.9.3. Extended activities
    1. What are the common eye problems according the age

        Common eye problems by age:

    Answers
    Babies’ eye infections need to be treated. Some of these are prevented by cleaning 
    the baby’s eyes and using eye ointment at birth (see page 33). 

    Young children’s vision problems may be hard to notice. Starting at 6 months old, 
    see if the child’s eyes move and follow a light or a toy when you move it around. A 
    child with a wandering or crossed eye can be helped (page 24) and glasses may 
    help with poor vision. For children with very limited or no vision, Hesperian’s book 
    Helping Children Who Are Blind shows many ways to help a blind child develop her 
    skills.

    School-age children who cannot see clearly cannot tell you they need 
    eyeglasses because they do not know what good vision would be like. 
    A child who has headaches, squints a lot or is having difficulty in school 
    or playing games may have a vision problem and need eyeglasses. It 
    is also a good idea to learn what to do if there is an eye injury from sports or 
    fighting at school.

    Any child can get eye injuries. Keep chemicals and sharp objects locked 
    away and out of reach of children. Adult vision may change at any age and sometimes 
    eyeglasses can help. If a person has diabetes or high blood pressure, treatment to 
    manage these problems will help prevent further harm to the eyes. Different kinds of 
    work make some eye injuries or eye conditions more likely.
    Older adults are more likely to develop cataracts and need 
    reading glasses.

    2. What are the illnesses that can affect the eyes

    ♦ Answers
    Some infections or illnesses affecting the whole body can harm the eyes. 
    When someone has eye problems, it is wise to consider if the cause could 
    be another illness. 

    Tuberculosis can infect the eyes and cause redness or poor vision. Most 
    often, signs of tuberculosis will appear first in the lungs or other parts of 
    the body. HIV and AIDS: Eye problems and loss of vision in people with HIV are 
    prevented by treatment with HIV medicines, called ART. Get tested so you 
    can start treatment if you need it.
    Herpes (cold sores) occasionally spreads to the eye, causing an ulcer of the 
    cornea with pain, blurred vision, and watery eyes. Antiviral medicines are 

    helpful. Do not use steroid eye drops—they make the problem worse.

    Problems in the liver: Jaundice, when the white part of the eye is yellow 
    (or the skin of a light-colored person gets yellow), can be a sign of hepatitis.
    People with diabetes may develop vision problems. As the disease 
    advances, diabetes can damage their eyes (a serious condition called 
    diabetic retinopathy). Without treatment, diabetes can lead to blindness. 
    Blurred vision can be an early sign that blood sugar is high and a person 
    may have diabetes. If someone with blurred vision also is very thirsty and 
    has to urinate a lot, it is likely they have diabetes. Inexpensive tests can let 
    them know for sure.

    Help people with diabetes get treatment to bring down their blood sugar 
    levels and encourage them to visit an eye specialist once a year to check 
    their eyes for damage from diabetes. Eye disease from diabetes can be 
    treated if found early.

    High blood pressure can affect the eyes and vision by damaging the 
    blood vessels inside the eye. Checking blood pressure during health care 
    visits is the best way to know if it is too high. Preventing and treating high 
    blood pressure will help protect the eyes.

    1. What are the treatment of following eye conditions
           • Cataract
           • Glaucoma
           • Fleshy growth across eye ( pterygium)
           • Blood in the white of the eye
           • Vitamin A deficiency (night blindness, xerophthalmia)

           • Crossed eyes, wandering eye, squint (strabismus)

    ♦ Answers
       Cataract
       Non-Surgical Cataract Treatment
    Early cataract treatment is aimed at improving the quality of vision. When cataract 
    symptoms appear, client may experience cloudy or blurry vision, light sensitivity, 
    poor night vision, double vision, and changes the eyewear prescription. Certain 
    changes can significantly reduce these symptoms.
    Cataract symptoms may be improved with new eyeglasses, anti-glare sunglasses, 
    or magnifying lenses. Certain tints and coatings also can be added to lenses to 

    reduce symptoms.

    Early cataract treatment is aimed at improving the quality of vision. When cataract 
    symptoms appear, client may experience cloudy or blurry vision, light sensitivity, 
    poor night vision, double vision, and changes the eyewear prescription. Certain 
    changes can significantly reduce these symptoms.

    Cataract symptoms may be improved with new eyeglasses, anti-glare sunglasses, 
    or magnifying lenses. Certain tints and coatings also can be added to lenses to 

    reduce symptoms.

    a) Surgical Cataract Treatment 
    If non-surgical measures do not help, surgery is the only effective treatment. It 
    is considered when a cataract progresses and decreases vision to a point that it 
    interferes with the lifestyle and daily activities.

    ♦ Glaucoma
    The treatment will largely depend on which type of glaucoma. The most common 
    type, primary open angle glaucoma, is usually treated with eye drops. Laser 
    treatment or surgery may be offered if drops do not help.

    Treatment for other types of glaucoma may include:
    • primary angle closure glaucoma (immediate treatment in hospital with 
      medicine to reduce the pressure in the eye, followed by laser treatment)
    • secondary glaucoma (eyedrops, laser treatment or surgery, depending on the 
       underlying cause)
    • childhood glaucoma ( surgery to correct the problem in the eye that led to the 
       build-up of fluid and pressure)
      The main treatments are described below.
    • Eye drops are the main treatment for glaucoma. There are several different 
      types that can be used, but they all work by reducing the pressure in your 
       eyes.
    • Eye drops can cause unpleasant side effects, such as eye irritation, and some 
    are not suitable for people with certain underlying conditions.

    Laser treatment
    Laser treatment may be recommended if eye drops do not improve your symptoms.
    This is where a high-energy beam of light is carefully aimed at part of your eye to 
    stop fluid building up inside it.

    Types of laser treatment include:
    • laser trabeculoplasty – a laser is used to open up the drainage tubes within 
      your eye, which allows more fluid to drain out and reduces the pressure inside
    • cyclodiode laser treatment – a laser is used to destroy some of the eye tissue 
       that produces the liquid, which can reduce pressure in the eye
    • laser iridotomy – a laser is used to create holes in your iris to allow fluid to 
       drain from your eye
    Surgery may be recommended in rare cases where treatment with eyedrops or 

    laser have not been effective.

    The most common type of surgery for glaucoma is called trabeculectomy. It involves 
    removing part of the eye-drainage tubes to allow fluid to drain more easily.

    Glaucoma surgery may be carried out under local anaesthetic (while the patient is 
    awake) or general anaesthetic (while the patient is asleep).

    Most people will not need to take eye drops any more after trabeculectomy, and you 
    should not be in a lot of pain after surgery.

    Fleshy growth across eye (pterygium)

    Treatment
    A pterygium often does not cause problems or require 
    treatment. However, two main treatment approaches can be 
    considered if the pterygium causes discomfort or affects vision.
    Medication Short-term use of topical corticosteroid eye drops may be 
    used to reduce redness and inflammation. Where dryness of the eye 

    is a problem, artificial tears are used to keep the eye well lubricated.

    Surgery
    Surgery may be recommended if vision is affected or symptoms are particularly 
    problematic.

    During surgery, the pterygium is carefully removed and a section of the conjunctiva 
    is taken from under the eyelid and is grafted onto the area where the pterygium 
    was. Surgery is performed using a local anaesthetic and takes approximately 30 
    minutes to perform. 

    It is possible for pterygia to recur after surgical removal, though this only happens 

    in a small percentage of cases.

    Prevention
    To reduce the risk of developing pterygia:
    • Use sunglasses that block out UV light (close-fitting, wrap around styles are 
       best)
    • Wear sunglasses and a hat with a wide brim when outdoors
    • Avoid exposure to environmental irritants, e.g.: smoke, dust, wind, and 
      chemical pollutants

    • Use appropriate eye safety equipment in work environments.

          Blood in the white of the eye
    Treatment for hyphemas and other types of eye bleeding may include:
         • laser surgery to bring eye pressure down
         • eye surgery in severe cases, such as non-clearing hyphemas that surgeons 
            need to evacuate in the operating room
         • eye drops to control inflammation, pain, and pressure

    The type of eye drop an ophthalmologist prescribes will depend on the cause of the 
    bleeding. Some examples include antibiotic, antiviral, and steroid eye drops.

    Sub conjunctival hemorrhages do not usually require treatment. The healing time 
    can vary from a few days to a few weeks, depending on the size of the spot.

    People can use artificial tears to relieve irritation or dryness. Artificial tears are 
    available in drug stores, pharmacies, and online.

    A doctor may prescribe antibiotic eye drops if the red spot is the result of a bacterial 
    infection.People should not be alarmed if the red spot changes colors from red to 
    yellow or orange. This is a sign that the hemorrhage is healing. Like a bruise, it may 
    slowly fade over time.

    Treatments for diabetic retinopathy include:
    • injectable medications to reduce swelling
    • laser eye surgery to close leaking blood vessels
    • vitrectomy, or surgery that involves removing vitreous gel and blood from the 
       back of the eye
    Floaters (seeing small spots)
    Fortunately, two different treatments can be performed to reduce the presence of 
    eye floaters, and sometimes even eliminate them:
             1. Vitrectomy
             2. Vitreolysis

      What is a vitrectomy?
    A vitrectomy is the primary treatment for eye floaters.

    This procedure involves removing the vitreous in order to eliminate 
    the collagen fibers that are causing the eye floaters.

    What to expect during a vitrectomy procedure

    A vitrectomy is a safe and relatively quick procedure that is generally performed 
    under local anesthesia. During this procedure, a small incision is made and the 
    vitreous is removed. A new fluid made of saline or silicone oil is then inserted into 

    the space of the vitreous.

         What to expect following a vitrectomy
    Following this procedure, an antibiotic ointment is applied to the eye to prevent 
    infection, and an eye patch is placed over the eye to protect it while it heals.

    It may take a couple of weeks to notice total vision improvement, though it is 
    important to speak with your doctor to find out what is to be expected in your 
    individual circumstances.

    Are there any complications associated with vitrectomy?
    As with any surgical procedure, there are some risks to consider before undergoing 
    a vitrectomy. The most common risks include eye damage, infection, bleeding, 
    high eye pressure, retinal detachment, cataracts, and changes to any pre-existing 
    refractive error.

    If you are not a candidate for a vitrectomy, your eye doctor may recommend a laser 
    procedure, called a vitreolysis, to treat your eye floaters.

    If you suspect you have eye floaters, contact an eye doctor near you, who can 
    diagnose and treat the condition.

    Vitreolysis uses a laser to diminish the size and thickness of eye floaters.

    This reduces the retinal shadows and visual disturbances caused by eye floaters in 
    order to restore clear vision and allow patients to return to their daily activities with 
    improved functioning and quality of life.

    What to expect during a vitreolysis procedure
    This in-office procedure is performed under local anesthesia, and typically takes 
    around 20-30 minutes to perform. Some patients require up to three laser treatments 
    over the course of four to six weeks in order to gain the full benefits of the procedure.

    ♦ Vitamin A deficiency (night blindness, xerophthalmia)
    Treatment for night blindness will vary depending on the cause.

    Treatment may include wearing specific types of glasses or contact lenses, which 
    can help to support correct vision.

    Wearing sunglasses can also protect the eye from ultraviolet light, which can cause 

    further eye damage. When the cause is a lack of vitamin A, treatment involves 

    adding more Vitamin A to the diet. Good sources of vitamin A include:

               • eggs
               • fortified cereals
               • fortified milk
               • orange and yellow vegetables and fruits
               • cod liver oil
               • dark, leafy green vegetables
    Treatment can occur in two ways: treating symptoms and treating the deficiency. 
    Treatment of symptoms usually includes the use of artificial tears in the form of 
    eye drops, increasing the humidity of the environment with humidifiers, and 
    wearing wraparound glasses when outdoors. Treatment of the deficiency can be 
    accomplished with a Vitamin A or multivitamin supplement or by eating foods rich 
    in Vitamin A. Treatment with supplements and/or diet can be successful until the 
    disease progresses as far as corneal ulceration, at which point only an extreme 
    surgery can offer a chance of returning sight.

    ♦ Crossed eyes, wandering eye, squint (strabismus)
    Strabismus is usually treated with a combination of eyeglasse, vision therapy, and 
    surgery, depending on the underlying reason for the misalignment. As with other 
    binocular vision disorders, the primary goal is comfortable, single, clear, normal 
    binocular vision at all distances and directions of gaze. 

    Whereas amblyopia (lazy eye), if minor and detected early, can often be corrected 
    with use of an eye patch on the dominant eye or vision therapy, the use of eye 
    patches is unlikely to change the angle of strabismus. 
    (Otitis, Cerumen plug/ear wax, Deafness, Hearing loss and 
    hearing impairment, and Ear trauma).

    2.1. Key unit competence: 
    Take appropriate decision on different common medical pathologies of ear.

    2.2. Prerequisite (knowledge, skills, attitudes, and values)
    To achieve the above competence, the associate nurse student needs the following 
    prerequisites: human body anatomy and physiology, fundamentals of Nursing and 

    pharmacology.

    2.3. Crosscutting Issues to be addressed 
    2.3.1. Standardization culture
    In health care system, the most case of patients is presented with medical pathology 
    of Otitis, Cerumen plug (earwax), Deafness, Hearing and hearing impairment). 
    The learners have to learn oral diseases and esophagus in order to handle and to 
    manage the patients with oral cavity and esophagus related diseases.

    2.3.2. Inclusive education
    The teacher involves the students in all learning activities concerning the kind of 
    learner or disabilities for example the slow learner should be reinforced in order to 
    catch up others, and the teacher takes into consideration respective disability of 
    learner.

    Grouping students, Students with special educational needs are grouped 
    with others and assigned roles basing on individual student’s abilities.
    Providing earning resources earlier before teaching session so that students get 
    familiar with them. After end lesson assessment, the identified slow learners are 
    exposed to the remedial learning activities.
    Every important point is written and spoken. The written points help students with 
    hearing impairment and speaking aloud helps students with visual impairment.
    Remember to repeat the main points of the lessons.

    2.3.3. Gender education
    Emphasize to learners that anybody irrespective of their gender can have medical 
    career mainly medical sciences. Give role models who are successful medical 
    pathology of oral and esophagus in the area where the learners come from. Make 
    sure that during classroom teaching and skills lab demonstration both boys and 
    girls shares and participate equally in practices, arranging and proper hygiene after 
    classroom and skills lab teaching session.

    2.4. Guidance on the introductory activity 

    This introductory activity helps you to engage learners in the introduction of medical 

  • UNIT 2:MEDICAL PATHOLOGIES OF EAR

    pathology of oral and esophagus and invite the learners to follow the next lessons.

    Teacher’s activity:
    • Ask students to read the text and discuss the given questions.
    • Engage students in working collectively the activity
    • Help students with different problems
    • Ask any four students to present their findings while others are following.
    • Prepare trip field to nearest health facility in order to be familiar with Ear,
       Nose and Throat (ENT) department equipment, and health assessment for 
       oral cavity disorders.
    • Invite guest person who has specialty in Ear, Nose and Throat department 

       domain to teach the learners. 

         2.5. List of Lessons/sub-headings (including assessment)

           

                 

        

        

         

     • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard, flipchart and whiteboard to take note of the main 
       students’ ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.

     Student‘s activity
    • The students answer the questions individually in learning activity 2.1 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully.
    • Summarize the content with the teacher and coming up with the conclusion.

       Expected answers to introductory activity 2.0
    1. These persons are complaining with severe ear pain, itching and irritability of 
        the ear
    2. Possible medical problems that the patients might complaint with otitis media, 
        ear trauma or injury.

    Expected Answers to Questions from Learning Activity 2.1
    1. The abnormal signs and symptoms that the patient was presenting are ear pain, 
         fever, drainage from the ear, trouble hearing, and inflammation of drum and 
         other surrounding membrane with the pus, body temperature of 38.5oc, White 
         Blood Cells (WBC) of 130000.
    2. The medical problem of this patient was acute or chronic otitis

    Lesson 2: Description of acute and chronic otitis (investigation 
    diagnosis, treatment plan, evolution and complication)

    a) Prerequisite
    This is the second lesson of the Second unit of medical pathologies of ear in sensory 
    organs. In this lesson, you will be dealing with the description of otitis such as its 
    investigation, medical diagnosis, treatment plan, evolution and complications. The 
    first thing to do before starting teaching is to remind learners that they have learnt 
    about lesson one of acute and chronic otitis.

    b) Learning objectives
    After completion of this lesson, the student will be able to:
    • Enumerate the investigations requested for patient with acute and chronic 
       otitis 
    • Identify the adequate medical diagnosis of acute and chronic otitis
    • Develop a treatment plan of patient with acute and chronic otitis
    • Explain the evolution and complications of acute and chronic otitis. 

    c) Teaching resources
    The teacher could avail the anatomical model of the normal ear and abnormal ear 
    whenever possible and ensure the students are able to interpret them. In addition, 
    the teacher should present to the students the library textbooks on medical-surgical 
    nursing especially ear related diseases and indicates the pages. All students must 
    have their student’s books. There is a need of black board and chalks or flipcharts 
    and markers. Algorithms about assessment and management of dental caries must 
    also be displayed.

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 2.1 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.

    • Judge the answers from learners by confirming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 2.1 in their 
        student book
    • The students ask the problems that may be raised from the provided activity 
        if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attempt to answer the self-assessment questions 2 .1

    The expected answers from Questions of learning activity 2.1
    1. Full Blood Count (FBC).
    2. Treatment plan involved the use of Antibiotic like Amoxicillin 500mg TDS 7/7, 
         Paracemol 500mg tds3/7 and Ibuprofen 400mg TDS 4/7 for pain relief.
    3. Swollen gums indicating gingivitis to dental caries

    The expected answers from Questions of self-assessment 2.1
    1. The signs and symptoms of acute and chronic otitis includes a fever, tinnitus, 
    malaise, severe earache, and hearing loss. Tenderness behind the ear indicates 
    mastoiditis. Redness of the eardrum and bulging. Pressure in the middle ear or 
    dysfunction of inner ear structures can cause nausea, vomiting, and dizziness. If 
    the tympanic membrane perforates, fluid drains into the external acoustic canal 
    and pain is relieved. Infants and children may have one or more of the following 
    symptoms: Crying, irritability, sleeplessness, pulling on the ears, ear pain, a 
    headache, neck pain, a feeling of fullness in the ear, fluid drainage from the ear, 
    a fever, vomiting, diarrhea, irritability, a lack of balance and hearing loss.

    2. The causes and risk factors of otitis media includes being between 6 and 36 
    months old, using a pacifier, attending daycare, being bottle fed instead of 
    breastfed (in infants), drinking while laying down (in infants). Other risk factors 
    are exposure to cigarette smoke, high levels of air pollution, experiencing 
    changes in altitude, experiencing changes in climate, being in a cold climate, 

    having had a recent cold, flu, sinus, or ear infection.

    3. The most complications of acute otitis media include meningitis, brain abscesses, 
         epidural abscesses, mastoiditis, permanent sensorineural hearing loss, and 
         death.
    4. The 5 elements to be monitored during otoscope examination includes redness, 
         swelling, blood, pus, air bubbles, fluid in the middle ear, perforation of the 

         eardrum.

    Lesson 3: Description of CERUMEN PLUG (Ear Wax) (definition, 
    causes, signs and symptoms, pathophysiology, investigation, 

    treatment plan, evolution and complication)

    a) Prerequisites
    This is the Third lesson of the Second unit of medical pathologies of ear in sensory 
    organs. In this lesson, you will be dealing with the description of different causes 
    and risk factors of acute and chronic otitis, pathophysiology, signs and symptoms, 
    investigation, management, evolution and complications. The first thing to do 
    before starting teaching is to remind learners what they have learnt about the 
    anatomy and physiology of the sensory organs (Ear), health assessment of ear 
    from fundamentals of nursing. The students will discuss the questions from the 
    case study from learning activity 2.2 so that they can prepare themselves for this 
    lesson.

    b) Learning objectives:
    After completion of this lesson, the student will be able to:
    • Define the term “Cerumen Plug (Ear wax)”
    • Describe causes, risk factors and pathophysiology of Cerumen Plug (Earwax).
    • Describe the signs and symptoms of Cerumen Plug (Earwax).
    • Enumerate the investigations requested for patient different types of Cerumen 
       Plug (Earwax).
    • Identify the adequate medical diagnosis of Cerumen Plug (Earwax).
    • Develop a treatment plan of Cerumen Plug (Earwax).
    • Explain the evolution and complications of Cerumen Plug (Earwax).

    c) Teaching resources
    The teacher could avail the ear anatomical model and otoscope ensure the students 
    are able to use them. In addition, the teacher should present to the students the 
    library textbooks on medical-surgical nursing especially ear diseases and indicates 
    the pages. All students must have their student’s books. There is need of black 
    board and chalks or flipcharts and markers. Algorithms about assessment and 

    management of conjunctivitis must also be displayed.

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 2.2 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
    knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by confirming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 2.2 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of oral candidiasis conditions
    • Attempt to answer the self-assessment questions 2.2

    The expected answers from Questions of learning activity 2.2
    1. Signs and symptoms that the patient was presenting are a fever, tinnitus, 
    malaise, severe earache hearing loss, tenderness behind the ear, redness of the 
    eardrum and bulging, nausea, vomiting, and dizziness. In infant and children: 
    Crying, irritability, sleeplessness, pulling on the ears, ear pain, a headache, neck 
    pain, a feeling of fullness in the ear, fluid drainage from the ear, a fever, vomiting, 

    diarrheas', irritability, a lack of balance and hearing loss.

    2. The medical problem from those signs and symptoms are Otitis media
    3. The otoscope examination was performed
    4. The clinical management includes sodium bicarbonate eardrops and ear 

          irrigation.

    The expected answers from Questions of self-assessment 2.2

    1. The client with impacted earwax may experience a sense of fullness or pain in the 
    ears, referred to as otalgia, and diminished hearing. The client asks that words 
    be repeated, misinterprets questions, or raises the volume on the television or 
    radio. Visual inspection with an otoscope shows an orange-brown accumulation 
    of cerumen in the distal end of the external acoustic meatus. Audiometric, Rinne, 
    and Weber tests reveal conductive hearing loss. Some symptoms of impacted 
    earwax include Hearing loss, earache, sense of ear fullness, itching in the ear, 
    dizziness, ringing in the ears, cough, tinnitus, which is a ringing in the ear, an 
    ear infection, vertigo, or a sense of being unbalanced that can lead to dizziness 
    and nausea

    2. The causes of cerumen plug are swimming for some people, individuals whose 
    ear canals are narrow or not fully formed people with very hairy ear canals, and 
    people with osteomata or benign bony growths in the outer part of the ear canal. 
    In addition, those with certain skin conditions, such as eczema, older people, 
    because earwax tends to become drier and harder with age, which increases 
    the risk of impaction, people with recurring ear infections and impacted earwax, 
    individuals with lupus or Sjogren’s syndrome. 

    3. The diagnosis of cerumen impaction is made by direct visualization with an 
    otoscope. Common symptoms include hearing loss, feeling of fullness in the ear, 
    itching, otalgia, tinnitus, cough, and, rarely, a sensation of imbalance. Hearing 
    loss from cerumen impaction can cause reversible cognitive impairment in older 
    persons. Some patients are unable to accurately convey symptoms, such as 
    those with dementia or developmental delay; nonverbal patients with behavioral 
    changes; and young children with fever, speech delay, or parental concerns. In 
    these patients, cerumen should be removed when it limits examination

    4. Ear syringing techniques consists of pulling the external ear up and back, and 
    aiming the nozzle of the syringe slightly upwards and backwards so that the 
    water flows as a cascade along the roof of the canal. The irrigation solution flows 
    out of the canal along its floor, taking wax and debris with it. The solution used to 
    irrigate the ear canal is usually warm water, normal saline, sodium bicarbonate 
    solution, or a solution of water and Vinegar to help prevent secondary infection.

    5. The common cerumen softeners include urea hydrogen peroxide (6.5%) and 
    glycerine, a solution of sodium bicarbonate in water, or sodium bicarbonate
    (sodium bicarbonate and glycerine), Cerumol (peanut oil, turpentine and 
    dichlorobenzene), cerumenex (triethanolamine), polypeptides and oleate
    condensate), docusate, an emulsifying agent, an active ingredient found in 

    laxatives, mineral oil.

    6. Some of the complications of earwax includes ear infections if a person does not 
    get treatment. Very rarely, the infection may spread to the base of the skull and 

    cause meningitis or cranial paralysis.

    Lesson 4: Description of deafness, hearing loss, and hearing 

    impairment 

     (Definition, causes and risk factors, Pathophysiology, signs and symptoms, 

    investigation, diagnosis, treatment plan, evolution and complication)

    a) Prerequisites
    This is the fourth lesson of the Second unit about medical pathologies of the ear. 
    In this lesson, you will be dealing with the definition, causes and risk factors, 
    Pathophysiology, signs and symptoms, investigation, diagnosis, treatment plan, 
    evolution and complication of deafness. The first thing to do before starting teaching 
    is to remind learners what they have learnt about the anatomy and physiology of 
    the sensory organs (ear), health assessment of oral cavity from fundamentals of 
    nursing. The students will discuss the questions from the case study from learning 
    activity 2.3 so that they can prepare themselves for this lesson.

    b) Learning objectives: 
    After completion of this lesson, the student will be able to:
    • Define the term “Deafness, hearing loss and Hearing impairment”
    • Describe causes, risk factors and pathophysiology of deafness.
    • Describe the signs and symptoms of deafness.
    • Enumerate the investigations requested for patient with deafness.
    • Identify the adequate medical diagnosis of deafness.
    • Enumerate the investigations requested for patient of deafness
    • Describe the way used for adequate medical diagnosis of deafness.
    • Develop a treatment plan of patient with deafness.
    • Explain the evolution and complications of deafness.

    c) Teaching resources
    The teacher could avail the oral cavity anatomical model and otoscope and ensure 
    the students are able to use them. In addition, the teacher should present to the 
    students the library textbooks on medical-surgical nursing especially deafness and 
    indicates the pages. All students must have their student’s books. There is need 
    of black board and chalks or flipcharts and markers. Algorithms about assessment 

    and management of conjunctivitis must also be displayed.

    d) Learning activities
       Teacher’s activities and methodology
    • Ask learners to do individually activity 2.3 in their student book and answer 
      the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones that are incorrect and try 
       again to complete those which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by confirming the right responses.

      Student’s activities
    • The students answer the questions individually in learning activity 2.3 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
        if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of oral cavity condition

    • Attempt to answer the self-assessment questions 2.3

    The expected answers from Questions of learning activity 2.3
    1. The signs and symptoms presented by the patient were difficulty understanding 
          words, especially against background noise or in a crowd, trouble hearing 
          consonants, He frequently asking others to speak more slowly, clearly and 
          loudly, He needs to turn up the volume of the television or radio while listening 
          to the radio and television’
    2. The medical problem could be deafness, hearing loss, and hearing impairment 
    3. Laboratory, Full blood accounts (FBC); Imageries: Chest x- ray, otoscopic 
         examination and audiometric tests complement each other for the diagnosis 
         of hearing loss. Objective tests measure the hearing loss at some specific 
         frequencies
    4. Hearing aids, Behind-the-ear (BTE) hearing aids, In-the-canal (ITC) hearing 
         aids, completely in the canal (CIC) hearing aids, Bone conduction hearing aids, 
         Cochlear implants.

    ♦ Answers for Self-Assessment 2.3
    1. The causes of loss of hearing in adult are the diseases of outer and middle ear, 
    the presence of wax in the ear canal, the congenital defects in the outer or middle 
    ear. In addition, defect and damage to the outer or middle ear, upper respiratory 
    tract infections, neglect of care of ears and oral cavity (mouth) contribute to the 
    conductive hearing loss. Moreover, the damage or disease of the inner ear or 
    auditory nerve, the infectious diseases like measles, mumps, meningitis and 
    Tuberculosis can cause the sensorineural hearing loss.

    Some conditions that may cause congenital sensorineural hearing loss includes 
    hereditary childhood deafness, Rh incompatibility, premature birth (birth before due 
    time), and birth Asphyxia (lack of oxygen supply to the newborn due to inability to 
    breathe. Other causes of sensorineural hearing loss are Viral infections in pregnancy, 
    exposure to X–rays in the first trimester of pregnancy (taking X–ray within the first 
    three months), harmful drugs of variety e.g. streptomycin, and acoustic neuroma 
    (Tumor of the auditory nerve).

    1. The physician will talk to the patient and ask several questions regarding the 
         symptoms, including when they started, whether or not they have gotten worse, 
         and whether the individual is feeling pain alongside the hearing loss. On physical 
         examination, the doctor will look into the ear using an otoscope

    2. Treatment plan of Hearing Loss includes hearing aids, Behind-the-ear (BTE) 
         hearing aids, In-the-canal (ITC) hearing aids, completely in the canal (CIC) 
         hearing aids, Bone conduction hearing aids, Cochlear implants

    3. The complications for hearing include conversation difficult, some people 
        experience feelings of isolation. Hearing loss is also associated with cognitive 
         impairment and decline, cognitive decline and Alzheimer’s disease, clinical 

         depression, diabetes, falls among the elderly, heart diseases. 

     Lesson 5: Description of ear injury or Trauma (definition causes, 
    pathophysiology, signs and symptoms, investigation, treatment plan, 

    evolution and complication)

    a) Prerequisite
    This is the fifth lesson of the Second unit about medical pathologies of the ear. 
    In this lesson, you will be dealing with the definition, causes and risk factors, 
    Pathophysiology, signs and symptoms, investigation, diagnosis, treatment plan, 
    evolution and complication of ear injury or trauma. The first thing to do before 
    starting teaching is to remind learners what they have learnt about the anatomy 
    and physiology of the sensory organs (ear), health assessment of oral cavity from 
    fundamentals of nursing. The students will discuss the questions from the case 
    study from learning activity 2.4 so that they can prepare themselves for this lesson.

    b) Learning objectives
    After completion of this lesson, the student will be able to:
    • Define the term “EAR INJURY”
    • Describe causes, risk factors and pathophysiology of Ear injury
    • Describe the signs and symptoms of Ear injury.
    • Enumerate the investigations requested for patient with Ear injury.
    • Describe the way used for the adequate medical diagnosis of Ear injury
    • Develop a treatment plan for patient with Ear injury
    • Explain the evolution and complications of Ear injury. 

    c) Teaching resources
    The teacher could avail the oral cavity anatomical model and otoscope and ensure 
    the students are able to use them. In addition, the teacher should present to the 
    students the library textbooks on medical-surgical nursing especially deafness and 
    indicates the pages. All students must have their student’s books. There is need 
    of black board and chalks or flipcharts and markers. Algorithms about assessment 

    and management of conjunctivitis must also be displayed.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course 
    and provide experiences that will enable students to engage in practice and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as: taking notes, course work and reading textbook 
    related to the lesson, group assignment and summarize the content, engagement 

    in debate and other clinical learning activities such as case study.

    Teacher’s activity:
    • Ask learners to do individually activity 2.4 in their student book and answer 
       the questions related.
    • Provide the necessary materials to the students.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those which are incomplete.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by conforming the right responses.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.

    Student’s activities
    • The students answer the questions individually in learning activity 2.4 in their 
        student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of esophagus condition
    • Attempt to answer the self-assessment questions 2.4

    The expected answers from Questions of learning activity 2.4
    1. Ear pain, dizziness, headache, hearing loss, bleeding from the same ear, tinnitus 
         sensation after falling down from motorcycle after road traffic accident
    2. The medical problem for this case suggests ear injury or trauma
    3. Complete Blood Count (CBC) ,Hemoglobin ,An otoscope exam and tympanometry 
        were performed 
    4. A sterile dry wound dressing was applied and Paracetamol 500mg TDS 3/7 as 
        well as cloxacillin 500mg TDS

    The expected answers from Questions of self-assessment 2.4
    1. Accidents, loud noises, changes in air pressure, trauma from contact sports and 
         foreign objects in the ear can cause injuries, causes of ear ruptures also include 
         getting hit in the ear, sustaining an injury during sports, falling on your ear, car 
         accidents 
    2. The signs and symptoms of ear injury includes Ear pain (earache), which can 
          be severe, dizziness and balance problems, headache, hearing loss, pus or 
          bleeding from the ear, tinnitus (buzzing or ringing in the ear).
    3. The investigations that can help the doctor to confirm the diagnosis of ear injury 
         are the fluid sample test, and an otoscope exam to look the ear canal. In addition, 
          an audiology exam allows the doctor to test the hearing range and eardrum 
          capacity. Other investigations include tympanometry to test the eardrum’s 
          response to pressure changes.
    4. Eardrum repair such as myringoplasty, Tympanoplasty

    2.6 Summary of the unit
    Medical pathology is a branch of medical science primarily concerning with the 
    diseases affecting different human organs such as respiratory tract organs, cardio
    vascular organs, digestive organs, urino-genetal organs, sensory organs etc. This 
    unit of medical pathologies of the ear described the most common ear conditions 
    that are frequently observable in Rwanda such as acute and chronic otitis media, 
    Cerumen plug (ear wax), deafness (Hearing loss, hearing impairment), Ear injury or 
    Trauma. This unit describes the ear medical conditions by providing their definition, 
    clinical features, causes and risk factors, pathophysiology, investigation, treatment 
    plan, evolution and complications. The student who will be complete this content 
    will be able to take appropriate decision on different common medical pathologies 
    affecting the ear in terms of diagnosing, treatment and prevent the complication of 

    otitis, Cerumen, deafness and ear trauma. 

         END OF UNIT 2 ASSESSMENT ANSWERS

         Section A: Multiple Choice Questions

           

              Section B: Essay Questions

    1. Answer: The first priority is to kill the insect. This can be accomplished in many 
    ways. Asphyxiation is probably best. The use of lidocaine gel or solution not 
    only will suffocate the bug, but also may help to provide some anesthetic to the 
    ear canal, aiding with later removal. Contact medical control to discuss your 
    options...Once the bug has stopped buzzing/moving your patient will be much 
    more cooperative.

    2. Answer: Hematomas of the outer ear will cause breakdown of the cartilage if 
    they are not treated with an incision and expression of clot, then a pressure 
    dressing. Cartilage breakdown will lead to the ‘cauliflower ear’ often seen in 
    boxers (and would-be boxers).

    3. Answer: As before, lacerations to the cartilage of the ear can lead to severe 
    cosmetic defects unless the cartilage laceration is repaired.

    4. Answer: The purpose of the Eustachian tube is to ventilate the middle ear, to 
    maintain air pressure within the ear and to drain infections. The primary function 
    of the Eustachian tube is to ventilate the middle ear space, ensuring that its 
    pressure remains at near normal ambient air pressure. The secondary function 
    of the Eustachian tube is to drain any accumulated secretions, infection, or debris 
    from the middle ear space. Several small muscles located in the back of the throat 
    and the palate control the opening and closing of the tube. Swallowing and 
    yawning cause contractions of these muscles and help to regulate Eustachian 
    tube function. If it were not for the Eustachian tube, the middle ear cavity would 
    be an isolated air pocket inside the head that would be vulnerable to every 
    change in air pressure, and lead to an unhealthy ear.

    5. Answer: Bottle-feeding. Bottle feeding is a risk factor for otitis media in infants. 
    Breastfeeding passes immunity to the child that helps prevent acute otitis media. 
    The position of the breastfeeding child is better than the bottle feeding position 
    for Eustachian tube function. If a child needs to be bottle-fed, hold the infant 
    instead of allowing the child to lie down with the bottle is best. A child should not 
    take the bottle to bed. In addition to increasing the chance for acute otitis media, 

    falling asleep with milk in the mouth increases the incidence of tooth decay.

    6. Answer: Ear infection symptoms generally include trouble hearing and fever; 
    fluid drainage and dizziness and congestion in the ear. The hallmark of 
    an acute ear infection is sudden, piercing pain in the ear. The pain may be 
    worse when lying down, making it difficult to sleep. Other symptoms include 
    difficulty hearing, fever, fluid drainage from the ears, dizziness, and congestion. 
    Young children with otitis media may be irritable, fussy, or have problems feeding 
    or sleeping. Older children may complain about pain and fullness in the ear 
    (earache). Fever may be present in a child of any age. These symptoms are 
    often associated with signs of upper respiratory infection such as a runny or 
    stuffy nose, or a cough.

    7. Answer: Hearing loss may occur as a result of an ear infection because pus 
    buildup dampens ear drum vibrations. Temporary hearing loss may occur during 
    an ear infection because the buildup of pus within the middle ear causes pain, 

    and dampens the vibrations of the eardrum.

    SECTION C: Questions to answer by True or False
    1. Answer: True. Acute otitis media (ear infection) describes inflammation of the 
    middle ear, or tympanum. During an ear infection, there is fluid in the middle ear 
    accompanied by signs or symptoms of ear infection including a bulging eardrum 
    usually accompanied by pain; or a perforated eardrum, often with drainage of 
    pus (purulent material).

    2. Answer: A: False. An ear infection itself is not contagious. Ear infections are 
    often the result of a previous infection of the throat, mouth, or nose that has 
    relocated and settled in the ears. 

    3. Answer: True. Untreated ear infections can lead to more serious complications, 
    including mastoiditis (a rare inflammation of a bone adjacent to the ear), 
    hearing loss, scarring and/or perforation of the eardrum, meningitis, speech and 
    language development problems, facial nerve paralysis, and possibly -- in adults 
    - Meniere’s disease.

    Note: Meniere’s disease is likely a disorder of the flow of fluids of the inner with 
                 symptoms that include vertigo, tinnitus, and hearing loss

    4. Answer: False. Remember that the common cold is a key cause of ear infections. 
    Because of the highly contagious nature of the common cold, one strategy 
    for prevention of the cold itself and subsequent ear infections is to keep cold 
    viruses at bay. The most effective way to do this is frequent and meticulous hand 
    washing. Other strategies to prevent acute ear infections are to ensure a child 
    is vaccinated. Ensuring that a child receives an annual flu vaccine and is up to 
    date with his/her pneumococcal vaccine are excellent strategies used to prevent 
    the most common causes of ear infections. Other lines of defense against ear 
    infections include avoiding second hand smoke and breastfeeding your baby for 

    the first year of life.

    2.7 Additional Information 

    Common additional information

    Otitis Externa

    Otitis externa is an inflammation of the tissue in the outer ear. Otitis externa means 
    that the inflammation is confined to the external part of the ear canal and does not 

    go further than the eardrum.

    Pathophysiology and etiology
    Inflammation usually is caused by an overgrowth of pathogens. The microorganisms 
    tend to follow trauma to the lining of the ear, or their growth is supported by retained 
    moisture from swimming. Another possibility is that a hair follicle becomes infected, 

    causing a furuncle or an abscess to develop.

    Several factors may predispose patients to the development of acute otitis externa. 
    One of the most common predisposing factors is swimming, especially in fresh 
    water. Other factors include skin conditions such as eczema and seborrhea, trauma 
    from cerumen removal, use of external devices such as hearing aids, and cerumen 
    buildup. These factors appear to work primarily through loss of the protective 
    cerumen barrier, disruption of the epithelium, inoculation with bacteria, and increase 

    in the pH of the ear canal.

        Signs and symptoms
    The tissue in the external ear looks red. Sometimes it is difficult to see the tympanic 
    membrane because of swelling. Clients describe discomfort that increases with 
    manipulation during the examination. Hearing is reduced because of swelling. In 
    severe infections, a fever develops and the lymph nodes behind the ear enlarge. 
    Otoscopic examination reveals diffuse or confined inflammation, swelling, and pus. 

    A culture of drainage identifies the specific pathogen.

    Acute otitis externa presents with the rapid onset of ear canal inflammation, resulting 

    in otalgia, itching, canal edema, canal erythema, and otorrhea, and often occurs 

    following swimming or minor trauma from inappropriate cleaning.

    Treatment Plan
    Treatment includes warm soaks, analgesics, and antibiotic ear medication, often 

    with corticosteroid medication, such as neomycin/polymyxin/hydrocortisone otic 

    solution.
    The nurse instructs the client to carry out the medical treatment and provides health 
    teaching to prevent recurrence. For example, he or she advises swimmers to wear 
    soft plastic ear plugs to prevent trapping water in the ear. If chewing produces or 
    potentiates discomfort, the nurse encourages the client to temporarily eat soft foods 
    or consume nourishing liquids. Above all, the nurse advises the client to avoid the 
    use of non-prescription remedies unless they have been approved by the physician 
    and to contact the physician if symptoms are not relieved in a few days.

    A young woman comes in the clinic complaining of severe pain of her left ear; it 
    hurts to touch it. She says that she swims at least 3 days a week. She is diagnosed 
    with otitis externa. The nurse practitioner prescribes analgesics and application of 
    heat to the affected ear and also tells the client to avoid swimming for 2 weeks. 
    Because this client swims regularly for exercise, what further instructions can the 
    nurse provide to prevent future problems?

    What actions would the nurse perform while administering ear drops to remove 
    excessive cerumen? Select all that apply.
           a. Avoid inserting the irrigating syringe too deeply.
           b. Boil the solution once.
           c. Direct the flow of the ear drops toward the eardrum.
           d. Direct the flow of the ear drops toward the roof of the canal.
           e. Shake the ear drops container vigorously.
            f. Warm the ear drops by holding the container in the hand for a few minutes.

    A client arrives at the emergency department after an insect has entered the ear. 
    Which of the following solutions would the nurse instill into the client’s ear to smother 
    the insect?
         a. Carbamide peroxide
         b. Hot water
         c. Mineral oil
         d. Triethanolamine
    Which is the best evidence that the antibiotic the nurse is administering for the 
    treatment of acute otitis media is having a therapeutic effect?
           a. Ear discomfort is relieved.
           b. Ear drainage is thin and watery.

           c. Ringing sounds within the ear stop.

    d. The ear feels less warm to the touch.

        Cerumen-Softening Agents for Cerumen Removal

         

          

       

             

        

              

                 

    on the lowest settings and head tilting to remove water from the ear canal, and 
    avoidance of self-cleaning or scratching the ear canal. Acetic acid 2% (Vosol) otic 
    solutions are also used, either two drops twice daily or two to five drops after water 
    exposure. 
    6. What is ototoxicity and enumerate the factors that are related to it?

    Answer: 
    Ototoxicity describes the detrimental effect of certain medications on the eighth 
    cranial nerve or hearing structures. Signs and symptoms of ototoxicity include tinnitus 
    and sensorineural hearing loss. Vestibular toxicity includes signs and symptoms of 
    light-headedness, vertigo, nausea, and vomiting. Drugs associated with ototoxicity 
    include salicylates, loop diuretics, quinidine, quinine, and aminoglycosides.
    7. Which is the most ototoxicity among the following antimalarial 
    drugs?
         a. Coartem
         b. Artesunate
         c. Quinine
         d. Chroloquine

    Answer: c
    8. Changes in the ear that occur with aging may include:
           a. atrophy of the tympanic membrane.
           b. increased hardness of the cerumen.
           c. degeneration of cells at the base of the cochlea.
          d. all of the above

    Answer: d
    9. The most common fungus associated with ear infections is:
          a. Staphylococcus albus.
          b. Staphylococcus aureus.
          c. Aspergillus.

          d. Pseudomonas

    Answer:c
    10. Nursing instructions for a patient suffering from external otitis 
               should include the:
               a. application of heat to the auricle.
               b. avoidance of swimming.
               c. ingestion of over-the-counter analgesics, such as aspirin.
               d. all of the above.

    Answer: d
    11. A tympanoplasty, the most common procedure for chronic otitis 
             media, is surgically performed to:
             a. close a perforation.
             b. prevent recurrent infection.
             c. reestablish middle ear function.
             d. accomplish all of the above

    Answer: d
    12. A symptom that is not usually found with acute otitis media is:
           a. aural tenderness.
           b. rhinitis.
           c. otalgia.
           d. otorrhea
    Answer:a
    13. An incident of otitis media is usually associated with:
           a. ear canal swelling.
           b. discharge.
           c. intense ear pain.

           d. prominent localized tenderness.

    Answer:c
    14. A myringotomy is performed primarily to:
            a. drain purulent fluid.
            b. identify the infecting organism.
            c. relieve tympanic membrane pressure.
            d. accomplish all of the above
    Answer:d
    15. Postoperative nursing assessment for a patient who has had a 
    mastoidectomy should include observing
    for facial paralysis, which might indicate damage to which cranial nerve?
            a. First
            b. Fourth
            c. Seventh
            d. Tenth
    Answer:c
    16. A facial nerve neuroma is a tumor on which cranial nerve?
           a. Third
           b. Fifth
           c. Seventh
           d. Eighth
    Answer:c
    3.1 Key unit competence
    Demonstrate understanding of the appropriate management of different common 
    Medical Pathologies of the Nose
    3.2 Prerequisite (Knowledge, skills, attitude and values)
    To achieve the above competence the associate nurse student needs to have learnt 
    the following subjects:
    • Human body anatomy and physiology: Sensory organs mainly Nose and 
       Throat 
    • Fundamental of Nursing: Vital signs and parameters measurements and 
        interpretation, Drugs administration (PO, inhalations, spray and injectable), 
        History taking, Complete health assessment from head to toes through 
         interview and Physical assessment regarding nose and throat.
    • Ethics and professional code of conduct: Respect of principles of ethics 
       during management of a patient with all medical diseases. The Associate 
       Nurse student should demonstrate good behaviors while interacting with the 
        patient.
    • Pharmacology: drugs acting on sensory system (NSAIDs, cortico-steroids, 
       anti-histamines drugs, antibiotics, etc.) with their posology and their mode of 
        administration.

    3.3. Cross-cutting issues to be addressed
             Standardization culture
    All health care facilities must use same standard and accurate equipment and 
    techniques in the management of the medical conditions. During the field trips, the 
    teacher should ensure the availability of standard medical equipment and technics 
    before selecting the health care facility to use. The learners have to learn the use 
    of those standards equipment and technics in the management of patients with 
    sensory diseases.

    3.3.1. Inclusive education
    All students should participate in all activities without discrimination of a student 
    with any disability. This may be challenging to students with special educational 
    needs especially those with disabilities, slow learners, those with low self-esteem, 
    etc. However, the teacher can make some arrangements like:

    • Grouping students: Students with special educational needs are grouped 
    with others and assigned the roles basing on individual student’s abilities.
    Providing procedure/checklists or protocols earlier before the practical work 
    so that students get familiar with them. They can be written on the chalkboard 
    or printed depending on available resources. If you have, students with low 
    vision remember to print in appropriate fonts. In addition, you are supposed 
    to pay attention to all categories of learners.
    • Every important point is written and spoken. The written points help students 
       with hearing impairment and speaking aloud helps students with visual 
        impairment.

    • Remember to repeat the main points of the lessons.

    3.3.2. Gender education
    Emphasize to learners that anybody irrespective of their gender can be a health 
    care professional. The teacher must present some role models of people who have 
    been successful in medical and nursing professions in the area where the learners 
    come from. Make sure that during practical work both boys and girls shares and 
    participate equally in practices, arranging and proper hygiene after procedures.

    3.4 Guidance on the introductory activity
    During the introductory activity 3.0, learners will observe all images illustrated and 
    the abnormal features from those images, and will remember the anatomy and 
    physiology of sensory system mainly nose and throat learnt in the unit of biology 
    and parts of sensory assessment learnt in unit of fundamentals of nursing. From all 
    these prerequisites, learners will be requested to observe the picture illustrated and 
    be able to list all abnormal features they see and list all medical conditions that can 
    lead to those abnormal features mentioned. 

    Teacher’s activity
    • Using brainstorming: Every learner is given opportunity to observe the image 
       and answer the questions related to the image illustrated.
    • Teacher writes on whiteboard the correct answers from the learners.

    The expected answers to introductory activity 3.0

    1) The observations about what the persons illustrated are 

  • UNIT 3: MEDICAL PATHOLOGIES OF THE NOSE

      complaining:
    Images 1, 2 and 4: the persons might be sneezing, blowing the nose, pressing due 
    to pain, etc. 
    Image 3: the person is having nose bleeding
    Images 5 and 6: the persons might be having wounds at the noses

    2) The medical conditions that might be having above mentioned 
    as clinical presentations: flu like syndrome, rhinitis, sinusitis, 
    tonsillitis, epistaxis, nose-bleeding, nasal injury, pharyngitis, 

    laryngitis, etc.

                   3.5 List of lessons/sub-heading (including assessment)

      

         

        

              Lesson 1: Description of Nose diseases (Introductory 
                activity 3.0) in general and Description of Rhinitis 

               (learning activity 3.1)

           a) Prerequisites
    This is the first lesson of the third unit on medical pathologies of sensory system 
    mainly the Nose and Throat. In this lesson, you will be dealing with the common 
    medical pathologies of the Nose and Throat. The learner will be able to revise the 
    anatomy and physiology of sensory system mainly the nose and throat.

    The first thing to do before starting teaching is to remind learners what they have 
    learnt about structure and function of nose in biology, health assessment of sensory 
    system focusing on ear, nose and throat from fundamentals of nursing and let them 
    discuss the questions as indicated in introductory activity 3.0. after brainstorming 
    in answering the questions relate to introductory activity 3.0, learners will be given 
    time to be into groups and read he case from the case study from learning activity 
    3.1 and provide answers. All these will be preparing the learners themselves for 
    this lesson.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • List all signs and symptoms that the patients on the images were presenting 
       that are common in the common nose diseases
    • List all Medical conditions that lead to all signs and symptoms listed
    • Demonstrate the knowledge about rhinitis and demonstrate competencies in 
       taking appropriate decisions in management of patients with rhinitis.

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve 
    learning objectives. The teaching materials are white board, flip chart, marker, 
    computer, screen, handout, textbook, videos. In addition, the teacher will avail 
    the didactic materials (all materials for physical examination focusing on sensory 
    system assessment mainly Nose and Throat, etc.). The teaching methods are 
    lecture, brainstorming, course work, and small group discussion. In addition, the 
    teacher guides the learners where they can find the supporting resources such 
    computer lab, Nursing skills lab, and Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course, 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as taking notes, course work, and read textbook 
    related to the lesson, group assignment, listening to the video and summarize the 
    content, engagement in debate and other clinical learning activities such as case 
    study.

    Teacher’s activity
    • Ask learners to brainstorm while answering the questions related to the image 
       in the introductory activity 3.0.
    • Supervise the work where the learners are grouped in small group and 
       teacher facilitates them to answer the questions by using the case study in 
       learning activity 3.1.
    • Ask learners to present what they have done in group
    • Identify the correct answers and complete those ones that are incomplete.
    • Correct the answers that are false.
    • Note on the blackboard the main student’s ideas.
    • Help learners to summarize what they have learnt and make conclusion.

    Student activity:
    • Brainstorm in answering the questions regarding the introductory activity 3.0.
    • Form group and participate in the group work
    • To read carefully the case study from learning activity 3.1 and answer the 
       questions
    • Group representatives will present their work
    • Other students will follow when group representatives will be presenting
    • Take notes from the correct answers

    • Make conclusion from what they have learnt. 

     

         Lesson 2: Description of nose related diseases 

         (Sinusitis)

    a) Prerequisites
    This is the second lesson of the third unit on medical pathologies of sensory system. 
    In this lesson, you will be dealing with two medical conditions (Sinusitis) specifically 
    their definitions, causes and risk factors and pathophysiology, signs and symptoms 
    of sinusitis, investigations to be requested, plan of management and the possible 
    complications. The learner will be able to revise the anatomy and physiology of the 
    nose and throat. The first thing to do before starting teaching is to remind learners 
    what they have learnt about structure and function of nose and throat in biology, 
    health assessment of sensory system with focus on nose and throat. In addition, the 
    teacher will let students discuss the questions from the case studies from learning 
    activity 3.2 so that they can prepare themselves for this lesson.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Demonstrate the knowledge about sinusitis and demonstrate competencies 
    in taking appropriate decisions in management of patients with sinusitis.
    • Demonstrate the knowledge about tonsillitis and demonstrate competencies 
    in taking appropriate decisions in management of patients with tonsillitis.
    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve 
    learning objectives. The teaching materials are white board, flip chart, marker, 
    computer, screen, hand out, textbook, and videos. In addition, the teacher will 
    avail the didactic materials such as materials for physical examination focusing on 
    sensory system assessment mainly Nose and Throat, etc. The teaching methods 
    are lecture, brainstorming, course work, and small group discussion. In addition, 
    the teacher guides the learners where they can find the supporting resources such 
    computer lab, Nursing skills lab, and Library.
    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course, 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as taking notes, course work, and read textbook 
    related to the lesson, group assignment, listening to the video and summarize the 
    content, engagement in debate and other clinical learning activities such as case 
    study.

    Teacher’s activity
    • Ask learners to be into different small groups and ask them to read the case 
       studies and answer the questions from learning activities 3.2 
    • Supervise the work where the learners are grouped in small group and 
       teacher facilitates them to answer the questions by using the case studies in 
        learning activities 3.2 
    • Ask learners to present what they have done in groups
    • Identify the correct answers and complete those ones that are incomplete.
    • Correct the answers that are false.
    • Note on the blackboard the main student’s ideas.
    • Help learners to summarize what they have learnt and make conclusion.

    Student activity:
    • Form small groups and participate in the group work
    • To read carefully the case study from learning activity 3.2 and answer the 
    questions related to the case.
    • Group representatives will present their work
    • Other students will follow when group representatives will be presenting
    • Take notes from the correct answers

    • Make conclusion and summary from what they have learnt.

       

          Lesson 3: Description of nose related diseases 

           (Epistaxis, Nose-bleeding and Nasal Injury)

      a) Prerequisites
    This is the third lesson of the third unit on medical pathologies of sensory system. 
    In this lesson, you will be dealing with the medical conditions of the nose (Epistaxis, 
    Nose-bleeding and Nasal Injury) specifically their definitions, causes and risk factors 
    and pathophysiology, signs and symptoms of each one among those diseases, 
    investigations to be requested, plan of management and the possible complications. 
    The learner will be able to revise the anatomy and physiology of the nose. The 
    first thing to do before starting teaching is to remind learners what they have learnt 
    about structure and function of nose in biology, and health assessment of sensory 
    system with focus on nose from fundamentals of nursing. In addition, the teacher 
    will let students discuss the questions from the case studies from learning activity 
    3.3 and 3.4 so that they can prepare themselves for this lesson.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Demonstrate the knowledge about epistaxis and nose bleeding, and 
    demonstrate competencies in taking appropriate decisions in management of 
     patients with epistaxis and nose bleeding.
    • Demonstrate the knowledge about nasal injury and demonstrate competencies 
       in taking appropriate decisions in management of patients with nasal injury.

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve 
    learning objectives. The teaching materials are white board, flip chart, marker, 
    computer, screen, hand out, textbook, and videos .In addition, the teacher will 
    avail the didactic materials such as materials for physical examination focusing on 
    sensory system assessment mainly Nose, etc. The teaching methods are lecture, 
    brainstorming, course work, and small group discussion. Moreover, the teacher 
    guides the learners where they can find the supporting resources such computer 

    lab, Nursing skills lab, and Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course, 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as taking notes, course work, and read textbook 
    related to the lesson, group assignment, listening to the video and summarize the 
    content, engagement in debate and other clinical learning activities such as case 

    study.

    Teacher’s activity
    • Ask learners to be into different small groups and ask them to read the case 
      studies and answer the questions from learning activities 3.3 and 3.4
    • Supervise the work where the learners are grouped in small group and 
       teacher facilitates them to answer the questions by using the case studies in 

       learning activities 3.3 and 3.4

    • Ask learners to present what they have done in groups
    • Identify the correct answers and complete those ones that are incomplete.
    • Correct the answers that are false.
    • Note on the blackboard the main student’s ideas.
    • Help learners to summarize what they have learnt and make conclusion.

    Student activity:
    • Form small groups and participate in the group work
    • To read carefully the case studies from learning activities 3.3 and 3.4 and 
        answer the questions related to those cases
    • Group representatives will present their work
    • Other students will follow when group representatives will be presenting
    • Take notes from the correct answers
    • Make conclusion and summary from what they have learnt. 

    ♦ Answers of learning activity 3.3
    1. The abnormal signs and symptoms that patient was presenting: 
         Patient had history of sinus infection that he has been using antihistamine nasal 
         spray and developed the continuous ooze of blood from the right nostril.
    2. The medical problem of this patient: Epistaxis or nose bleeding.
    3. The investigations that have been ordered are: A full blood count that revealed 
         the hemoglobin level of 9 g/dl and the blood group type was done and revealed 
         type B, Rh+.
    4. The management plan included to put the patient in a quiet area, advised to 
          apply the pressure by pinching the anterior aspect of the nose.
    5. If the epistaxis is not treated, it leads to many consequences:
        If epistaxis has severe form, the complications might be hemorrhagic shock, septic 
        shock, pneumocephalus, sinusitis, septal pressure necrosis, neurogenic syncope 
        during packing, epiphora (from blockage of the lacrimal duct), hypoxia (from 
        impaired nasal air movement), aspiration, hypovolemia in heavy bleeding, cerebral 

        abscess. 

        

         

             Lesson 4: Description of nose and throat related 

            diseases (Pharyngitis, and Tonsillitis)

            a) Prerequisites
    This is the fourth lesson of the third unit on medical pathologies of sensory system. 
    In this lesson, you will be dealing with the medical conditions of the nose and throat 
    (Pharyngitis/Tonsillitis and Laryngitis) specifically their definitions, causes and 
    risk factors and pathophysiology, signs and symptoms of each one among those 
    diseases, investigations to be requested, plan of management and the possible 
    complications. The learner will be able to revise the anatomy and physiology of 
    the nose and throat. The first thing to do before starting teaching is to remind 
    learners what they have learnt about structure and function of nose and throat in 
    biology, and health assessment of sensory system with focus on nose and throat 
    from fundamentals of nursing. The teacher will let students discuss the questions 
    from the case studies from learning activity 3.5 and 3.6 so that they can prepare 
    themselves for this lesson.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Demonstrate the knowledge about pharyngitis, and demonstrate competencies 
       in taking appropriate decisions in management of patients with pharyngitis
    • Demonstrate the knowledge about laryngitis and demonstrate competencies 
       in taking appropriate decisions in management of patients with Tonsillitis.

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. These teaching aids are white board, flip chart, marker, computer, screen, 
    hand out, textbook, and videos. The teacher will avail the didactic materials such as 
    materials for physical examination focusing on sensory system assessment mainly 
    nose and throat, etc. The teaching methods are lecture, brainstorming, course 
    work, and small group discussion. In addition the teacher guides the learners where 
    they can find the supporting resources such computer lab, Nursing skills lab, and 

    Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course, 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as taking notes, course work, and read textbook 
    related to the lesson, group assignment, listening to the video and summarize the 
    content, engagement in debate and other clinical learning activities such as case 
    study.

    Teacher’s activity
    • Ask learners to be into different small groups and ask them to read the case 
       studies and answer the questions from learning activities 3.5 and 3.6
    • Supervise the work where the learners are grouped in small group and 
       teacher facilitates them to answer the questions by using the case studies in 
       learning activities 3.5 and 3.6
    • Ask learners to present what they have done in groups
    • Identify the correct answers and complete those ones that are incomplete.
    • Correct the answers that are false.
    • Note on the blackboard the main student’s ideas.
    • Help learners to summarize what they have learnt and make conclusion.

    Student activity:
    • Form small groups and participate in the group work
    • To read carefully the case studies from learning activities 3.5 and 3.6 and 
       answer the questions related to those cases
    • Group representatives will present their work
    • Other students will follow when group representatives will be presenting
    • Take notes from the correct answers
    • Make conclusion and summary from what they have learnt. 

    ♦ Answers of learning activity 3.5
    1. The abnormal signs and symptoms that the patient was presenting are sore 
    throat and cough. She has had some hoarseness in her voice over the past 
    few days and subjective sweats but no documented fever. She has a history of 
    seasonal allergies. She complains of isolated throat pain, without any rhinorrhea, 
    sinus pressure, or headache. She had severe unilateral sore throat, bulging of 
    pharyngeal wall, neck pain, swelling, and dysphagia with pharyngeal wall that 
    had whitish plaques.

    2. The medical diagnosis the child was presenting is Pharyngitis.
    3. The investigations requested to diagnose the medical condition are Full blood 
      count (FBC), erythrocytes sedimentation rate (VS), throat swab for culture. 
    4. The treatment plan of that patient include health education about home remedies 
       (drink plenty of fluids and rest), ibuprofen for fever management, and was given 
       appointment to come back when the results of culture might be available.
    5. The complications that might result from untreated and poorly managed 
          pharyngitis:

    Severe infections of the pharynx and surrounding soft tissue can be life-threatening. 
    Upper airway obstruction can result from severe pharyngeal inflammation. Bacterial 
    invasion of the deep tissue of the neck can lead to infection and/or abscess 
    formation in the peritonsillar, submandibular, parapharyngeal, or retropharyngeal 
    space suppurative thrombophlebitis (Lemierre syndrome) can arise from bacterial 
    invasion and clot formation of the jugular vein.

    GAS (group A streptococcus) infection can lead to suppurative and nonsuppurative 
    complications. Suppurative complications of GAS pharyngitis are due to invasion 
    of the organism beyond the pharynx and include otitis media, peritonsillar cellulitis 
    or abscess, sinusitis, meningitis, bacteremia, and necrotizing fasciitis. Non
    suppurative complications of GAS pharyngitis are immune mediated and include 

    acute rheumatic fever, post-streptococcal glomerulonephritis, and reactive arthritis.

    ♦ Answers of learning activity 3.6
    1. The abnormal signs and symptoms that patient was presenting are throat is 
        so sore that she has difficulty swallowing even liquids. Patient also has acutely 
        swollen and reddened area of the soft palate is noted in her mouth, half occluding 
       the orifice from the mouth into the pharynx. Yellow exudate is present.
    2. The medical problem of this patient is Tonsillitis.
    3. The investigations that have been ordered include full blood count that revealed 
         elevated white blood cells.
    4. The management plan included Amoxicillin 500mg TDS for 7 days, paracetamol 
        500mg TDS for 3 days, and ibuprofen 400mg TDS. The patient was also advised 
        to drink warm or very cold fluids to help with throat pain and gargle with warm 
         alt water.
    5. If not well treated, the consequences might be:
    Complications usually happen only if bacteria caused the infection. These 
    complications include:
    • A collection of pus around the tonsil (peritonsillar abcess) 
    • Middle ear infection
    • Breathing problems or breathing that stops and starts while sleeping 
      (obstructive sleep apnea)
    • Tonsillar cellulitis, or infection that spreads and deeply penetrates nearby 
       tissues
    If the patient has streptococcus bacteria and does not get treatment, the illness 
    could lead to a more serious problem, including rheumatic fever, scarlet fever, 
    sinusitis, kidney infection called glomerulonephritis.

    Lesson 5: Description of nose and throat related diseases (Laryngitis)

    a) Prerequisites
    This is the fifth lesson of the third unit on medical pathologies of sensory system. In 
    this lesson, you will be dealing with the medical condition of the throat (Laryngitis) 
    specifically its definition, causes and risk factors and pathophysiology, signs and 
    symptoms, investigations to be requested, plan of management and the possible 
    complications. The learner will be able to revise the anatomy and physiology of the 
    throat. The first thing to do before starting teaching is to remind learners what they 
    have learnt about structure and function of nose and throat in biology, and health 
    assessment of sensory system with focus on nose and throat from fundamentals of 
    nursing. The teacher will let students discuss the questions from the case studies 
    from learning activity 3.7 so that they can prepare themselves for this lesson.

    b) Learning objectives
    On completion of this lesson, the learner will be able to:
    • Demonstrate the knowledge about Laryngitis, and demonstrate competencies 
       in taking appropriate decisions in management of patients with laryngitis.

    c) Teaching resources
    This lesson will be taught with different aids and methods in order to achieve learning 
    objectives. These teaching aids are white board, flip chart, marker, computer, 
    screen, hand out, textbook, and videos. The teacher will avail the didactic materials 
    such as materials for physical examination focusing on sensory system assessment 
    mainly throat, etc. The teaching methods are lecture, brainstorming, course work, 
    and small group discussion. In addition the teacher guides the learners where they 
    can find the supporting resources such computer lab, Nursing skills lab, and Library.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course, 
    and provide experiences that will enable students to engage in practice, and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as taking notes, course work, and read textbook 
    related to the lesson, group assignment, listening to the video and summarize the 
    content, engagement in debate and other clinical learning activities such as case 

    study.

     Teacher’s activity
    • Ask learners to be into different small groups and ask them to read the case 
       studies and answer the questions from learning activities 3.7
    • Supervise the work where the learners are grouped in small group and 
       teacher facilitates them to answer the questions by using the case study in 

       learning activity 3.7 

    • Ask learners to present what they have done in groups
    • Identify the correct answers and complete those ones that are incomplete.
    • Correct the answers that are false.
    • Note on the blackboard the main student’s ideas.

    • Help learners to summarize what they have learnt and make conclusion.

       Student activity:
    • Form small groups and participate in the group work
    • To read carefully the case studies from learning activities 3.5 and 3.6 and 
      answer the questions related to those cases
    • Group representatives will present their work
    • Other students will follow when group representatives will be presenting
    • Take notes from the correct answers

    • Make conclusion and summary from what they have learnt. 

    ♦ Answers of learning activity 3.7
    1. The abnormal signs and symptoms that the patient was presenting are acute 
        episode of hoarseness progressing to aphonia, which she had experienced 3 
        days before her appointment. She also reported a sore throat, odynophagia, and 

        cough for 5 days.

    2. The medical diagnosis of this patient is acute laryngitis.
    3. The possible causes and risk factors of laryngitis:
    Most cases of laryngitis are temporary and improve after the underlying cause gets 
    better. Causes of acute laryngitis include viral infections similar to those that cause 
    a cold, vocal strain caused by yelling or overusing the voice, bacterial infections, 
    although these are less common.

    Laryngitis that lasts longer than three weeks is known as chronic laryngitis. This 
    type of laryngitis is generally caused by exposure to irritants over time. Chronic 
    laryngitis can cause vocal cord strain and injuries or growths on the vocal cords 
    (polyps or nodules). The other causes include inhaled irritants such as chemical 
    fumes, allergens or smoke; acid reflux also called gastroesophageal reflux disease 
    (GERD); chronic sinusitis; excessive alcohol use; habitual overuse of the voice 
    (such as in singers or cheerleaders); smoking

    Less common causes of chronic laryngitis include bacterial or fungal infections, 
    Infections with certain parasites.

    Other causes of chronic hoarseness include cancer, vocal cord paralysis, which 
    can result from nerve injury due to surgery, injury to the chest or neck, cancer, nerve 
    disorders, or other health conditions, bowing of the vocal cords.
    Other risk factors for laryngitis include having a respiratory infection, such as a cold, 
    bronchitis or sinusitis, exposure to irritating substances, such as cigarette smoke, 
    excessive alcohol intake, stomach acid or workplace chemicals, overusing your 
    voice, by speaking too much, speaking too loudly, shouting or singing.

    1) The treatment plan of this patient included:
    She had been taking a cough suppressant (Dextromethorphan15mg 2x/day/5days), 
    antihistamine (azatadinex3/day/3days), decongestant (Sudafed take 1 tablet every 
    4 hours), and acetaminophen (Paracetamol 500mg tds/4days) to relieve her 
    symptoms, and she was advised the oral hydration. She was also treated with 
    amoxicillin-clavulanate 500mg tds/day for 10 days and a methylprednisolone 1 
    tablet per day in 7days.

    2) The possible complications of laryngitis:
    Acute laryngitis: complications are rare, as the disease is usually self-limiting. 
    Damage to the vocal cords is possible in patients who try to overcompensate for 
    the dysphonia.
    Chronic laryngitis: the main complications are voice loss, obstruction of the airways 
     and chronic cough. Laryngeal stenosis may develop occasionally. Rarely, in severe 
    infections such as those with herpes viruses, laryngeal erosion and necrosis may 
    occur.
    In some cases of laryngitis caused by infection, the infection may spread to other 

    parts of the respiratory tract.

        

           4. The treatment plan of allergic rhinitis focuses on trigger avoidance (exposure to

    tobacco smoke can be reduced if household members stop smoking or smoke 
    only outside of the home. It is also important to avoid smoke exposure in the 
    workplace. Exposure to pollutants and irritants can be reduced by avoiding 
    wood-burning stoves and fireplaces; properly venting other stoves and heaters; 
    and avoiding cleaning agents and household sprays that trigger symptoms. 
    Exposure to strong perfumes and scented products may be more difficult), 
    medications (daily use of a nasal glucocorticoid (steroid) and/or an antihistamine 
    nasal spray can be helpful for people with allergic rhinitis. 

    These medications may be used alone or in combination), and/or nasal rinsing or 
    irrigation (simply rinsing the nose with a salt water (saline) solution one or more 
    times per day is helpful for many patients with rhinitis, as well as for other rhinitis 
    conditions. Nasal rinsing is particularly useful for symptoms of postnasal drainage. 
    Nasal rinsing can be done before use of nasal medication so that the lining is freshly 
    cleansed when the medication is applied). All these include respect of remedies, 
    use of antihistamines (loratidine, cetirizine, etc), use of decongenstants (cetirizine, 
    oxymetazoline, etc), use of corticosteroids, eye drops and/or nasal sprays, and 
    Immunotherapy if the patient has severe allergies.

    If the rhinitis is not treated well, the possible medical complications are inability to 
    sleep from symptoms keeping sleepless during night; development or worsening of 
    asthma symptoms frequent ear and nasal infection, absences from school or work 
    because of reduced productivity, frequent headaches. Other complications can 
    also arise from antihistamine side effects like drowsiness (feeling of being sleepy 
    and lethargic), headache, anxiety, and insomnia. In rare cases, antihistamines can 

    cause gastrointestinal, urinary, and circulatory effects.

         

          

         

             

    Direct visualization with a good directed light source, a nasal speculum, and nasal 
    suction should be sufficient in most patients. However, computed tomography (CT) 
    scanning, magnetic resonance imaging (MRI), or both may be indicated to evaluate 
    the surgical anatomy and to determine the presence and extent of rhinosinusitis, 
    foreign bodies, and neoplasms. Nasopharyngoscopy may also be performed if a 
    tumor is the suspected cause of bleeding. Sinus films are rarely indicated for a 
    nosebleed.
    The diagnosis of posterior epistaxis is diagnosed by focusing on:
        • Complete Blood Count (CBC), which is a blood test to check for blood 
             disorders.
        • Partial Thromboplastin Time (PTT) or INR, which is a blood test that checks 
               how long it takes for the blood to clot.
        • Nasal endoscopy.
        • CT scan of the nose.

        • X-ray of the face and nose.

    4. The management plan of epistaxis include the following elements:
    The first treatment is direct pressure. Grasp the nose firmly between the thumb 
    and forefinger and squeeze it for 10 to 30 minutes without stopping. Putting an ice 
    pack on the neck or bridge of the nose may help slow blood flow. Leaning forward 
    to spit out blood instead of letting it run down the throat and be swallowed may help 
    prevent vomiting. Using salt water nasal sprays and humidifying the air may help 
    dryness.

    Most anterior nosebleeds can be stopped by applying direct pressure, which helps 
    by promoting blood clots. Those who suffer a nosebleed should first attempt to blow 
    out any blood clots and then apply pressure for at least five minutes and up to 20 
    minutes. Pressure should be firm and tilting the head forward helps decrease the 
    chance of nausea and airway obstruction as seen in the picture on the right. When 
    attempting to stop a nosebleed at home, the head should not be tilted back. 
    Patient will be advised to breathe through the mouth, use a tissue or damp washcloth 
    to catch the blood, use the thumb and index finger to pinch together the soft part of 
    the nose. Make sure to pinch the soft part of the nose against the hard bony ridge 
    that forms the bridge of the nose. Squeezing at or above the bony part of the nose 
    will not put pressure where it can help stop the bleeding.

    B. Nasal packing: if pressure and chemical cauterization cannot stop bleeding, nasal 
    packing is the mainstay of treatment. There are several forms of nasal packing 
    that can be contrasted by anterior nasal packing and posterior nasal packing. 
    Traditionally, nasal packing was accomplished by packing gauze into the nose, 
    thereby placing pressure on the vessels in the nose and stopping the bleeding. 
    Traditional gauze packing has been replaced with products such as Merocel and 
    the Rapid Rhino. The Merocel nasal tampon is similar to gauze packing except it is 
    a synthetic foam polymer (made of polyvinyl alcohol and expands in the nose after 
    application of water) that provides a less hospitable medium for bacteria. The Rapid 
    Rhino stops nosebleeds using a balloon catheter, made of carboxymethylcellulose, 
    which has a cuff that is inflated by air to stop bleeding through extra pressure in the 
    nasal cavity.

    C. Medications: use of tranexamic acid: helps promote blood clotting. For nosebleeds 

    it can be applied to the site of bleeding, taken by mouth, or injected into a vein. 

    Vasoconstrictive medications such as oxymetazoline (Afrin) or phenylephrine 
    are widely available for treatment of allergic rhinitis and may also be used to 
    control benign cases of epistaxis. Those with nosebleeds that last longer than 20 
    minutes (in the setting of direct pressure as seen in the image to the right) should 
    seek medical attention. Oral and topical antibiotics to prevent rhinosinusitis and 
    possibly toxic shock syndrome. Avoidance of aspirin and other nonsteroidal anti
    inflammatory drugs (NSAIDs). Medications to control underlying medical problems 
    (e.g., hypertension, vitamin K deficiency) in consultation with other specialists.

    D. Cauterization: this method involves applying a chemical such as silver nitrate to 
    the nasal mucosa, which burns and seals off the bleeding.

    E. Surgery: ongoing bleeding despite good nasal packing is a surgical emergency 
    and can be treated by endoscopic evaluation of the nasal cavity under general 
    anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood 
    vessels supplying the nose. The bleeding can also be stopped by intra-arterial 
    embolization using a catheter placed in the groin and threaded up the aorta to the 
    bleeding vessel by an interventional radiologist. 

    There is no difference in outcomes between embolization and ligation as treatment 
    options, but embolization is considerably more expensive. All these other 
    alternatives are also considered: foreign body removal should be considered if the 
    foreign body is the cause of the nose bleed, surgical repair of a broken nose or 
    correction of a deviated septum if this is the cause of the nosebleed, and ligation (in 
    this procedure, the culprit blood vessel is tied off to stop the bleeding).

    5. If epistaxis is not well managed treated, it will lead to some severe forms of the 
    complications like hemorrhagic shock, septic shock, pneumocephalus, sinusitis, 
    septal pressure necrosis, neurogenic syncope during packing, epiphora (from 
    blockage of the lacrimal duct), hypoxia (from impaired nasal air movement), 

    aspiration, hypovolemia from heavy bleeds, cerebral abscess.

         

            

    Nasal obstruction: Nasal blockage usually occurs after the injury due to swelling 
    inside the nose and this may take a few days to settle. If the nose is still blocked 
    after three weeks, it may be due to the septum being deviated and buckled which 
    blocks the nasal passage. Septal deviation may require surgical correction if the 

    blockage is significant.

    Nosebleeds (epistaxis): Nosebleeds are common and usually settle on their own 
    with simple first aid by gently pinching the lower half of the nose for 15 minutes. 
    Nasal packing or cautery in hospital is reserved for nosebleeds that do not stop of 
    their own accord.

    Cerebrospinal fluid leak: severe nasal trauma can push the nasal bones into the 
    face, giving the face a pug-like appearance. The thin cribriform plate at the roof 
    of the nose may fracture causing the cerebrospinal fluid that bathes the brain to 
    leak out. Small fractures seal spontaneously with conservative management (95% 
    within two weeks). Antibiotics are not given unless infection is proven to be present. 
    If fluid leak continues, more treatment may be required.

    Loss of sense of smell (anosmia): the smell organ in the roof of the nose can also 

    be damaged.

         

    The clinical syndrome of diphtheria is characterized by pharyngitis, low-grade fever, 
    malaise, and cervical lymphadenopathy. Symptom onset is usually gradual. The 
    hallmark of diphtheria, the formation of a tightly adherent gray membrane that bleeds 
    when dislodged, occurs in at least one-third of patients. Although diphtheria is rare, 
    suspicion should be raised in patients who have recently lived in or traveled to 
    areas where diphtheria remains endemic and in unvaccinated patients), Francisella 
    tularensis (can cause pharyngeal tularemia, particularly when infection is acquired 
    by ingestion of contaminated food or water. Pharyngeal tularemia is characterized by 
    fever and severe exudative pharyngitis, which is often accompanied by oral ulcers 
    and painful cervical lymphadenopathy. As with diphtheria, a pharyngeal membrane 

    may be present). Rare causes of bacterial pharyngitis include also gonorrhea.

    The most common noninfectious causes of pharyngitis include allergic rhinitis or 
    sinusitis, gastroesophageal reflux disease, smoking or exposure to second-hand 
    smoke, and exposure to dry air (particularly in the winter). Trauma (e.g., caused by 
    tracheal intubation) or vocal strain have also been reported to cause sore throat. 
    Other risks include the use of angiotensin-converting enzyme (ACE) inhibitors and 
    some chemotherapeutics, autoimmune disorders like Kawasaki disease, periodic 
    fever. Frequent exposure to colds and flus can increase your risk for pharyngitis. 
    Allergy, frequent sinus infections and exposure to second hand smoke may also 

    raise your risk.

    2) Investigations to diagnose the pharyngitis focus on:
    • The complete history taking and physical exam that will mainly focus on ear, 
        nose, throat and neck.
    • Throat swab culture: this involves using a cotton swab to take a sample 
       of the secretions from the throat for the rapid strep test in the consultation 
       room for Group A beta-hemolytic streptococcal rapid antigen detection test 
       (preferred diagnostic method in emergency settings), or the swab is sent to 
       a lab for further testing and results. This is criterion standard for diagnosis of 
       GAS infection (90-99% sensitive).
    • Testing for coronavirus 2 (SARS-CoV-2) by rapid test after taking nasal swabs 
       or polymerase chain reaction (PCR) with oro-pharyngeal swab.
    • Blood tests: mainly to determine whether the patient has mononucleosis. 
       A complete blood count (CBC) may be done to look for any other type of 
       infection. Other laboratory studies that may be helpful include peripheral 
       blood smear, erythrocytes sedimentation rate, blood culture or gonococcal 
       culture if indicated by the history.
    • Imaging studies generally are not indicated for uncomplicated viral or 
      streptococcal pharyngitis. However, the following may be considered: lateral 
      neck x-ray in patients with suspected epiglottitis or airway compromise, soft
      tissue neck CT if concern for abscess or deep-space infection exists

    3) The treatment plan of pharyngitis include:
    The main goals in evaluation of adults with pharyngitis are the exclusion of serious 
    or potentially life-threatening conditions and the identification of treatable causes. 

    Viral infections do not need to be treated with antibiotics, and treatment is 

      

      

    complications. Suppurative complications of GAS pharyngitis are due to invasion 
    of the organism beyond the pharynx and include otitis media, peritonsillar cellulitis 
    or abscess, sinusitis, meningitis, bacteremia, and necrotizing fasciitis. Non
    suppurative complications of GAS pharyngitis are immune mediated and include 

    acute rheumatic fever, post-streptococcal glomerulonephritis, and reactive arthritis.

       

           4) The management plan of tonsillitis:
        The treatment of tonsillitis depends on the causes:

    A. Medications: if the tests find bacteria, client will get antibiotics. These drugs might 
    be given in a one-time injection or in pills that patient will swallow for several days. 
    The antibiotics usually used are Penicillins for tonsillitis due to group Astreptococcus. 
    Other antibiotics might also be used if patient is allergic to penicillin.
    Antibiotic therapy, analgesics such as acetaminophen, and saline gargles may 
    be used to treat the infection and associated discomfort. Chronic tonsillitis and 
    adenoiditis may require tonsillectomy. 

    B. Home remedies: if client has a virus, antibiotics won’t help, and the body will fight 
    the infection on its own. In the meantime, client can try some home remedies:
    • Get lots of rest
    • Drink warm or very cold fluids to help with throat pain 
    • Eat smooth foods, such as flavored gelatins, ice cream, and applesauce
    • Use a cool-mist vaporizer or humidifier in your room
    • Gargle with warm salt water
    • Suck on lozenges with bensoine or other medications to numb the throat
    • Take over-the-counter pain relievers such as acetaminophen or ibuprofen
    • If the causative organism is group A streptococcus, the nurse ensures that the 
      client and family members can manage self-care at home by communicating 
       the following points:
    – Report any signs of bleeding to the physician, this is particularly important in 
        the first 12 to 24 hours, and then 7 to 10 days after surgery as the throat heals.
    – Gently gargle with warm saline or an alkaline mouthwash to assist in removing 
       thick mucus.
    – Maintain a liquid and very soft diet for several days after surgery, avoid spicy 
       foods and rough-textured foods.
    – Also, avoid milk and milk products if the client does not tolerate them well. 
       Streptococcus, prompt treatment is needed to prevent potential cardiac and 
       renal complications.

    C. Surgery
    Tonsils are an important part of the immune system, so the best option is to do all 
    best to ensure they kept. But if the tonsillitis keeps coming back or won’t go away, or 
    if swollen tonsils make it hard to breathe or eat, client might need to have the tonsils 
    taken out. This surgery is called tonsillectomy (usually, a sharp tool called a scalpel 
    is used to take out the tonsils. But other options are available including lasers, radio 
    waves, ultrasonic energy, or electrocautery to remove enlarged tonsils). The criteria 
    for performing tonsillectomy are repeated episodes of tonsillitis, hypertrophy of the 
    tonsils, enlarged obstructive adenoids, repeated purulent otitis media, hearing 
    loss related to serous otitis media associated with enlarged tonsils and adenoids, 
    and other conditions (e.g., asthma, rheumatic fever) exacerbated by tonsillitis. 
    Tonsillectomy and adenoidectomy are generally done as outpatient procedures. 
    Post tonsillectomy recovery, patient will be advised to get plenty of rest and drink 
    lots of fluids while recovering, but don’t eat or drink any dairy products for the first 

    24 hours.

      5) The complications for tonsillitis:
    Complications usually happen only if bacteria caused the infection. These 
    complications include:
         • A collection of pus around the tonsil (peritonsillar abcess) 
         • Middle ear infection
         • Breathing problems or breathing that stops and starts while sleeping 
              (obstructive sleep apnea)
         • Tonsillar cellulitis, or infection that spreads and deeply penetrates nearby 
            tissues
    If the patient has streptococcus bacteria and does not get treatment, the illness 
    could lead to a more serious problem, including rheumatic fever, scarlet fever, 

    sinusitis, kidney infection called glomerulonephritis.

            

    Laryngitis that lasts longer than three weeks is known as chronic laryngitis. This 
    type of laryngitis is generally caused by exposure to irritants over time. Chronic 
    laryngitis can cause vocal cord strain and injuries or growths on the vocal cords 
    (polyps or nodules). The other causes include inhaled irritants such as chemical 
    fumes, allergens or smoke; acid reflux also called gastroesophageal reflux disease 
    (GERD); chronic sinusitis; excessive alcohol use; habitual overuse of the voice 
    (such as in singers or cheerleaders); smoking

    Less common causes of chronic laryngitis include bacterial or fungal infections, 
    Infections with certain parasites.

    Other causes of chronic hoarseness include cancer, vocal cord paralysis, which 
    can result from nerve injury due to surgery, injury to the chest or neck, cancer, nerve 
    disorders, or other health conditions, bowing of the vocal cords.

    Other risk factors for laryngitis include having a respiratory infection, such as a cold, 
    bronchitis or sinusitis, exposure to irritating substances, such as cigarette smoke, 
    excessive alcohol intake, stomach acid or workplace chemicals, overusing your 
    voice, by speaking too much, speaking too loudly, shouting or singing.

    3. The treatment plan for someone who has signs and symptoms of laryngitis 
    involve:

    Supportive care: no matter what the cause, laryngitis is best treated by giving the 
    voice a rest by reducing vocal activity as much as possible. Steam inhalation and 
    drinking fluids also help to soothe irritated tissue, moderate symptoms, and speed 
    healing. Topical medications or remedies such as saltwater, over-the-counter throat 
    lozenges, sore throat syrups, hard candy, herbal teas, herbal sprays, or herbal 
    lozenges only work by coming in contact with inflamed or irritated tissues and so 
    will help only with irritation in the throat itself. The larynx, however, is the doorway 
    to the lungs. If topical medications like saltwater, lozenges, or cough syrup could 
    enter the larynx, the result would be choking or drowning.

    Medications: pain, sore throat, and dry cough are most effectively relieved with 
    over-the-counter pain relievers. In severe cases, or for voice professionals, a 
    doctor may use oral or inhaled corticosteroids to rapidly reduce swelling. Other 
    medications will be used only to treat the underlying cause, not the laryngitis itself. 
    Because laryngitis is not usually caused by a bacterial infection, doctors rarely use 
    antibiotics unless if the cause is bacterial. Pain relievers such as acetaminophen, 
    ibuprofen, naproxen, or aspirin are also used. Corticosteroids as prednisone might 
    be used for severe laryngitis cases or voice professionals, an oral or inhaled 
    corticosteroid helps to rapidly reduce swelling. Because of the side effects, which 
    include laryngitis, corticosteroids are only rarely used

    Treating the underlying cause: when identified, the underlying condition must be 
     managed. If laryngitis is caused by acid reflux, dietary changes and medications 
    that reduce stomach acid may be prescribed. Laryngitis caused by medications or 
    irritants will be treated by discontinuing the medication or avoiding the irritant. In 
    particular, tobacco users will be advised to quit smoking to relieve chronic laryngitis 
    due to smoking. Allergies will be treated with allergy medications and lifestyle 
    changes. Laryngitis due to an upper respiratory infection caused by a bacteria 
    or fungus will be treated with the appropriate antimicrobial medications, either 

    antibiotics or antifungals.

    Voice therapy: in cases of chronic laryngitis, voice therapy trains patients in vocal 
    behaviors and lifestyle changes that help preserve the voice. Sessions are directed 

    by speech-language therapists and usually last for four to eight weeks.

    There is no “best” medication for laryngitis. In most cases, the best treatment for 
    laryngitis is vocal rest, steam inhalation, and proper hydration. Medications are 

    used to treat a possible underlying cause or to provide symptom relief.

    To prevent dryness or irritation to your vocal cords avoid smoking and stay away 
    from secondhand smoke, limit alcohol and caffeine, drink plenty of water, keep 
    spicy foods out of your diet, include a variety of healthy foods in your diet, avoid 

    clearing your throat, avoid upper respiratory infections. 

    4. Diagnosis of laryngitis focus on:

    Complete physical exam and review of medical history and symptoms. 
    Listen to the voice and examine the vocal cords (Laryngoscopy: using the 
    laryngoscope, the health care provider can visually examine the vocal cords by 
    using a light and a tiny mirror to look into the back of the throat. The doctor may 
    use fiber-optic laryngoscopy, and he or she may refer you to an ear, nose and throat 
    specialist).

    Taking the oro-pharyngeal swab for culture and/or Biopsy: If the doctor sees a 
    suspicious area, he or she may do a biopsy, taking a sample of tissue for examination 
    under a microscope.

    5. The complications if the laryngitis is not treated:
    Acute laryngitis: complications are rare, as the disease is usually self-limiting. 
    Damage to the vocal cords is possible in patients who try to overcompensate for 
    the dysphonia.

    Chronic laryngitis: the main complications are voice loss, obstruction of the airways 
    and chronic cough. Laryngeal stenosis may develop occasionally. Rarely, in severe 
    infections such as those with herpes viruses, laryngeal erosion and necrosis may 
    occur.
    In some cases of laryngitis caused by infection, the infection may spread to other

    parts of the respiratory tract.

         End Unit 3 Assessment

    ♦ Answers to multiple choice questions

      

        

           

       3.6 Additional information
    The Heimlich maneuver for dislodging an airway obstruction:

    • Ask the person if he or she is choking. (Note: Hands crossed at the neck is 
       the universal sign of choking.)
    • Assess ability to speak and cough. If the person cannot talk or cough, say that 
       you can help and place your arms around his or her waist.
    • Make a fist with one hand and place the thumb toward the victim above the 
       umbilicus.
    • Hold your fist with the other hand and thrust upward into the abdomen 
    • Repeat thrusts.
    • If the object is dislodged and the victim can cough effectively, encourage him 
      or her to do so to eject the object.
    • If the object is not ejected or coughed out and the victim loses consciousness, 
       lower the victim to the ground.
    • Straddle the victim’s body and place the heel of one hand on top of the other. 
       Position the hands midway between the umbilicus and the xiphoid process.
    • Deliver thrusts and repeat.
    • Open the mouth to assess if the object can be swept out with a hooked finger 
       (do not sweep the mouth in children).
    • If the airway remains obstructed, repeat the procedure.
    • Clients with serious airway conditions require aggressive treatment to 

        maintain an airway or relieve airway obstruction.  

        TRACHEOTOMY AND TRACHEOSTOMY
    A tracheotomy is the surgical procedure that makes an opening into the trachea. 
    A tracheostomy is a surgical opening into the trachea into which a tracheostomy 
    or laryngectomy tube is inserted. A tracheostomy may be temporary or permanent. 
    A permanent opening in the trachea is required for certain disorders, such as a 
    laryngectomy for laryngeal cancer.

    Tracheostomy tubes come in several sizes and differ from laryngectomy tubes in 
    their length and diameter. A cuffed tracheostomy tube has a cuff on the lower end 
    that is inflated with air to provide a snug fit. 

    The cuff prevents aspiration of liquids or escape of air when a mechanical ventilator 
    is used. The physician specifies the amount of air to be injected into the cuff, usually 
    to achieve a pressure between 20 and 25 mm H2O. The amount of air determines 
    the seating of the cuff in the trachea. The pressure in the cuff requires monitoring 
    with a pressure gauge every 8 hours. During the immediate postoperative period, 
    the physician

    may change the tracheostomy tube every 3 to 5 days. To pass a tracheostomy tube 
    into the tracheal opening, an obturator is placed in the tube to facilitate placement. 
    Once the tracheostomy tube is in place, the obturator is removed. The outer tube is 
    held snugly in place by tapes inserted in openings on either side of it and tied at the 
    side of the client’s neck. The respiratory passages react to the creation of the new 
    opening with inflammation and excessive mucus secretion. Copious respiratory 
    secretions are life-threatening. The client cannot be left unattended during the 
    immediate postoperative period because the secretions make frequent suctioning 
    necessary. Additionally, inspired air passes directly into the trachea, bronchi, and 
    lungs without becoming warmed and moistened by passing through the nose. Dry 
    secretions can subsequently develop, which easily form crusts and can break off, 
    obstruct the lower airway, and cause serious respiratory problems. Humidification 
    by a mist collar is usually necessary to prevent drying and incrustation of the mucous 
    membrane in the trachea and the main bronchus. 

    The longterm and short-term complications of tracheostomy include infection, 
    bleeding, airway obstruction resulting from hardened secretions, aspiration, 
    injury to the laryngeal nerve, erosion of the trachea, fistula formation between the 
    esophagus and trachea, and penetration of the posterior tracheal wall.

    Nursing Management
    After surgery, the nurse monitors vital signs and auscultates breath sounds. 
    He or she assesses skin color, level of consciousness, and mental status. The 
    nurse monitors for potential complications and checks airway patency frequently. 
    Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in 
    severe respiratory difficulty or death by asphyxiation. If the airway is obstructed, the 
    client becomes cyanotic, restless, and frightened. To facilitate breathing during the 
    immediate postoperative period, the nurse positions the client as ordered. When 
    the client is fully awake and blood pressure is stable, the nurse elevates the head of 
    the bed to about 45 degrees. This position decreases edema and makes breathing 

    easier.

    The nurse inspects the tracheostomy carefully, ensuring that tapes are secure. If 
    the tube is not tied securely, the client can cough it out, a serious occurrence if the 
    edges of the trachea have not been sutured to the skin. This may be the case in a 
    temporary tracheostomy. The nurse keeps a tracheal dilator at the bedside at all 
    times. If the outer tube accidentally comes out, the nurse inserts the dilator to hold 
    the edges of the stoma apart until the physician arrives to insert another tube. A 
    tracheal tube must never be forced back in place.

    Use of force may compress the client’s trachea (by pushing the tube alongside and 
    compressing the trachea, rather than inserting the tube into the stoma). Such action 

    could cause respiratory arrest.

      Suctioning the Client with a Tracheostomy:
    • Use sterile equipment (e.g., gloves, suction catheter, normal saline) and 
       aseptic technique for tracheal suctioning.
    • Place client in Fowler’s position. 
    • Pre-oxygenate client for at least 1 to 2 minutes. 
    • Check that suction pressure is at a low setting.
    • Open the suction kit, don gloves, lubricate a sterile, 10 to 14 sized French 
       disposable catheter with sterile saline, and insert it into the lumen of the tube.
    • Do not apply suction while the catheter is inserted down the trachea because 
        this irritates the lining of the trachea.
    • Begin intermittent suctioning while slowly withdrawing and rotating the 
       catheter. Do not suction for more than 10 seconds at a time.
    • Allow client to rest and deep breathe before repeating if more suctioning is 
       necessary.
    • Discard the suction catheter after use.

    Providing Tracheostomy Care:
    • Maintain aseptic technique, washing hands before, during, and after the 
       procedure.
    • Position client in a supine or low Fowler’s position.
    • Using a clean glove, remove the soiled stomal dressing and discard it, glove 
       and all, in an appropriate receptacle.
    • Open the tracheostomy kit without contaminating the contents.
    • Don sterile gloves—keep the dominant hand sterile. 
    • Pour hydrogen peroxide and normal saline into respective containers.
    • Unlock the inner cannula by turning it counterclockwise.
    • Remove it and place in hydrogen peroxide. Clean the inside and outside of 
       the cannula with pipe cleaners.
    • Rinse the cleaned cannula with normal saline. 
    • Tap the cannula and wipe the excess solution with sterile gauze.
    • Replace the inner cannula and turn it clockwise within the outer cannula.
    • Clean around the stoma with an applicator moistened with normal saline.
    • Place a sterile dressing around the tracheostomy tube. 
    • Change the tracheostomy ties by placing the new ones on first, and removing 
    the soiled ones last. 
    • Tie the new ends securely, but not tightly, at the side of the neck.

      3.7. End unit 3 summary
    Disorders of the nose and throat are considered as disorders of the upper airway 
    and range from common colds to cancer. The severity depends on the nature of the
    disorder and the client’s physiologic response. Most people experience common 
    colds and sore throats and find them more inconvenient than serious. For others, 
    even the most common disorders of the upper respiratory airway are of great 
    concern because other physical problems compound their effects.

    Laryngitis is inflammation and swelling of the mucous membrane that lines the 
    larynx. Edema of the vocal cords frequently accompanies laryngeal inflammation. 
    Laryngitis may follow a URI and results from spread of the infection to the larynx. 
    Other causes include excessive or improper use of the voice, allergies, and smoking. 
    Hoarseness, inability to speak above a whisper, or aphonia (complete loss of voice) 
    are the usual symptoms. 

    In addition, clients complain of throat irritation and a dry, nonproductive cough. The 
    diagnosis is based on the symptoms. If hoarseness persists more than 2 weeks, 
    the larynx is examined (laryngoscopy). Persistent hoarseness is a sign of laryngeal 
    cancer and thus merits prompt investigation. Treatment involves voice rest and 
    treatment or removal of the cause. Antibiotic therapy may be used if a bacterial 
    infection is the cause. If smoking is the cause, the nurse encourages smoking 
    cessation and refers the client to a smoking-cessation program.

    Tonsillitis is inflammation of the tonsils, and adenoiditis is inflammation of the 
    adenoids. These conditions generally occur together—the common diagnosis is 
    tonsillitis. Although both disorders are more common in children, they also may be 
    seen in adults. The tonsils and adenoids are lymphatic tissues and common sites 
    of infection. Primary infection may occur in the tonsils and adenoids, or the infection 
    can be secondary to other URIs. Chronic tonsillar infection leads to enlargement 
    and partial upper airway obstruction. Chronic adenoidal infection can result in acute 
    or chronic infection in the middle ear (otitis media). If the causative organism is 
    group A streptococcus, prompt treatment is needed to prevent potential cardiac and 
    renal complications.

    Pharyngitis, inflammation of the throat, is often associatedwith rhinitis and other 
    URIs. Viruses and bacteria cause pharyngitis. The most serious bacteria are the 
    group A streptococci, which cause a condition commonly referred to as strep 
    throat. Strep throat can lead to dangerous cardiac complications (endocarditis and 
    rheumatic fever) and harmful renal complications (glomerulonephritis). Pharyngitis 
    is highly contagious and spreads via inhalation of or direct contamination with 
    droplets. The incubation period for pharyngitis is 2 to 4 days. 

    The first symptom is a sore throat, sometimes severe, with accompanying dysphagia 
    (difficulty swallowing), fever, chills, headache, and malaise. Some clients exhibit a 
    white or exudate patch over the tonsillar area and swollen glands. A throat culture 
    reveals the specific causative bacteria. Rapid identification methods, such as the 
    Biostar or the Strep A optical immunoassay (OIA), are available to diagnose group 
    The first symptom is a sore throat, sometimes severe, with accompanying dysphagia 
    (difficulty swallowing), fever, chills, headache, and malaise. Some clients exhibit a 
    white or exudate patch over the tonsillar area and swollen glands. A throat culture 
    reveals the specific causative bacteria. Rapid identification methods, such as the 
    Biostar or the Strep A optical immunoassay (OIA), are available to diagnose group 
    A streptococcal infections. These tests are done in clinics and physician offices. 
    Standard 24-hour throat culture and sensitivity tests identify other organisms. 
    Early antibiotic treatment is the best choice for pharyngitis to treat the infection 
    and help prevent potential complications. Penicillin or its derivatives are generally 
    the antibiotics of choice. Clients sensitive to penicillin receive erythromycin. The 

    antibiotic regimen is 7 to 14 days.

    Sinusitis is inflammation of the sinuses. The maxillary sinus is affected most often. 
    Sinusitis can lead to serious complications, such as infection of the middle ear or 
    brain. The principal causes are the spread of an infection from the nasal passages 
    to the sinuses and the blockage of normal sinus drainage. Interference with sinus 
    drainage predisposes a client to sinusitis because trapped secretions readily 
    become infected. Impaired sinus drainage may result from allergies (which cause 
    edema of the nasal mucous membranes), nasal polyps, or a deviated septum.

    Rhinitis is inflammation of the nasal mucous membranes. It also is referred to as 
    the common cold, or coryza. Rhinitis may be acute, chronic, or allergic, depending 
    on the cause. The most common cause is the rhinovirus, of which more than 100 
    strains exist. Colds are rapidly spread by inhalation of droplets and direct contact 
    with contaminated articles (e.g., telephone receivers, doorknobs). Allergic rhinitis is 
    a hypersensitive reaction to allergens, such as pollen, dust, animal dander, or food. 
    Rhinitis is usually not a serious condition; however, it may lead to pneumonia and 
    other more serious illnesses for debilitated, immunosuppressed, or older clients. 
    Symptoms associated with rhinitis include sneezing,

    nasal congestion, rhinorrhea (clear nasal discharge), sore throat, watery eyes, 
    cough, low-grade fever, headache, aching muscles, and malaise. With the common 
    cold, these symptoms continue for 5 to 14 days. A sustained elevated temperature 
    suggests a bacterial infection or infection in the sinuses or ears. Symptoms of 
    allergic rhinitis will persist as long as the client is exposed to the specific allergen. 
    For most clients, treatment for rhinitis is minimal. Unless specific bacteria are 
    identified as the cause of the infection, antibiotics are not used. Clients may be 
    advised to use antipyretics, such as acetaminophen or nonsteroidal analgesics, for 
    fever. Decongestants such as pseudoephedrine may be recommended for severe 
    nasal congestion. 

    For clients experiencing a prolonged cough, antitussives may be ordered. Saline 
    gargles are useful for a sore throat, as is saline spray for nasal congestion and 
    prevention of crusting. For allergic rhinitis, antihistamines are often used. An 
    example of a first-generation antihistamine is diphenhydramine (Benadryl). Newer 
    antihistamines include loratadine (Claritin), fexofenadine (Allegra), and cetirizine 
    (Zyrtec). Combination decongestants and antihistamines may also be helpful. An 
    example of this is brompheniramine/pseudoephedrine (Dimetapp). Medications 
    that desensitize or suppress immune responses, such as cromolyn (Nasalcrom) 
    or intranasal glucocorticosteroids, such as fluticasone (Flonase) may also be 

    prescribed for allergic rhinitis.

    Epistaxis, or nosebleed, is a common occurrence. It is not usually serious but can 
    be frightening. Nosebleeds are the rupture of tiny capillaries in the nasal mucous 
    membrane.

    They occur most commonly in the anterior septum, referred to as Kiesselbach’s 
    plexus. Causes of nosebleed include trauma, rheumatic fever, infection, 
    hypertension, nasal tumors, and blood dyscrasias. Epistaxis that results from 
    hypertension or blood dyscrasias is likely to be severe and difficult to control. Those 
    who abuse cocaine may have frequent nosebleeds. Foreign bodies in the nose 
    and deviated septum contribute to epistaxis, along with forceful nose blowing and 
    frequent or aggressive nose picking.

    Obstruction of the nasal passage interferes with air passage. Three primary 
    conditions lead to nasal obstruction: a deviated septum, nasal polyps, and 
    hypertrophied turbinates.

    A peritonsillar abscess is an abscess that develops in the connective tissue between 
    the capsule of the tonsil and the constrictor muscle of the pharynx. It may follow a 
    severe streptococcal or staphylococcal tonsillar infection. Clients with a peritonsillar 
    abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, 
    and difficulty talking. On visual examination, the affected side is red and swollen, 
    as is the posterior pharynx. Drainage from the abscess is cultured to identify the 
    microorganism. Sensitivity studies determine the appropriate antibiotic therapy. 
    Immediate treatment of a peritonsillar abscess is recommended to prevent the 
    spread of the causative microorganism to the bloodstream or adjacent structures. 
    Penicillin or another antibiotic is given immediately after a culture is obtained and 
    before results of the culture and sensitivity tests are known. Surgical incision and 
    drainage of the abscess are done if the abscess partially blocks the oropharynx. 
    A local anesthetic is sprayed or painted on the surface of the abscess, and the 
    contents are evacuated. Repeated episodes may necessitate.

    a tonsillectomy. Nursing management of the client undergoing drainage of an 
    abscess includes placing the client in a semi-Fowler’s position to prevent aspiration. 
    An ice collar may be ordered to reduce swelling and pain. The nurse encourages 
    the client to drink fluids. He or she observes the client for signs of respiratory 
    obstruction (e.g., dyspnea, restlessness, cyanosis) or excessive bleeding.

    A nasal fracture usually results from direct trauma. It causes swelling and edema 
    of the soft tissues, external and internal bleeding, nasal deformity, and nasal 
    obstruction. In severe nasal fractures, cerebrospinal fluid, which is colorless and 
    clear, may drain from the nares. Drainage of cerebrospinal fluid suggests a fracture 
    in the cribriform plate. The diagnosis of a nasal fracture may be delayed because of 
    significant swelling and bleeding. As soon as the swelling decreases, the examiner 
    inspects the nose internally to rule out a fracture of the nasal septum or septal 
    hematoma. Both conditions require treatment to prevent destruction of the septal 
    cartilage. If drainage of clear fluid is observed, a Dextrostix is used to determine 
    the presence of glucose, which is diagnostic for cerebrospinal fluid. Radiography 

    studies are done to ascertain any other facial fractures.

    Laryngeal trauma occurs during motor vehicle accidents when the neck strikes 
    the steering wheel or other blunt trauma occurs in the neck region. Endoscopic 
    and endotracheal intubations are other possible causes. Although uncommon, a 
    fracture of the thyroid cartilage is also traumatic to the larynx. Laryngeal obstruction 
    is an extremely serious and often life-threatening condition. Some causes of upper 
    airway obstruction include edema from an allergic reaction, severe head and neck 
    injury, severe inflammation and edema of the throat, and aspiration of foreign 

    bodies.

      3.8 Additional activities

      A. Remedial activities

      A1. Multiple choices Questions

    1. Nursing measures associated with the uncomplicated common cold include all 
         of the following except:
         a) Administering prescribed antibiotics to decrease the severity of the viral 
              infection.
         b) Informing the patient about the symptoms of secondary infection, the major 
             complication of a cold.
         c) Suggesting adequate fluid intake and rest.
         d) Teaching people that the virus is contagious for 2 days before symptoms 
                 appear and during the first part of the symptomatic phase.
    2. Health teaching for viral rhinitis (common cold) includes advising the patient to:
           a) Blow his or her nose gently to prevent spread of the infection.
           b) Blow through both nostrils to equalize the pressure.
           c) Rest, to promote overall comfort.
           d) Do all of the above.
    3. About 60% of cases of acute rhinosinusitis are caused by bacterial organisms. 
          The antibiotic of choice is:
         a) Augmentin.
         b) Amoxil.
         c) Erythromycin.
         d) Septra.
    4. Acute pharyngitis of a bacterial nature is most commonly caused by:
            a) Group A, beta-hemolytic streptococci.
            b) Gram-negative Klebsiella.
            c) Pseudomonas.
            d) Staphylococcus aureus.
    5. A complication of acute pharyngitis can be:
            a) Mastoiditis.
            b) Otitis media.
            c) Peritonsillar abscess.
            d) All of the above.
    6. Nursing management for a patient with acute pharyngitis includes:
            a) Applying an ice collar for symptomatic relief of a severe sore throat.
            b) Encouraging bed rest during the febrile stage of the illness.
            c) Suggesting a liquid or soft diet during the acute stage of the disease.
            d) All of the above measures.
    7. The most common bacterial pathogen associated with tonsillitis and adenoiditis is:
            a) Group a, beta-hemolytic streptococcus.
            b) Gram-negative klebsiella.
            c) Pseudomonas.
            d) Staphylococcus aureus.
    8. Nursing intervention for a patient with a fractured nose includes all of the following 
                     except:
           a) Applying cold compresses to decrease swelling and control bleeding.
           b) Assessing respirations to detect any interference with breathing.
           c) Observing for any clear fluid drainage from either nostril.
           d) Packing each nostril with a cotton pledget to minimize bleeding and help 

                maintain the shape of the nose during fracture setting

      

          

       

            

               

                  C. Extended activities

                 C1: Multiple choice Questions:

    1. A patient was seen in the clinic for an episode of epistaxis, which was controlled 
        by placement of anterior nasal packing. During discharge teaching, the nurse 
        instructs the patient to:
            a) Use aspirin for pain relief.
            b) Remove the packing later that day.
            c) Skip the next dose of antihypertensive medication.
            d) Avoid vigorous nose blowing and strenuous activity.
    2. A patient with allergic rhinitis reports severe nasal congestion; sneezing; and 
         watery, itchy eyes and nose at various times of the year. To teach the patient to 
          control these symptoms, the nurse advises the patient to:
           a) Avoid all intranasal sprays and oral antihistamines.
           b) Limit the usage of nasal decongestant spray to 10 days.
            c) Use oral decongestants at bedtime to prevent symptoms during the night.
            d) Keep a diary of when the allergic reaction occurs and what precipitates it.
    3. A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish 
         exudate, and headache. The nurse anticipates that the collaborative management 
          will include (select all that apply)
          a) Antiviral agents to treat influenza.
          b) Treatment with antibiotics starting asap.
          c) A throat culture or rapid strep antigen test.
          d) Supportive care, including cool, bland liquids.
          e) Comprehensive history to determine possible etiology.
    4. The best method for determining the risk of aspiration in a patient with a 
             tracheostomy is to:
           a) Consult a speech therapist for swallowing assessment.
           b) Have the patient drink plain water and assess for coughing.
           c) Assess for change of sputum color 48 hours after patient drinks small amount 
                  of blue dye.
           d) Suction above the cuff after the patient eats or drinks to determine presence 
                  of food in trachea.
    5. Which nursing action would be of highest priority when suctioning a patient with 
                a tracheostomy?
           a) Auscultating lung sounds after suctioning is complete
           b) Providing a means of communication for the patient during the procedure
           c) Assessing the patient’s oxygenation saturation before, during, and after 
                      suctioning

           d) Administering pain and/or antianxiety medication 30 minutes before suctioning

    Case studies

    A. Isabel, a 14-year-old girl, has just undergone a tonsillectomy and adenoidectomy. 
    The staff nurse assists her with transport from the recovery area to her room.
    1. On the basis of knowledge about tonsillar disease, the nurse knows that Isabel 
    must have experienced symptoms that required surgical intervention. Clinical 
    manifestations may have included:
           a) Hypertrophy of the tonsils.
           b) Repeated attacks of otitis media.
           c) Suspected hearing loss secondary to otitis media.
           d) All of the above.
    2. The nurse assesses Isabel’s postoperative vital signs and checks for the most 
         significant postoperative complication of:
         a) Epiglottis.
         b) Eustachian tube perforation.
         c) Hemorrhage.
         d) Oropharyngeal edema.
    3. The nurse maintains Isabel in the recommended postoperative position of:
          a) Prone with her head on a pillow and turned to the side.
          b) Reverse trendelenburg with the neck extended.
          c) Semi-fowler’s position with the neck flexed.
          d) Supine with her neck hyperextended and supported with a pillow.
    4. Isabel is to be discharged the same day of her tonsillectomy. The nurse makes 
         sure that her family knows to:
         a) Encourage her to eat a house diet to build up her resistance to infection.
         b) Offer her only clear liquids for 3 days, to prevent pharyngeal irritation.
         c) Offer her soft foods for several days to minimize local discomfort and supply 
            her with necessary nutrients.
        d) Supplement her diet with orange and lemon juices because of the need for 
             vitamin c to health tissues.
    B. Gilberta, a 14-year-old high school student, is sent with her mother to the 
         emergency department of a local hospital for uncontrolled epistaxis.
    1. Describe what the school nurse should tell Gilberta to manage the bleeding site

         while being transported to the hospital.

    2. Initial nursing measures in the emergency department that can be used to stop 
           the nasal bleeding include:
          a) Compressing the soft outer portion of the nose against the midline septum 
             continuously for 5 to 10 minutes.
         b) Keeping Gilberta in the upright position with her head tilted forward to prevent 
              swallowing and aspiration of blood.
         c) Telling Gilberta to breathe through her mouth and to refrain from talking.
         d) All of the above.
    3. The nurse expects that emergency medical treatment may include insertion of a 
                 cotton pledget moistened with:
           a) An adrenergic blocking agent.
           b) A topical anesthetic.
           c) Protamine sulfate.
           d) Vitamin K.
    4. The nurse can advise the mother that nasal packing used to control bleeding can 
               be left in place:
             a) No longer than 2 hours.
             b) An average of 12 hours.
             c) An average of 24 hours.

             d) Anywhere from 2 to 6 days.

           

         

              

  • UNIT 4:MEDICAL PATHOLOGIES OF ORAL AND OESOPHAGUS

    4.1. Key unit competence: 
    Take appropriate decision on different common medical pathologies of Oral and 
    oesophagus.

    4.2. Prerequisite (knowledge, skills, attitudes, and values)
    To achieve the above competence, the associate nurse student needs the following 
    prerequisites: human body anatomy and physiology, fundamentals of Nursing, 
    pharmacology.

    4.3. Cross-cutting Issues to be addressed 
    4.3.1. Standardization culture
    In health care system, the most case of patients is presented with medical pathology 
    of oral cavity and esophagus such dental caries/teeth, oral pharyngeal candida, 
    injuries, esophagitis. The learners have to learn oral diseases and esophagus in 
    order to handle and to manage the patients with oral cavity and esophagus related 
    diseases.

    4.3.2. Inclusive education
    The teacher involves the students in all learning activities concerning the kind of 
    learner or disabilities for example the slow learner should be reinforced in order to 
    catch up others, and the teacher takes into consideration respective disability of 
    learner.

    Grouping students, Students with special educational needs are grouped 
    with others and assigned roles basing on individual student’s abilities.
    Providing earning resources earlier before teaching session so that students get 
    familiar with them. After end lesson assessment, the identified slow learners are 
    exposed to the remedial learning activities.

    Every important point is written and spoken. The written points help students with 
    hearing impairment and speaking aloud helps students with visual impairment.
    Remember to repeat the main points of the lessons.

    4.3.3. Gender education
    Emphasize to learners that anybody irrespective of their gender can have medical 
    career mainly medical sciences. Give role models who are successful medical 
    pathology of oral and esophagus in the area where the learners come from. Make 
    sure that during classroom teaching and skills lab demonstration both boys and 
    girls shares and participate equally in practices, arranging and proper hygiene after 

    classroom and skills lab teaching session.

    4.4. Guidance on the introductory activity 
    This introductory activity helps you to engage learners in the introduction of medical 
    pathology of oral and esophagus and invite the learners to follow the next lessons.

    Teacher’s activity:
    • Ask students to read the text and discuss the given questions.
    • Engage students in working collectively the activity
    • Help students with different problems
    • Ask any four students to present their findings while others are following.
    • Prepare trip field to nearest health facility in order to be familiar with dental 
       department equipment, and health assessment for oral cavity disorders.
    • Invite guest person who has specialty in oral health dental department domain 
       to teach the learners.
     

    4.5. List of Lessons/sub-headings (including assessment)

                    

                  

                   

                 

                   

                     Lesson 1: Introduction of Medical Pathologies of dental caries 
                    (Definition, causes, pathophysiology, signs and symptoms of dental 

                     caries

    a) Prerequisites
    This is the first lesson of the four unit on medical pathologies of oral and esophagus. 
    In this lesson, you will be dealing with the common medical pathologies of dental 
    caries and esophagus, which are dental caries, oropharyngeal candidiasis, injuries 
    and esophagitis. Definition, causes, pathophysiology, signs and symptoms of dental 
    caries for each disease will described. The first thing to do before starting teaching 
    is to remind learners that they have learnt about structure and function of teeth in 
    biology, health assessment of oral cavity from fundamentals of nursing. The teacher 
    will let students discuss the questions as indicated in introductory activity and from 
    the case study from learning activity 4.1 so that they can prepare themselves for 
    this lesson.

    b) Learning objectives
    • List the common medical pathologies of oral and oesophagus: dental caries, 
    oropharyngeal candidiasis, injuries and esophagitis.
    • Define the term “dental caries”
    • Describe causes, risk factors and pathophysiology of dental caries
    • Describe the signs and symptoms of dental caries.

    c) Teaching resources
     The teacher could avail the anatomical model of the normal teeth and abnormal 
    teeth and ensure that the students are able to interpret. In addition, the teacher 
    should present to the students the library textbooks on medical-surgical nursing, 
    especially dental caries and indicates the pages. All students must have their 
    student’s books. The algorithm or protocols about oral diseases management must 

    be available. There is a need of black board and chalks or flipcharts and markers.

    d) Learning activities 4.1
    Teacher ‘activities and methodology:
    • Ask learners to do individually activity 4.1 in their student book and answer 
       the question number 1, 2, 3 and 4.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
    knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard, flipchart and whiteboard to take note of the main 
        students’ ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.

    Student‘s activity
    • The students answer the questions individually in learning activity 4.1 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully.
    • Summarize the content with the teacher and coming up with the conclusion.

       Expected answers to introductory activity 4.0
    1. The possible types of oral health problems illustrated by the picture B, C, D 
         and E might be dental diseases, dental caries, dental accident, teeth eruption, 
         teeth fracture, candidiasis, oral epithelial carcinoma, stenosis of the esophagus, 
         narrowing of the esophagus, esophagitis

    2. The picture A looks normal, the picture B may be presenting necrotic dental 
         tissue, dental tissue damage, darkness of oral cavity etc. The picture C indicates 
         oral whitish, swollen tonsils. The picture D may indicate bleeding in the teeth, 
        cut off the teeth. The Picture E indicates the redness of esophagus, narrowed 

        esophageal lumen.

    3. Poor hygiene especially retained food is suggestive risk factor in the development 
        of dental caries as microorganisms invade the teeth surfaces and attract the 
        microorganisms that later damage the dental tissue resulting from dental caries
    4. The possible risk factors in diseases process on picture B is poor hygiene, lack 
         of brushing with adequate tooth paste, elderly, childhood, poor diet
       The picture C is having risk factors such as chronic immune depressive disease, 
       chronic severe infection, and malnutrition.

    Lesson 2: Description of dental caries (investigation diagnosis, 

    treatment plan, evolution and complication)

    a) Prerequisite
       This is the second lesson of the fourth unit on medical pathologies of oral and 
       esophagus in sensory organs. In this lesson you will be dealing with the description 
       of dental caries such its investigation, diagnosis treatment plan evolution and 
       complication. The first thing to do before starting teaching is to remind learners that 

       they have learnt about lesson one of dental caries.

    b) Learning objectives
    After completion of this lesson, the student will be able to:
    • Enumerate the investigations requested for patient with dental caries 
    • Identify the adequate medical diagnosis of dental caries
    • Develop a treatment plan of patient with dental caries

    • Explain the evolution and complications of dental caries. 

    c) Teaching resources
        The teacher could avail the Snellen chart, slip lamp, and ensure the students 
        are able to interpret them. In addition, the teacher should present to the students 
        the library textbooks on medical-surgical nursing, especially oral Diseases and 
        indicates the pages. All students must have their student’s books. There is a need 
        of black board and chalks or flipcharts and markers. Algorithms about assessment 

        and management of dental caries must also be displayed.

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 4.1 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
       Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
        again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by conforming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 4.1 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attempt to answer the self-assessment questions 4 .1

    The expected answers from Questions of learning activity 4.1
    1. The signs and symptoms that the patient was presenting were tooth sensitivity 
         to hot meal, constant tooth pain, dark spots on the teeth, and bad breath. In 
         addition, the physical exam reveals cavities in teeth and tenderness on palpation 
         (pain), facial swelling. The x-ray reveals the presence of holes in the 34, swelling 
         of gingiva, and fever with body temperature of 38.8°C. An acutely swollen and 
        reddened area of the soft gingiva is noted in her mouth, and an elevated WBC 
        of 16,000/mm3, 
    2. The x-ray and Full Blood Count (FBC) were performed
    3. The medical problem is Dental caries
    4. Treatment plan involved the use of Antibiotic like Amoxicillin 500mg TDS 7/7, 

         and Ibuprofen 400mg TDS 4/7 for pain relief.

    Lesson 3: Description of oral pharyngeal candidiasis 
    (definition, causes, pathophysiology, signs and 
    symptoms, investigation, treatment plan, evolution 

    and complication)

    a) Prerequisites
    This is the third lesson of the fourth unit about medical pathologies of the oral 
    and esophagus. In this lesson, you will be dealing with the description of different 
    causes and risk factors of oral pharyngeal candidiasis, pathophysiology, signs and 
    symptoms, investigation, management, evolution and complications. The first thing 
    to do before starting teaching is to remind learners what they have learnt about the 
    anatomy and physiology of the sensory organs (oral cavity), health assessment of 
    oral cavity from fundamentals of nursing. The students will discuss the questions 
    from the case study from learning activity 4.2 so that they can prepare themselves 
    for this lesson.

    b) Learning objectives:
    After completion of this lesson, the student will be able to:
    • Define the term “oral pharyngeal candidiasis”
    • Describe causes, risk factors and pathophysiology of oral pharyngeal 
       candidiasis.
    • Describe the signs and symptoms of oral pharyngeal candidiasis.
    • Enumerate the investigations requested for patient different types of oral 
       pharyngeal candidiasis.

    • Identify the adequate medical diagnosis of oral pharyngeal candidiasis.
    • Develop a treatment plan of oral pharyngeal candidiasis.
    • Explain the evolution and complications of oral pharyngeal candidiasis.

    c) Teaching resources
    The teacher could avail the oral cavity anatomical model, Penlight and tongue 
    depressor and ensure the students are able to use them. In addition, the teacher 
    should present to the students the library textbooks on medical-surgical nursing, 
    especially oral pharyngeal candidiasis Diseases and indicates the pages. All 
    students must have their student’s books. There is need of black board and chalks 
    or flipcharts and markers. Algorithms about assessment and management of 

    conjunctivitis must also be displayed.

    d) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 4.2 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
      knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
      again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by confirming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 4.2 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of oral candidiasis conditions
    • Attempt to answer the self-assessment questions 4.2

       The expected answers from Questions of learning activity 4.2
    1. Signs and symptoms that the patient was presenting are soreness, cotton
        like feeling in the mouth, loss of taste, dysphagia, cracking and redness at the 
         corners of the mouth.
    2. The problem that the patient may be presenting would be oral lesions, oral 
         thrush, oral cavity tissues trauma etc. 
    3. Full Blood Count of 112,000/mm3
    4. The treatment plan includes Antifungal drugs were prescribed such as 
          Fluconazole 800mg OD 14/7, or oral Nystatin 500000UI QID7/7 and Oral 
          paracetamol 500mg TDS 3/7 for pain relief

    Lesson 4: Description of injuries (Definition, causes 
    and risk factors, Pathophysiology, signs and 
    symptoms, investigation, diagnosis, treatment plan, 

    evolution and complication)

    a) Prerequisites
    This is the third lesson of the fourth unit about medical pathologies of the oral and 
    esophagus. In this lesson, you will be dealing with the definition, causes and risk 
    factors, Pathophysiology, signs and symptoms, investigation, diagnosis, treatment 
    plan, evolution and complication of oral injuries. The first thing to do before starting 
    teaching is to remind learners what they have learnt about the anatomy and 
    physiology of the sensory organs (oral cavity), health assessment of oral cavity 
    from fundamentals of nursing. The students will discuss the questions from the 
    case study from learning activity 4.3 so that they can prepare themselves for this 
    lesson.

    b) Learning objectives: 
    After completion of this lesson, the student will be able to:
    a. Define the term “oral cavity injuries”
    b. Describe causes, risk factors and pathophysiology of injuries.
    c. Describe the signs and symptoms of injuries.
    d. Enumerate the investigations requested for patient with oral cavity injuries.
    e. Identify the adequate medical diagnosis of oral cavity injuries
    f. Enumerate the investigations requested for patient of injuries
    g. Describe the way used for adequate medical diagnosis of injuries.
    h. Develop a treatment plan of patient with injuries.
    i. Explain the evolution and complications of injuries. 
    j) Teaching resources
    The teacher could avail the oral cavity anatomical model and Penlight and tongue 
    depressor and ensure the students are able to use them. In addition, the teacher 
    should present to the students the library textbooks on medical-surgical nursing, 
    especially oral pharyngeal candidiasis Diseases and indicates the pages. All 
    students must have their student’s books. There is need of black board and chalks 
    or flipcharts and markers. Algorithms about assessment and management of 

    conjunctivitis must also be displayed.

    k) Learning activities
    Teacher’s activities and methodology
    • Ask learners to do individually activity 4.3 in their student book and answer 
       the questions related.
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide they answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
    again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
    in making that conclusion.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by conforming the right responses.

    Student’s activities
    • The students answer the questions individually in learning activity 4.3 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of oral cavity condition

    • Attempt to answer the self-assessment questions 4.3

    The expected answers from Questions of learning activity 4.3
    1. oral mucous lesions involving multiple oral cavity structure with high sensitivity 
    on palpation following accidental tooth bite after patient fall during sport with 
    the presence of whitish, linear, filament like plicae formation observed via
    inspection body temperature was 36.8°C, Blood pressure 100/60 mmHg, pulse 
    rate: 64beats per minute, respiratory rate was 16 breaths per minutes the x-ray 
    was performed and revealed the presence of slight tooth fracture
    2. Medical problem could be like tooth fracture, oral mucous lesions
    3. The only x-ray was performed to rule out any tooth fracture
    4. The medical treatment included Antibiotic drugs were prescribed such as 
        amoxicillin 500mg TDS 7/7 for bacterial infection prevention and saline water to 

        be used to wash out, Diclofenac tablet 100mg TDS 3/7 for pain relief

          

         Lesson 5: Description of esophagitis (definition 
                             causes, pathophysiology, signs and symptoms, 
                             investigation, treatment plan, evolution and 

                            complication)

    a) Prerequisite
    This is the fifth lesson of the fourth unit about medical pathologies of the oral 
    and esophagus. In this lesson, you will be dealing with the definition, causes and 
    risk factors, pathophysiology, signs and symptoms, investigation, management, 
    evolution and complications of esophagus. The first thing to do before starting 
    teaching is to remind learners what they have learnt about the anatomy and 
    physiology of the sensory organs (oral cavity), esophagus, health assessment of 
    oral cavity from fundamentals of nursing. The students will discuss the questions 
    from the case study from learning activity 4.4 so that they can prepare themselves 

    for this lesson.

    b) Learning objectives
    After completion of this lesson, the student will be able to:
    • Define the term “esophagitis”
    • Describe causes, risk factors and pathophysiology of esophagitis
    • Describe the signs and symptoms of esophagitis.
    • Enumerate the investigations requested for patient with esophagitis
    • Describe the way used for the adequate medical diagnosis of esophagitis
    • Develop a treatment plan for patient with esophagitis
    • Explain the evolution and complications of esophagitis.

    c) Teaching resources
    The teacher could avail the oral cavity anatomical model, Penlight, and tongue 
    depressor and ensure the students are able to use them. In addition, the teacher 
    should present to the students the library textbooks on medical-surgical nursing 
    especially esophagitis disease and indicates the pages. All students must have 
    their student’s books. This lesson will be taught with different aids like (white board 
    or black board, computer, chalks or flipcharts and markers. Algorithms about 
    assessment and management of esophagitis must also be displayed.

    d) Learning activities
    Learning activities should be directly related to the learning objectives of the course 
    and provide experiences that will enable students to engage in practice and gain 
    feedback on specific progress towards those objectives. The various learning 
    activities will be carried out such as: taking notes, course work and reading textbook 
    related to the lesson, group assignment and summarize the content, engagement 
    in debate and other clinical learning activities such as case study.

    Teacher’s activity:
    • Ask learners to do individually activity 4.4 in their student book and answer 
       the questions related.
    • Provide the necessary materials to the students.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the knowledge.
    • Invite any five students to provide their answers
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student’s ideas
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Use brainstorming while collecting the answers from different learners.
    • Judge the answers from learners by confirming the right responses.
    • Harmonize and conclude on the learned knowledge and still engage student 
        in making that conclusion.

      Student’s activities
    • The students answer the questions individually in learning activity 1.5 in their 
       student book
    • The students ask the problems that may be raised from the provided activity 
       if any in order to get clarification
    • Some students present the findings from the learning activity while others are 
       following carefully
    • Summarize the content with the teacher and coming up with conclusion.
    • Attend the library for reading related book of esophagus condition

    • Attempt to answer the self-assessment questions 4.4

      

    3. The three types of medical investigations to rule out the esophagitis diagnosis 
           include Barium X-ray, Endoscopy and biopsy.
    4. Reflux esophagitis may include over-the-counter treatments. These include 
    antacids (Maalox, Mylanta, others); medications that reduce acid production, 
    called H-2-receptor blockers, such as cimetidine (Tagamet HB); and medications 
    that block acid production and heal the oesophagus, called proton pump 
    inhibitors, these include H-2-receptor blockers as well as proton pump inhibitors, 
    such as esomeprazole (Nexium), omeprazole (Prilosec). The metoclopramide 
    may be prescribed.
    5. The three major complications of esophagitis include scarring or narrowing 
    (stricture) of the esophagus, tearing of the esophagus lining tissue from retching 
    (if food is stuck) or during endoscopy (due to inflammation), Barrett’s oesophagus.

    1.6 Summary of the unit
    Medical pathology is a branch of medical science primarily concerning the diseases 
    affects different human organs such as respiratory tract organs, cardio-vascular 
    organs, digestive organs, uro-genital organs, sensory organs etc. This unit of 
    medical pathology of the oral and esophagus described the most common oral 
    cavity and esophagus conditions that are frequently observable in Rwanda such 
    dental caries/teeth, oral-pharyngeal candidiasis, injuries and esophagitis. The 
    medical conditions of oral and oesophagus are described by the definition, clinical 
    features, causes and risk factors, pathophysiology, investigation, treatment plan, 
    evolution and complications. The student who will be complete this content will 
    be able to take appropriate decision on different common medical pathologies in 
    terms of diagnosing, treatment and prevent the complication of dental caries, oral 
    pharyngeal, injuries and esophagitis. 

    1.7 Additional Information 
    Common additional oral cavity disorders.
    • Gingivitis
    • Cancer of the esophagus

    1. GINGIVITIS
    Gingivitis is an often-painful inflammation of the gums, or gingiva. It typically occurs 
    due to plaque buildup on the teeth. People may generally refer to this as gum 
    disease. Gingivitis is an early form of gum disease and typically produces mild 

    symptom

    Causes
    The most common cause of gingivitis is the accumulation of bacterial plaque 
    between and around the teeth. Dental plaque is a biofilm that accumulates naturally 
    on the teeth. It occurs when bacteria attach to the smooth surface of a tooth.
    Several underlying conditions and outside factors trusted source can increase plaque 
    formation or a person’s risk of gum inflammation. Changes in hormones: this may 
    occur during puberty, menopause, the menstrual cycle and pregnancy. The gums 
    might become more sensitive, raising the risk of inflammation. Some diseases: 
    cancer, diabetes and HIV are linked to a higher risk of gingivitis; medications that 
    reduce saliva production can affect a person’s oral health. Dilantin, an epilepsy 
    medication, and angina drugs can also cause abnormal growth of gum tissue, 
    increasing the risk of inflammation, smoking, age, family history of gingivitis are 
    also a risk factor of gingivitis.

     Signs and Symptoms 
    The signs and symptoms of gingivitis might include gum inflammation and 
    discoloration, tender gums that may be painful to the touch, bleeding from the gums 
    when brushing or flossing, halitosis or bad breath, receding gums, soft gums
    However, in mild cases of gingivitis, there may be no discomfort or noticeable 
    symptoms

    Adequate diagnosis
    A dentist or oral hygienist will check for symptoms, such as plaque and tartar in the 
    oral cavity. They may also order tests to check for signs of periodontitis. This can 
    be done by x-ray or periodontal probing, using an instrument that measures pocket 
    depths around a tooth

    Treatment Plan
    If diagnosis happens early and treatment is prompt and proper, a person may be 
    able to treat gingivitis at home with good oral hygiene. However, if symptoms do 
    not resolve, or the condition affects a person’s quality of life, they may wish to seek 
    professional help.
    Treatment often involves care by a dental professional and follow-up procedures 
    carried out by the patient at home. A person may be able to prevent gingivitis at 
    home by practicing regular good oral hygiene. This includes brushing teeth at least 
    twice a day, using an electric toothbrush, flossing teeth at least once a day, regularly 

    rinsing the mouth with an antiseptic mouthwash Top of Form

    Complications
    Some complications include abscess or infection in the gingiva or jawbone, 
    periodontitis a more serious condition that can lead to loss of bone and teeth, 
    recurrent gingivitis, trench mouth, where bacterial infection leads to ulceration of 
    the gums

    2. Cancer of Esophagus
    Oesophageal cancer is a serious condition. Clients usually do not experience 
    symptoms until the disease has progressed to interfere with swallowing and 
    passage of food, leading to weight loss.

    Causes and risk factors
    The major cause of oesophageal cancer is chronic irritation of the oesophagus from 
    any source. Alcohol abuse and cigarette smoking, clients with GERD are at higher 
    risk for adenocarcinoma of the oesophagus, other risk factors include habitual 
    ingestion of hot liquids or foods, poor or inadequate, oral hygiene, and nutritional 
    deficiencies

    Signs and symptoms
    Mild, with vague discomfort and difficulty swallowing some foods, Weight loss, 
    progressive dysphagia. As the disease continues the client resorts to consuming 
    liquids only.
    He or she may experience regurgitation of food, haemorrhage, haemoptysis 
    (Vomiting of blood), back pain and respiratory distress due to expansion of the 
    tumour, loss and weakness.

    Investigation
    A barium swallow demonstrates a filling defect caused by a space-occupying mass. A 
    biopsy of tissue removed during esophagoscopy or an esophagogastroduodenoscopy 
    reveals malignant cells.

    A bronchoscopy may determine whether the cancer cells have affected the trachea. 
    Computed tomography (CT) of the chest and abdomen to determine whether 
    metastasis has occurred. If oesophageal cancer is diagnosed in early stages, 

    treatment.

    Treatment Plan
    If oesophageal cancer is diagnosed in early stages, treatment is directed at a cure 
    and includes surgery, chemotherapy, and/or radiation. The surgery is a complete 
    resection of the oesophagus (esophagectomy), which involves removing the tumor 
    and a wide margin of tumor-free tissue as well as surrounding lymph node

    Additional activities
    Remedial activities
    1. Using different literature, define the following medical pathology of oral and 
         oesophagus medical condition
         a. Dental caries
         b. Oral candidiasis
         c. esophagitis
    ANSWERS:
    a. Dental caries also known as a dental decay is defined as a disease that is 
         caused by the breakdown of tooth enamel or it is a chemical dissolution 
         of a tooth surface that brought about by metabolic activity in a microbial 
         deposit covering a tooth surface at any given time.
    b. Oral candidiasis is an infection caused by a yeast (a type of fungus) called 
         candida which normally lives on the skin and inside the body in area 
         such as the mouth, throat, gut and vagina, without causing any problem 
         problems.
    c. Esophagitis is defined as an inflammation that may damage tissues of the 
         esophagus, the muscular tube that delivers food from the patient’s mouth 
         to the stomach.
    2. Oesophageal candidiasis is one of the MOST common infections in the following 
         group of people:
    a. People with Non communicable diseases
    b. People living with HIV/AIDS
    c. People with low salt intake diet
    d. People with hearing bulimia

      ANSWER: b

        

        

            

        1.9.2 Consolidation activities
    A common disease of oral tissue characterized by painful, inflamed, and swollen 
    gums is:
    a. Candidiasis.
    b. Gingivitis.
    c. Herpes simplex.
    d. Periodontitis.

    ANSWER: b
    The incidence of most dental caries is directly related to an increase in the dietary 
    intake of:
    a. Fat.
    b. Protein.
    c. Salt.
    d. Sugar.

    ANSWER: d
    Usually, the first symptom associated with oesophageal disease is:
    a. Dysphagia.
    b. Malnutrition.
    c. Pain.
    d. Regurgitation of food.

    ANSWER: a
    Extended activities
    1. The nurse suspects that a patient who presents with the symptom of food 
    “sticking” in the lower portion of the oesophagus may have the motility disorder 
       known as:
    a. Achalasia
    b. Diffuse spasm
    c. Gastroesophageal reflex

    d. Hiatal hernia

    ANSWER: c 
    1. Match the abnormality of the lips, mouth, or gums listed in column II with its 

    associated symptomatology of the lip, mouth, or gums listed in column I.

          

             

    1. Discuss the following topics with your classmates.
    1. Discuss at least eight healthy oral hygiene habits that have been found to 
    promote good dental health.

    Answer:
    1. Discuss the nursing interventions for a patient with cancer of the oesophagus.
    Answer:
    2. CASE STUDY: Cancer of the Mouth
    Edith, a 64-year-old mother of two, has been a chain smoker for 20 years. During 
    the past month she noticed a dryness in her mouth and a roughened area that is 
    irritating. She mentioned her symptoms to her dentist, who referred her to a medical 
    internist.
    Q1. On the basis of the patient’s health history, the nurse suspects oral cancer. 
    Describe what the nurse would expect the lesion to look like.
    …………………………………………………………………………….
    ………………………………………………………………….
    Answer:
    Q2. During the health history, the nurse noted that Edith did not mention a late 
    occurring symptom of mouth cancer, which is:
    b. Drainage.
    c. Fever.
    d. Odor.
    e. Pain.

    Answer: d
    Q3. On physical examination, Edith evidenced changes associated with cancer of 
          the mouth, such as:
    a. A sore, roughened area that has not healed in 3 weeks.
    b. Minor swelling in an area adjacent to the lesion.
    c. Numbness in the affected area of the mouth.

    d. All of the above.

    Answer: d
    Q4. To confirm a diagnosis of carcinoma of the mouth, a physician would order:
    e. A biopsy.
    f. A staining procedure.
    g. Exfoliative cytology.

    h. Roentgenography.

    Answer: a

    Q5. What is the differential medical diagnosis of esophagitis?

    Answer:
    The differential medical diagnosis of esophagitis includes acute coronary syndrome 
    with atypical chest pain, malignancy, peptic ulcer disease, rings and webs, 
    pneumonia, pulmonary embolism, achalasia, and esophageal motility disorder

    Q6. Differentiate periodontal disease from pulpitis?

    Answer:
    Periodontal (gum) disease is the infection of the gum tissue, and is a more severe 
    version of gingivitis while Pulpitis is the infection of the tooth’s pulp, which is made 

    up of blood vessels, nerves and connective tissue

  • UNIT 5: MEDICAL PATHOLOGIES OF THE SKIN

    5.1. Key unit Competence
    Take appropriate decision on different common medical pathologies of the skin

    5.2. Prerequisite (knowledge, skills, attitudes, and values) 
    To achieve the above competence the associate nurse student needs to have learnt 
    the following subjects:
    • Human body anatomy and physiology: Anatomy of integumentary system is 
       human body’s outer layer, it consists skin, hair, nails and gland. The skin 
       protects human body from infection and injuries that could get from the 
       external environment.
    • Fundamental of Nursing: Vital signs taking and parameters measurements, 
       drugs administration, History taking, Complete health assessment from head 
       to toes trough interview and Physical assessment regarding cardiovascular 
       system.
    • Pharmacology: Some topical and oral drugs for skin condition include: 
        antibacterials,antiinflamatory,corticosteroids,antibiotics,antifungal,antiviral 
         drugs

    5.3. Cross-cutting issues to be addressed
    5.3.1. Gender education
    Emphasize to learners that anybody irrespective of their gender can present and 
    report during group activities.
    During interactive lecturing, make sure that the response of both boys and girls are 
    equally considered.
    Ensure that boys and girls participate equally in all activities such as group work 
    presentations.

     5.3.2. Environment and sustainability
    They also get skills and attitudes that will enable them in their everyday life to address 
    the environment and climate change issues and to have a sustainable livelihood. 
    Help the learners to know maximum skills and attitudes on the environmental 
    sustainability and to be responsible in caring for the skills laboratory where they 

    perform their practice even at health facilities.

    5.4. Guidance on the introductory activity
    This introductory activity helps you to engage learners in introduction of medical 
    pathologies of integumentary system and invite the learners to follow the next 

    lessons.

    Teacher`s activity:
    • Ask learners to observe the schematic representation of skin diseases and 
    answer the given questions.
    • Engage learners in working individually on the activity.
    • Ask any three learners to give their answers

     The expected answers:
    1) The organs and layers of the integumentary include the epidermis(Nails, hair, 
         gland), dermis (It contains sweat and oil glands and hair follicles.),Hypodermis 
         (It’s the fatty layer of skin that helps insulate the body)
    2) The integumentary system is responsible of protective barrier against 
         mechanical, thermal and physical injury and hazardous substances. 
         Prevents loss of moisture. Reduces harmful effects of UV radiation. Acts as 
        a sensory organ (touch, detects temperature)
    3) The different skin conditions due various microorganism such as bacteria, 
         fungi, virus and some allergy agent. 
    4) The most common genetic skin diseases(albinism) and atopic dermatitis 
        (eczema) 
    5) Treatment of Skin conditions such as antihistamines; medicated creams and 
         ointments; antibiotics; vitamin or steroid injections; laser therapy; targeted 

         prescription medications.


        

         

        a) Prerequisites
    This is the first lesson of the fifth unit of medical pathologies of integumentary 
    system. In this lesson, you will be dealing with the common medical skin conditions, 
    which are dermatitis, skin infection, and genetic diseases. The first thing to do before 
    starting teaching is to remind learners that they have learnt about structure of skin 
    and skin function, health assessment of integumentary system from fundamentals 
    of nursing. The teacher will let students discuss the questions as indicated in 
    introductory activity and from the case study from learning activity 5.1 so that they 
    can prepare themselves for this lesson.

    b) Learning objectives: 
    • List the common medical skin conditions of integumentary system: erythema, 
       eczema, albinism, vitiligo, psoriasis, furuncle and acne.
    • Describe causes, risk factors and pathophysiology of skin diseases

    c) Teaching resources
    The teacher could avail the model of skin structure. In addition, the teacher should 
    present to the students the library textbooks on diseases, which affect the human 
    skin, and indicates the pages. All students must have their student’s books. There 
    is need of black board and chalks or flipcharts and markers.

    d) Learning activities 
    Teacher ‘activities and methodology
    • Ask learners to do individually activity 5.0 in their student book and answer 
    the questions number 1, 2 and learning activity 5.1
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student`s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 

       in making that conclusion

    The expected answers from Questions of introductory activity5.0
    1. Probably the patients are complaining of rashes, itchiness, skin changes 
        and damage of body image.
    2. The different medical conditions could be Vitiligo, eczema, psoriasis, 
         acne etc.

    The expected answers from Questions of learning activity 5.1
    1. The abnormal signs and symptoms that patient was presenting are: 
        Physical examination revealed multiple rounded purplish nodules located bilaterally 
        on the extensor surface of the lower extremities, and red bumps on the soles, palms, 
        arms, face and legs that grow into circles that may look like targets, itchiness.

    2. The medical problem of this patient could be:
         Skin conditions like eczema, scabies, and pityriasis versicolor.

    3. The following investigations have been ordered to guide the confirmation of the 
        medical problem:
       Laboratory investigations revealed an elevated C-reactive protein – CRP (119.82 
        mg/l, normal 5.0 mg/l) and erythrocyte sedimentation rate – ESR (74 mm/h; normal 
        0–10 mm/h). Urine and blood culture results were negative. Throat swab revealed 
        growth of normal flora. The diagnostic test for Yersinia was negative. His chest 
        X-ray revealed bihilar lymphadenopathy.

    4. The management of this case include:
        Further evaluation with high-resolution chest computed tomography confirmed 
        the lymphadenopathy and demonstrated thickened bronchial walls of both lungs 
       and nodular lesions, which suggested an alveolar sarcoidosis. The foot ultrasound 
       showed a small amount of fluid in the right ankle joint and effusion in all sheaths of the 
       flexor, extensor digitorum and the big toe tibial and peroneal tendons. Sonography 
       also showed massive bilateral swelling of the subcutaneous tissue up to 1/2 shank.

    5. If not treated, the consequences will be:
        Altered body image, generalized infection, anxiety and depression.

    The expected answers from Questions of self-assessment 5.1
    1) Definition of Erythema
    Erythema is redness of the skin or mucous membranes, caused by hyperemia 
    (increased blood flow) in superficial capillaries.It occurs with any skin injury, 
    infection, or inflammation. Examples of erythema not associated with pathology 

    include nervous blushes.

    2) The Types of Erythema are:
    There are various types of erythema, of which erythema multiforme is the most 
    common. Each type of erythema has a different cause, and therefore needs different 
    treatments. Some forms of erythema include:
    • Erythema multiforme (EM), which occurs due to an allergic reaction to 
       medications or infection
    • Erythema nodosum (EN), which is characterized by nodular eruptions on the 
       lower legs 
    • Erythema Ab Igne, which is caused by continued exposure to heat
    • Erythema chronicum migrans, which is noted in in the early stages of Lyme 
      disease
    • Erythema induratum, which is associated with tuberculosis
    • Erythema infectiosum (also called the Fifth disease), which is commonly 
       caused during childhood
    • Erythema marginatum, which is characterized by pink rings on the limbs
    • Erythema toxicum (ET), which affects neonates
    • Erythema gyratum repens, which is a component of a paraneoplastic process
    • Palmar erythema, which is characterized by reddening on the palms of hands
    • Erythema annulare centrifugum, presents with erythema (redness) in a ring 
      (annulare) form that spreads from a center (centrifugam). This condition was 
       first described by Darier in 1916.
    • Erythema nodosum (EN), which is characterized by nodular eruptions on the 
    lower legs. Specific symptoms include weight loss, uneasiness, low-grade 
    fever, cough and pain in joint (arthralgia) with or without arthritis.
    There are two serious forms of erythema multiforme – Stevens Johnson syndrome 
    (SJS) and Toxic epidermal necrolysis (TENS)

    3) The Causes of Erythema are:
      The causes of erythema vary in different conditions. Common causes include an 
       allergic reaction to:
    • Medications such as penicillin, antibiotics, sulfonamides, barbiturates and 
       phenytoin
    • Infections such as herpes simplex virus (HSV), or mycoplasma. 
      Other causes of erythema include exposure to:
    • Heat
    • Radiation
    • Insect bites

    • Hormonal problems

    4) The Symptoms of Erythema are the following:
    The symptoms associated with erythema vary from one type to another. The most 
    common symptoms of erythema multiforme include: Itchy skin, Joint pain, Vision 
    problems with dry and itchy eyes, Mouth sores, Fatigue, Photosensitivity (sensitivity 
    to light or sun), Flu-like symptoms in severe cases, Fever.
    The skin sores or lesions may be raised, discolored and have a central sore 
    surrounded by pale red rings that look like a bulls-eye, earning them the name 
    Target lesions. Some lesions are liquid-filled blisters while others look like hives. 
    They can appear on face, lips, legs, feet, hands, arms or palms.

    5) The diagnosis of Erythema
    Different types of erythema manifest differently, and the diagnosis may depend 
    on the physical appearance of the skin. Doctors normally recognize erythema 
    multiforme just by examining the skin. The doctor may also ask a series of questions 
    such as a history of recent infections and medications to pinpoint out the cause. In 
    some cases, a skin biopsy may be done.

    6) Treatment plan of Erythema
    Supportive care for erythema includes:
    • Cool compresses on the affected areas
    • Pain killers( Paracetamol ) or antihistamines(Polaramine), for itching
    • Steroid(hydrocortisone, dexamethasone)) or IV medications in severe cases
    • Soothing creams for itchy or sore skin
    These medications and supportive care do not shorten the duration of the condition, 
    but provide comfort to the patient. 
    Erythema is treated depending on the severity and type of erythema.
    • For mild rashes: These may be treated with only moisturizers and topical 
    corticosteroid creams to reduce itching and burning of the skin.
    A Burrow’s compress, which has antibacterial and antifungal properties, is an 
    effective way to treated erythema.
    For severe rashes: These can be life threatening and must be treated as soon as 
    possible. Patients with severe rashes may need to stay in a burns unit. Severe pain 
    due to blisters and nodules may require pain medications such as acetaminophen, 
    hydrocodone or others as recommended by your doctor. The blisters can be 
    infected and leak large amounts of pus, which needs to be monitored and treated. 
    Intravenous immunoglobulins such as immunoglobulin G (IgG) may be needed. 
    Antivirals may be administered if the cause of the erythema is suspected to be 
    herpex simplex virus (HSV). Other specialists may be consulted if different organs 
    such as the eyes are affected. Photomodulation therapy, which is a red light therapy 

    for the skin is another effective way to treat severe cases.

    For recurrent rashes: Recurrent rashes due to HSV infection may require a daily 
    dose of the anti-viral medication acyclovir orally to suppress the virus for several 
    months.

    Lesson 2: Description of albinism and vitiligo 

    a) Prerequisites
    This is the second lesson of the fifth unit of medical pathologies of integumentary 
    system. In this lesson, you will be dealing with the common medical skin conditions, 
    which are albinism and vitiligo. The first thing to do before starting teaching is to 
    remind learners that they have learnt about structure of skin and skin function, health 
    assessment of integumentary system from fundamentals of nursing. In addition, the 
    teacher will remind the learners what they have learnt on erythema. The teacher 
    will let students discuss the questions from the case studies from learning activity 
    5.2 and 5.3 so that they can prepare themselves for this lesson.

    b) Learning objectives: 
    • Define the term of albinism and Vitiligo
    • Identify the causes of albinism and Vitiligo
    • Explain the different signs and symptoms of albinism and Vitiligo
    • Explain pathophysiology of albinism and Vitiligo
    • Describe the different types of albinism and Vitiligo.
    • Describe different medical diagnosis of albinism and Vitiligo
    • Describe different treatment of albinism and Vitiligo

    c) Teaching resources
    The teacher could avail the model of skin structure. In addition, the teacher should 
    present to the students the library textbooks on diseases, which affect the human 
    skin, and indicates the pages. All students must have their student’s books. There 
    is need of black board and chalks or flipcharts and markers.

    d) Learning activities 
    Teacher ‘activities and methodology
    • Ask learners to do individually activity 5.2 and 5.3 in their student book and 
    answer the questions number from the learning activities 5.2 and 5.3
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
    knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student`s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
       in making that conclusion.

    ♦ Expected answers to Learning Activity 5.2 
    1) The abnormal signs and symptoms that patient was presenting 
    are: 
    • Freckles
    • Moles, with or without pigment — moles without pigment are generally pink colored
    • Large freckle-like spots (lentigines)
    • Sunburn and the inability to tan

    2) The medical problem of this patient could be:
    Skin diseases like vitiligo, hypopigmentation, albinism

    3) The investigations that have been ordered to guide the confirmation 
    of the medical problem: None
    Physical examination is helpful to diagnose the eczema

    4) The management of this case:
    Albinism is a lifelong genetic condition with no cure. Therefore, treatment focuses 
    on minimizing the symptoms and watching for skin changes.
    People with albinism must receive appropriate eye care, including: 
    • prescription glasses
    • dark glasses to protect the eyes from the sun
    • regular eye exams
    Surgery on the optical muscles can sometimes minimize the “shaking” that occurs 
    in nystagmus. Procedures to minimize strabismus can make it less noticeable, but 
    surgery does not improve the vision. The level of success in reducing symptoms 
    varies among individuals.
    People should watch their skin carefully for any changes and use sunscreen for 

    protection.

    5) If not treated, the consequences are:
    If the albinism is not treated, the patient will present eye problems, poor eyesight – 
    either short-sightedness or long-sightedness, and low vision (sight loss that cannot 
    be corrected)

    astigmatism – where the cornea (clear layer at the front of the eye) is not perfectly 
    curved or the lens is an abnormal shape, causing blurred vision, photophobia – 
    where the eyes are sensitive to light, nystagmus – where the eyes move involuntarily 

    from side to side, causing reduced vision.

       

          

             6) Treatment plan of albinism
    There is no cure for albinism. You must manage the condition by being vigilant 
    about sun protection. You can protect your skin, hair and eyes by:
    • Staying out of the sun.
    • Wearing sunglasses.
    • Covering up with sun-protective clothing.
    • Wearing hats.
    • Applying sunscreen regularly.
    If you have crossed eyes (strabismus), a surgeon may be able to correct the issue 
    with surgery.

    ♦ Expected answers to Learning Activity 5.3
    1. The abnormal signs and symptoms that pictures present are:
    2. Discoloration of skin, hypopigmentation, white patches
    3. The medical problem of this patient could be Vitiligo or albinism.
    4. The investigations that have been ordered to guide the confirmation of the 
    medical problem
    Skin disease as vitiligo is diagnosed by physical examination according to health 
    experience of working with patient suffering the vitiligo.
    A skin biopsy involves removing a small portion of the affected skin tissue to check 
    whether there are pigment cells (melanocytes) in the skin. The skin sample will be 
    evaluated under a microscope in the lab. If it shows that there are no pigment cells 
    present, a diagnosis of vitiligo will likely be confirmed.

    1) The management of this case
    There is no cure for vitiligo. The goal of medical treatment is to create a uniform skin 
    tone by either restoring color (repigmentation) or eliminating the remaining color 
    (depigmentation). Common treatments include camouflage therapy, repigmentation 
    therapy, light therapy and surgery. Counseling may also be recommended.

    2) If not treated, the consequences will be the following:
    Vitiligo does not pose a serious threat to one’s health, but it can result in physical 
    complications, such as eye issues, hearing problems, and sunburn. People with 
    vitiligo also tend to be more likely to have another autoimmune disease (like thyroid 

    disorders and some types of anemia)

      

        

         6) Treatment plan of vitiligo
    There is no cure for vitiligo. The goal of medical treatment is to create a uniform skin 
    tone by either restoring color (repigmentation) or eliminating the remaining color 
    (depigmentation). Common treatments include camouflage therapy, repigmentation 
    therapy, light therapy and surgery. Counseling may also be recommended.

    Camouflage therapy:
    • Using sunscreen with an SPF of 30 or higher. Also, the sunscreen should 
    shield ultraviolet B light and ultraviolet A light (UVB and UVA). Use of 
    sunscreens minimizes tanning, thereby limiting the contrast between affected 
    and normal skin.
    • Makeups help camouflage depigmented areas. One well-known brand is 
    Dermablend®.
    • Hair dyes if vitiligo affects the hair.
    • Depigmentation therapy with the drug monobenzone can be used if the 
    disease is extensive. This medication is applied to pigmented patches of skin 
    and will turn them white to match the areas of vitiligo.

    Repigmentation therapy:
    • Corticosteroids can be taken orally (as a pill) or topically (as a cream put on 
    the skin). Results may take up to 3 months. The doctor will monitor the patient 
    for any side effects, which can include skin thinning or striae (stretch marks) 
    if used for a prolonged period.
    • Topical vitamin D analogs.
    • Topical immunomodulators such as calcineurin inhibitors.

    Light therapy:
    • Narrow band ultraviolet B (NB-UVB) requires two to three treatment sessions 
    per week for several months.
    • Excimer lasers emits a wavelength of ultraviolet light close to that of narrow 
    band UVB. This is better for patients who do not have widespread or large 
    lesions since it is delivered to small, targeted areas.
    • Combining oral psoralen and UVA (PUVA) is used to treat large areas of skin 
    with vitiligo. This treatment is said to be very effective for people with vitiligo 
    in the areas of the head, neck, trunk, upper arms and legs. 

    Surgery:
    • Autologous (from the patient) skin grafts: Skin is taken from one part of
      the patient and used to cover another part. Possible complications include 
       scarring, infection or a failure to repigment. This might also be called mini 
        grafting.
    • Micropigmentation: A type of tattooing that is usually applied to the lips of 
       people affected by vitiligo.

    Counseling:
    • Vitiligo can cause psychological distress and has the ability to affect a person’s 
    outlook and social interactions. If this happens, your caregiver may suggest 
    that you find a counselor or attend a support group.

    Lesson 3: Description of Eczema and Psoriasis

    a) Prerequisites
    This is the third lesson of the fifth unit of medical pathologies of integumentary 
    system. In this lesson, you will be dealing with the common medical skin conditions, 
    which are Eczema and Psoriasis . The first thing to do before starting teaching is 
    to remind learners that they have learnt about structure of skin and skin function, 
    health assessment of integumentary system from fundamentals of nursing. In 
    addition, the teacher will remind the learners what they have learnt on erythema, 
    albinism and vitiligo. The teacher will let students discuss the questions from the 
    case studies from learning activity 5.4 and 5.5 so that they can prepare themselves 
    for this lesson.

    b) Learning objectives: 
    • Define the term of psoriasis and eczema
    • Identify the causes of psoriasis and eczema 
    • Explain the different signs and symptoms of psoriasis and eczema 
    • Explain pathophysiology of psoriasis and eczema 
    • Describe the different types of psoriasis and eczema 
    • Describe different medical diagnosis of psoriasis and eczema
    • Describe different treatment of psoriasis and eczema 

    c) Teaching resources
    The teacher could avail the model of skin structure. In addition, the teacher should 
    present to the students the library textbooks on diseases, which affect the human 
    skin, and indicates the pages. All students must have their student’s books. There 

    is need of black board and chalks or flipcharts and markers.

    d) Learning activities 
    Teacher ‘activities and methodology
    • Ask learners to do individually activity 5.4 and 5.5 in their student book and 
    answer the questions number from the learning activities 5.4 and 5.5
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
    knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student`s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 
        in making that conclusion.
    ♦ Expected Answers from questions of Learning Activity 5.4
    1. The abnormal signs and symptoms that patient was presenting 
          Plaques of red skin often covered with silver-colored scales. These plaques may 
          be itchy and painful, and they sometimes crack and bleed. In severe cases, the 
          plaques will grow and merge, covering large areas.
          Disorders of the fingernails and toenails, including discoloration and pitting of the 
          nails. The nails may also crumble or detach from the nail bed.
    2. Basing on those signs and symptoms, The medical problem could be Psoriasis, 
         eczema or Pityriasis vesicolor
    3. The investigations that have been ordered to guide the confirmation of the 
         medical problem: None
       Investigation is based by physical examination done by experienced health care 
          providers
    4. The management of this case include:
    • Steroid creams
    • Moisturizers for dry skin
    • Coal tar (a common treatment for scalp psoriasis available in lotions, creams, 
       foams, shampoos, and bath solutions)
    • Vitamin D-based cream or ointment (a strong kind ordered by your doctor. 
       Vitamin D in foods and pills has no effect.)
    • Retinoid creams
    5. If not treated, the consequences will be the following:
    The short-term symptoms of psoriasis may include: thick, discolored skin patches 
    with a covering of silvery scales, dry and cracked skin that may bleed or itch, 
    thick, ridged, and pitted nails, psoriatic arthritis (PsA),

    Expected Answers from questions of Self-assessment 5.4

    1) Definition of psoriasis
    Psoriasis is a skin disorder that causes skin cells to multiply up to 10 times faster 
    than normal. This makes the skin build up into bumpy red patches covered with 
    white scales.

    2) Types of psoriasis
    • Psoriatic arthritis
    • Pustular psoriasis
    • Guttate psoriasis
    • Inverse psoriasis
    • Erythrodermic psoriasis

    3) The Causes of psoriasis are not known
    Things that can trigger an outbreak of psoriasis include:
    • Cuts, scrapes, or surgery
    • Emotional stress
    • Strep infections
    • Medications, including blood pressure medications, anti-malarial drugs, 
        lithium and other mood stabilizers, antibiotics, and NSAIDs.

    4) Signs and Symptoms of psoriasis are the following:
    Plaques of red skin often covered with silver-colored scales. These plaques may 
    be itchy and painful, and they sometimes crack and bleed. In severe cases, the 
    plaques will grow and merge, covering large areas.
    Disorders of the fingernails and toenails, including discoloration and pitting of the 
    nails. The nails may also crumble or detach from the nail bed.

    Plaques of scales or crust on the scalp Arthritis

    5) Diagnosis of psoriasis
    Physical exam. It is usually easy for the doctor to diagnose psoriasis, especially if 
    the patient has some plaques on areas such as on the Scalp, Ears, Elbows, Knees, 
    Belly button, and Nails. The health care provider performs full physical exam and 
    ask if people in the family have psoriasis.
    Lab tests. The doctor might do a biopsy -- remove a small piece of skin and test it 
    to make sure you do not have a skin infection. There is no other test to confirm or 
    rule out psoriasis.
    6) Treatment of psoriasis
    • Steroid creams
    • Moisturizers for dry skin
    • Coal tar (a common treatment for scalp psoriasis available in lotions, creams, 
    foams, shampoos, and bath solutions)
    • Vitamin D-based cream or ointment (a strong kind ordered by your doctor. 
    Vitamin D in foods and pills has no effect.)
    • Retinoid creams
    Treatments for moderate to severe psoriasis include:
    • Light therapy
    • Biologic treatments .These work by blocking the part of the body’s immune 
    system that is overactive in psoriasis. Biologic medications such as 
    adalimumab.
    • An enzyme inhibitor

    ♦ Expected Answers from questions of Learning Activity 5.5
    1) The abnormal signs that above picture present
         Red to brownish-gray patches, especially on the hands, feet, ankles, wrists, neck, 
         upper chest, eyelids, inside the bend of the elbows and knees, and in infants, the 
        face and scalp. Small, raised bumps, which may leak fluid and crust over when scratched.
    2) Based the signs that picture have, it should be eczema, psoriasis, pityriasis
    3) The investigations that have been ordered to guide the confirmation of the 
          medical problem
          Investigation is based by physical examination done by experienced health care 
          providers
    4) The management of this case include:
       Use a humidifier if dry air makes your skin dry
    Moisturize your skin using a cream or ointment. Lotions do not work as well.
    Use skin products that contain ceramide. These moisturizers replace some 
    of the “glue” (the barrier) missing from your skin.
    Apply cortisone creams and ointments. Cortisone is an over-the-counter steroid 
    found in hydrocortisone (Cortisone 10®) and hydrocortisone acetate (Cort-Aid®). 

    They may help control the itching and redness

    ♦ Expected Answers to Self-assessment 5.5
    1) Definition of eczema
    Eczema (eg-zuh-MUH) is an inflammatory skin condition that causes itchiness, 
    dry skin, rashes, scaly patches, blisters and skin infections. Itchy skin is the most 
    common symptom of eczema. There are seven different types of eczema: atopic 
    dermatitis, contact dermatitis, dyshidrotic eczema, nummular eczema, seborrheic 

    dermatitis and stasis dermatitis.

    2) Types of eczema
    There are several types of eczema:
    • Besides atopic dermatitis
    • Allergic contact dermatitis: This is a skin reaction that occurs following contact 
      with a substance or allergen that the immune system recognizes as foreign.
    • Dyshidrotic eczema: This refers to irritation of the skin on the palms of the 
        hands and soles of the feet. It is characterized by blisters.
    • Neurodermatitis: This leads to scaly patches of skin on the head, forearms, 
       wrists, and lower legs. It occurs due to a localized itch, such as from an insect 
       bite.
    • Discoid eczema: Also known as nummular eczema, this type presents as 
      circular patches of irritated skin that can be crusted, scaly, and itchy.
    • Stasis dermatitis: This refers to skin irritation of the lower leg. It is usually 
       related to circulatory problems.

    3) The Causes of eczema
    Researchers do not know the definitive cause of eczema, but many health 
    professionals believe that it develops from a combination of genetic and 
    environmental factors.
    Children are more likely to develop eczema if a parent has it or another atopic 

    condition. If both parents have an atopic condition, the risk is even higher.

    The following environmental factors may also bring out the symptoms of eczema:
    • Irritants: These include soaps, detergents, shampoos, disinfectants, juices 
    from fresh fruits, meats, and vegetables.
    • Allergens: Dust mites, pets, pollens, and mold can all lead to eczema. This is 
    known as allergic eczema.
    • Microbes: These include bacteria such as Staphylococcus aureus, viruses, 
    and certain fungi.
    • Hot and cold temperatures: Very hot and very cold weather, high and low 
    humidity, and perspiration from exercise can bring out eczema.
    • Foods: Dairy products, eggs, nuts and seeds, soy products, and wheat can 
    cause eczema flares.
    • Stress: This is not a direct cause of eczema, but it can make the symptoms 
        worse.
    • Hormones: Females may experience increased eczema symptoms when 
       their hormone levels are changing, such as during pregnancy and at certain 
        points in the menstrual cycle.

    4) The Symptoms of eczema
    The following atopic dermatitis symptoms are common in adults:
    • rashes that are more scaly than those occurring in children
    • rashes that commonly appear in the creases of the elbows or knees or the 
    nape of the neck
    • rashes that cover much of the body
    • very dry skin on the affected areas
    • rashes that are permanently itchy
    • skin infections

    5) The diagnosis of eczema
    The healthcare provider may recommend patch testing on the skin. In this test, 
    small amounts of different substances are applied to the skin and then covered. 
    The healthcare provider looks at the skin during visits over the next few days to look 
    for signs of a reaction. Patch testing can help diagnose specific types of allergies 
    causing your dermatitis

    6) Treatment plan of eczema
    The goal is to reduce itching and discomfort and prevent infection and additional 
    flare-ups.
    Consider these treatment tips: 
    • Use a humidifier if dry air makes your skin dry. 
    • See a psychiatrist for medication and a therapist for counseling if you are 
      experiencing symptoms of poor mental/emotional health. 
    • Moisturize your skin using a cream or ointment. Lotions do not work as well. 
      Apply several times a day, including after you bathe or shower. Use lukewarm 
      water in the tub or shower instead of hot. 
    • Use mild soaps and other products that are free of perfumes, dyes and 
       alcohol. Look for products labeled “fragrance free,” “hypoallergenic” and “for 
       sensitive skin.” 
    • Use skin products that contain ceramide. These moisturizers replace some of 
       the “glue” (the barrier) missing from your skin. 
    • Apply cortisone creams and ointments. Cortisone is an over-the-counter 
       steroid found in hydrocortisone (Cortisone 10®) and hydrocortisone acetate 
      (Cort-Aid®). They may help control the itching and redness. 
    • Take over-the-counter antihistamines for severe itching. 
    • Take prescription medications. Your healthcare provider may prescribe 
       steroid creams, pills and/or shots. Long-term risks include side effects like 
       high blood pressure, weight gain and thinning of the skin. There are newer 
       medications, called topical immunomodulators (TIMs) that show progress in 
       treating patients who do not respond to other treatments. They change the 
       body’s immune response to allergens and have fewer side effects. 
    • Phototherapy: The ultraviolet light waves found in sunlight have been shown 
       to help certain skin disorders, including eczema. Phototherapy uses ultraviolet 
        light, usually ultraviolet B (UVB), from special lamps.

    Lesson 5: Description of furuncle and acne

    a) Prerequisites
    This is the fifth lesson of the unit 5 of medical pathologies of integumentary system. 
    In this lesson, you will be dealing with the common medical skin conditions, which 
    are furuncle and acne. The first thing to do before starting teaching is to remind 
    learners that they have learnt about structure of skin and skin function, health 
    assessment of integumentary system from fundamentals of nursing. In addition, 
    the teacher will remind the learners what they have learnt on erythema, albinism, 
    vitiligo, psoriasis, and eczema. The teacher will let students discuss the questions 
    from the case studies from learning activity 5.6 and 5.7 so that they can prepare 
    themselves for this lesson.

    b) Learning objectives: 
    • Define the term of furuncle and acne
    • Identify the causes of furuncle and acne 
    • Explain the different signs and symptoms of furuncle and acne 
    • Explain pathophysiology of furuncle and acne 
    • Describe the different types of furuncle and acne 
    • Describe different medical diagnosis of furuncle and acne 
    • Describe different treatment of furuncle and acne 

    c) Teaching resources
    The teacher could avail the model of skin structure. In addition, the teacher should 
    present to the students the library textbooks on diseases, which affect the human 
    skin, and indicates the pages. All students must have their student’s books. There 
    is need of black board and chalks or flipcharts and markers.

    d) Learning activities 
    Teacher ‘activities and methodology
    • Ask learners to do individually activity 5.6 and 5.7 in their student book and 
       answer the questions number from the learning activities 5.6 and 5.7
    • Provide the necessary materials.
    • Move around in silence to monitor if they are having some problems
    • Remember to assist those who are weak but without giving them the 
       knowledge.
    • Invite any five students to provide their answers 
    • Ask other students to follow carefully the answers provided by students
    • Note on the blackboard the main student`s ideas.
    • Tick the correct responses and correct those ones, which are incorrect and try 
       again to complete those, which are incomplete.
    • Harmonize and conclude on the learned knowledge and still engage student 

       in making that conclusion.

        

           

              Self-assessment 5.6
    1) Definition of furuncle
    A boil (or furuncle) is a pus-filled bump that develops in your skin. Carbuncles are 
    clusters of several boils. Boils usually begin as red bumps, which quickly increase 
    in size and fill with pus. Boils are usually caused by the bacteria Staphylococcus 
    aureus (staph infection)
    Furuncles (boils) are skin abscesses caused by staphylococcal infection, which 
    involve a hair follicle and surrounding tissue. Carbuncles are clusters of furuncles 
    connected subcutaneously, causing deeper suppuration and scarring. They are 
    smaller and more superficial than subcutaneous abscesses.

    2) Types of furuncle are :
    • Carbuncle.
    • Hidradenitis suppurativa (seen in the armpit or groin)
    • Pilonidal cyst (area on the back where the buttocks merge)
    • Cystic acne.
    • Sty (stye)

    3) The Causes of furuncle are:
    Bacteria typically cause a furuncle, the most common being Staphylococcus aureus 
    — which is why furuncles can also be called staph infections. S. aureus normally 
    resides on some areas of the skin.
    S. aureus can cause an infection in situations where there are breaks in the skin, 
    such as a cut or a scratch. Once the bacteria invade, the immune system tries to 
    fight the microorganisms. The boil is actually the result of your white blood cells 
    working to eliminate the bacteria

    4) The Symptoms of furuncle are the following:
    Furuncles develop rapidly as pink or red bumps. They are often painful. The 
    surrounding skin is typically red, inflamed and tender.
    The lesions often appear on the neck, breast, face, buttocks, or thighs. They occur
    in places prone to hair, sweat, and friction, and they tend to start in a hair follicle
    The bump fills with pus within a few days, and it grows. The bigger it gets, the more 
    painful it becomes.

    5) The diagnosis of furuncle
    The health care provider will likely be able to diagnose a boil or carbuncle simply 
    by looking at it. A sample of the pus may be sent to the lab for testing. This may 
    be useful if you have recurring infections or an infection that has not responded to 
    standard treatment.

    6) Treatment plan of furuncle include:
    Antibiotics should only be used if recommended by a medical professional. The 
    best medicine for furuncle are clindamycin (Cleocin, Benzaclin, Veltin), doxycycline 
    (Doryx, Oracea, Vibramycin), erythromycin (Erygel, Eryped), gentamicin (Gentak), 
    levofloxacin (Levaquin), mupirocin (Centany), sulfamethoxazole/trimethoprim 
    (Bactrim, Septra), tetracycline. The health care provider prescribe the painkiller 
    such paracetamol, etc.

    ♦ Expected answers to Learning Activity 5.7 
    1. The medical skin conditions that above pictures present are acne, abcess ,
         and     furuncle
    2. The causes of the above skin conditions are Some microorganism such as 
         bacteria, virus, fungiuman body and hormonal change in 
    3. The treatment of the above skin condition
          Prescribe the antibiotics, anti inflammatory, and pain killer
    4. If they are not treated , it can be complicated into the abscess, damage body 

         image of adolescent.

               

    6) Treatment plan of acne
    The most common topical prescription medications for acne are:
    • Retinoids and retinoid-like drugs. Drugs that contain retinoic acids or tretinoin 
       are often useful for moderate acne. ... 
    • Antibiotics. These work by killing excess skin bacteria and reducing redness 
       and inflammation. ... 
    • Azelaic acid and salicylic acid. ... 

    • Dapsone.

    1.5. SUMMARY OF THE UNIT
    Skin diseases are conditions that affect your skin. These diseases may cause 
    rashes, inflammation, itchiness or other skin changes. Some skin conditions 
    may be genetic, while lifestyle factors may cause others. Skin disease treatment 
    may include medications, creams or ointments, or lifestyle changes. Common 
    skin conditions include acne, contact dermatitis, benign tumors, cancers, atopic 

    dermatitis (also called eczema), and psoriasis.

    END UNIT 5 ASSESSMENT OF MEDICAL PATHOLOGIES OF THE SKIN 

    (TO BE HIGHLIHTTED)

                    

                  

            ADDITIONAL INFORMATION 

             1. Scabies

         

           Source: World Health Organisation (2022),scabies retreived from https://www.
           who.int/news-room/fact-sheets/detail/scabies

    Scabies is a skin infestation caused by a mite known as the Sarcoptes scabiei. 
    Untreated, these microscopic mites can live on your skin for months. They reproduce 
    on the surface of your skin and then burrow into it to lay eggs. This causes an itchy, 
    red rash to form on your skin.

    Signs and Symptoms
    After the initial exposure to scabies, it can take 2 to 5 weeks Trusted Source for 
    symptoms to appear. 
    The hallmark symptoms of scabies include a rash and intense itching that gets 
    worse at night.
    Common sites for scabies in older children and adults include the:
    • wrist
    • elbow
    • armpit
    • nipple
    • penis
    • waist
    • buttocks
    • area between the fingers
    Scabies in babies and toddlers, and sometimes the very elderly or 
    immunocompromised, can show up on the:
    • head
    • face
    • neck
    • hands
    • soles of the feet

    The rash itself can consist of: 
    • tiny bites
    • hives
    • bumps under the skin
    • pimple-like bumps
    The burrow tracks of the mite can sometimes be seen on the skin. They may appear 
    as tiny raised or discolored lines.

    Types of scabies
    There is only one type of mite that causes a scabies infestation in humans. This 
    mite is called Sarcoptes scabiei. However, these mites can cause several types of 
    infestations.

    Typical scabies
    This infestation is the most common. It causes an itchy rash on the hands, wrists, 
    and other common spots. However, it does not infest your scalp or face.

    Nodular scabies
    This type of scabies may develop as itchy, raised bumps or lumps, especially 
    around your genitals, armpits, or groin.

    Scabies diagnosis
    The health care provider is able to diagnose scabies simply by performing a physical 
    exam and inspecting your affected area of skin. In some cases, your doctor may 
    want to confirm the diagnosis by removing a mite from your skin with a needle.
    If a mite cannot easily be found, your doctor will scrape off a small section of skin to 
    obtain a tissue sample. This sample will then be examined under a microscope to 
    confirm the presence of scabies mites or their eggs.
    A scabies ink test (or Burrow Ink Test) can help spot burrowed paths in your skin 
    created by the mites. To do this test, your doctor can drop ink from a fountain pen 
    onto an area of the skin that appears to be infested. They then wipe away the ink.
    Any ink that fell into the burrowed tunnels will remain and be obvious to the naked 
    eye. That is a good indication you have an infestation.

    Scabies treatment
    Products used to treat scabies are called scabicides because they kill scabies mites; 
    some also kill mite eggs. Scabicides used to treat human scabies are available only 
    with a doctor’s prescription.
    Scabicide lotion or cream should be applied to all areas of the body from the neck 
    down to the feet and toes.
    Scabies treatment includes administration of a scabicidal agent (eg, permethrin, 
    lindane, or ivermectin), as well as an appropriate antimicrobial agent if a secondary 
    infection has developed.
    The two most widely used treatments for scabies are permethrin cream and 
    malathion lotion (brand name Derbac M). Both medications contain insecticides 
    that kill the scabies mite. Permethrin 5% cream is usually recommended as the first 
    treatment. Malathion 0.5% lotion is used if permethrin is ineffective.

    Medications for scabies itch
    There are additional medications to help relieve some of the bothersome symptoms 
    associated with scabies. These medications include:
    • antihistamines, such as diphenhydramine (Benadryl or pramoxine lotion to 
       help control the itching
    • antibiotics to kill any infections that develop as a result of constantly scratching 
         your skin
    • steroid creams to relieve swelling and itching
     Pityriasis versicolor

      Carefully observe the picture below and answer the following questions:

         

        

          Source: Wikipedia (2022),tinea verscolor,retrieved from https://en.wikipedia.org/

             wiki/Tinea_versicolor

    Pityriasis versicolor is a rash caused by a yeast-like germ. It is not harmful or passed 
    on through touching (contagious). Treatment can clear the rash. Some people who 
    are prone to this condition need regular treatment to prevent the rash from coming 
    back (recurring).

    Signs and Symptoms
    Discolored patches of skin are the most noticeable symptom of tinea versicolor, and 
    these patches usually show up on the arms, chest, neck, or back. These patches 
    may be:
    • lighter (more common) or darker than the surrounding skin
    • pink, red, tan, or brown
    • dry, itchy, and scaly
    • more prominent with tanning
    • prone to disappear in cooler, less humid weather
    Tinea versicolor that develops in people with dark skin may result in the loss of skin 
    color, known as hypopigmentation. For some people, the skin may darken instead 
    of lighten. This condition is known as hyperpigmentation.

    Pathophysiology of Tinea versicolor (Ptyriasis versicolor)
    Pityriasis versicolor (Tinea versicolor) is a superficial chronic fungal infection 
    caused by Pityrisporum species which are normal “inhabitants” of the cutaneous 
    flora. The morphologic changes from yeast to mycelial hypha form are important in 
    the development of clinical lesions.

    Pityriasis versicolor is a superficial fungal infection of the stratum corneum, due 
    to dimorphic yeasts of the genus Malassezia, leading to hypo- or hyperpigmented 
    macular lesions on seborrheic areas of the trunk.

    Eruption is most common in the summer months in adolescents. Often has a 
    relapsing nature requiring frequent treatment or prophylaxis.

    Primarily a clinical diagnosis that is confirmed by a KOH preparation demonstrating 
    fungal elements with a characteristic spaghetti-and-meatballs appearance indicating 
    the presence of both yeast and short hyphae.

    Easily treated with either topical medications, including zinc pyrithione shampoo, 
    selenium sulfide shampoo, or azole-class topical antifungal creams. More extensive 
    disease may require systemic therapy with antifungal drugs.

    After successful treatment, remind patients that it may take up to 6 weeks before 
    their normal skin pigmentation returns.

    Causes of Ptyriasis Versicolor ( Tenea Versicolor)
    The fungus that causes tinea versicolor can be found on healthy skin. It only starts 
    causing problems when the fungus overgrows. A number of factors may trigger this 
    growth, including:
    • Hot, humid weather
    • Oily skin
    • Hormonal changes
    • Weakened immune system

    Medical Diagnosis
    The health care provider can diagnose tinea versicolor by physical exam (inspection). 
    If there’s any doubt, he or she may take skin scrapings from the infected area and 
    view them under a microscope.

    Treatment
    If tinea versicolor is severe or doesn’t respond to over-the-counter antifungal 
    medicine, you may need a prescription-strength medication. Some of these 
    medications are topical preparations that you rub on your skin. Others are drugs 
    that you swallow. Examples include:
    • Ketoconazole (Ketoconazole, Nizoral, others) cream, gel or shampoo
    • Ciclopirox (Loprox, Penlac) cream, gel or shampoo
    • Fluconazole (Diflucan) tablets or oral solution
    • Itraconazole (Onmel, Sporanox) tablets, capsules or oral solution

    • Selenium sulfide (Selsun) 2.5 percent lotion or shampoo

      5.8. REMEDIAL ACTIVITIES

      Question one: Fulfill the following table

        

             QUESTION TWO: MULTIPLE CHOICE QUESTIONS: Circle the most one correct 

              answer

             Bottom of Form

    1) Which of the following pathogens can cause skin infections?
    a. Fungi 
    b. Bacteria
    c. Virus

    d. All of above

    Answer: d

    2) Topical skin infection can spread to internal organs.
    a. True

    b. False

     Answer: a 

    3) Which of the following can make you susceptible for a skin 
        infection?
    a. Burn injury
    b. Poor injury
    c. Skin disease

    d. All of above

    Answer: d
    5) Which of the following drugs is commonly recommended as 
    topical cream for skin infections?
    a. Fusidic acid
    b. Cefaclor
    c. Ampicillin

     Answer: a
    4) Which of the following is the most common micro-organism 
    responsible for causing skin infections?
    a. Mycobacterium tuberculae
    b. Staphylococcus aureus
    c. Plasmodium

    Answer: b
    4) Bacterial skin infection may occur due to alternation of normal 
    skin flora    .
    a. True
    b. False

     Answer: a
    3) Which of the following symptoms indicate a possible skin 
    infection?
    a. Erythema /warmth
    b. Pain /tenderness
    c. Swelling 
    d. All of above

     Answer: d
    5.9 CONSOLIDATION ACTIVITIES
    Question 1 
    What is the most common causative agent of erythema multiforme (EM)?
    a. Penicillin and sulphonamides
    b. Systemic lupus erythema
    c. HSV infection
    d. Malignancy

    Answer: c
    HSV is the most common etiologic agent of EM, which presents as a targetoid 
    rash and bullae. All the other options are also associated with the disorder, but less 
    commonly.

     Question 2 How does impetigo present?
    a. Golden honey coloured crust over an erythematous base
    b. Salmon coloured plaque with silvery scale
    c. Comedones , pustules and nodules
    d. Flesh coloured papule with a rough surface

     Answer: a
    Impetigo is a superficial skin infection caused by Staph aureus or Strep pyogenes. 
    It frequently affects children. It is treated with penicillin and topical preparations e.g. 
    mupirocin. 

    Question 3
    What is the infective agent implicated in acne?
    a. Staphylococcus aureus
    b. Streptococcus pyogenes
    c. Staphylococcus epidermidis
    d. Propionibacterium acnes

    Answer: d
    Propionibacterium acnes infection produces lipases resulting in inflammation and 

    breakdown of sebum, leading to pustule formation. 

        5.10 EXTENDED ACTIVITIES

        Question one: Fulfill the following table

     

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  • Topic 9

  • Topic 10