الفهرس 
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Abstract
The eye is normally protected from dryness, infection, and injury by anatomical,
physiological, and mechanical defensive mechanisms. Microorganisms, for example, are frequently
flushed from the eyes, and tears are disseminated through the blink reflex to moisten the ocular
surface. These defensive systems become impaired in critically ill patients due to a variety of risk
factors such as altered state of consciousness, sedation, and/or neuromuscular medications.
Unfortunately, patients undergoing mechanical ventilator have a significantly increased risk of
getting eye complications (ECs). Furthermore, keeping the eyes open for an extended amount of
time puts the patient at danger of corneal damage and infection.
Despite critically ill patients are more susceptible to ECs, eye care has been considered a
secondary nursing issue. Critical care nurses (CCNs) should prioritize eye care regardless if
the patient’s survival is in doubt, because ECs are easily avoided but if not early assessed and
adequately treated result in compromised vision, which has a disastrous effect on the quality of
life in those patients who improve and are allowed to leave the ICU.
Aim of the Study
This study aims to determine the effect of implementing a nurse - led eye care protocol
on the prevention of ECs in the mechanically ventilated patients.
Materials &Method
A quasi experimental research design was utilized to accomplish this study. This study
was carried out in the general medical ICUs at Damanhur Medical National Institute in
Damanhur City, El Behera Governate namely: General ICU ”I” and the General ICU ”II”.A
convenience sampling of 100 mechanically ventilated adult patients who had just been admitted
to the previously mentioned settings was used in the study. Patients were considered suitable if
they were unconscious with a Glasgow Coma Score (GCS) of 3-8, sedated with a Richmond
Agitation Sedation Scale (RASS) of -2 to -5, had grade 1 or 2 Lagophthalmos, and aged more
than or equal 18 years of both sex. The patients have been divided into two groups of 50 each;
the control group and the intervention group.
To accomplish the aim of the current study; two tools were used for data collection .Tool
one “Patient’s Admission Assessment Form” to collect baseline data of patients on admission
which reflected their medical conditions and hemodynamic status. It was developed by the
researcher after researching the relevant literature (Knaus et al., 1985; Dawson, 2005;
Nikseresht et al., 2021; de Franca et al., 2016). Tool two: “eye Complications Evaluation
Scales” to assess the incidence and severity of four different ECs which may develop for the
mechanically ventilated patients. It was adapted by the researcher after reviewing the relevant
literature (Dawson, 2005; Dragana et al. 2017; Aggarwal et al., 2020; Ervin et al. 2010 ; Kara
et al. 2005). It consist of four parts; Part I: eye dryness scale, Part II: periorbital edema scale,
Part III :conjunctival injection scale and Part IV: conjunctival discharge scale.
The study design was accomplished as follows:
Approval from the Research Ethics Committee of the Faculty of Nursing at Alexandria
University was obtained. An official approval to collect data was obtained after explaining the
study’s aim. An informed consent was obtained from patients’ legal relatives. The study tools
were tested for content validity by 5 experts in the field of the study. The necessary modifications were done accordingly .A pilot study was conducted on 10% of the sample to
test the clarity and the applicability of the study tool.
Data were collected over a period of six consecutive months (from October 2022 to March
2023).All the eligible patients were assigned to two studied groups. Those assigned to the
control group received the conventional eye care by the CCNs (n=50), while those in the
intervention group received the nurse – led eye care protocol by the researcher(n=50).Data
were collected from the control group first and after its completion, it was collected from the
study group.
For both groups: patients were assessed on admission for degree of lagophthalmos and
baseline socio demographic and clinical data was collected from patient’s chart or family and
recorded. Tool one part I was used daily through a seven consecutive days of follow up to
collect clinical data including GCS and RASS .If the patient regain their consciousness , became
not sedated or weaned from MV at any day of the follow up days, they were excluded from the
sample. Moreover, the incidence and severity of ECs for the two groups were assessed daily
using tool II .The assessment findings were documented, and any abnormalities were
communicated to the ICU physician for consideration of ophthalmology referral.
For the control group: Patients were subjected to the routine eye care procedure that is
performed by the CCNs without the researcher’s interference. They cleansed the eye with tap
water as a part of the patient’s bed bath and applied an eye lubricant if prescribed. Eye care is
performed once per day.
For the intervention group: The researcher implemented the Nurse – led eye care
protocol every four hours for seven consecutive days which included ; hand washing using the
seven steps, cleansing of the eye while maintaining the ANTT technique, application of eye
ointment and finally covering the eye with transparent adhesive tape.
Results of the study
More than half of the patients in the control and intervention groups were males aged more
than 60 years old with grade two of lagophthalmos .The majority of patients for the two studied
groups were on SIMV mode of the MV. Furthermore, there was no significant difference between
the studied groups regarding demographic and clinical data namely age, sex, GCS, RASS,
APACHE score, reason for ICU admission, CVP, PEEP ,peak pressure and FIO2.
The findings of the current study revealed that the overall incidence of ECs decreased from
84% among patients in the control group to 46% among patients in the intervention group .In terms
of eye dryness, patients in the intervention group showed lower incidence and severity compared
with the control group. While, severe eye dryness increased from 0 % on the 1st day of the study to
44% on the 4th,5th, and 6th day and to 58% on the 7th day of the study in the control group ,it increased
from 0% on the 1st day of the study to only 18% on the 6th and 7th day in the intervention group with
high significant difference between the two groups ((p<0.001).
As regards to periorbital edema, the present study depicted that the occurrence of periorbital
edema was significantly lower among patients in the intervention group as compared with the control
group. on the 1st day, the two studied groups similarly did not show any periorbital edema (zero %).
On the 7th day, the percentage of Grade 3 periorbital edema increased to 46% for patients in the
control group and to 20% for patients in the intervention group with a statistically significant
difference between the two studied groups (p-value = 0.021).
In relation to conjunctival injection, it can be noted that the occurrence rate among
patients in the control group was higher compared with intervention group with significant difference between the two studied groups throughout the study. It was observed that from the
3rd to the 7th day of the study, the control group had significantly higher percentages of grade
1 conjunctival injection than the study group.
Pertaining to eye discharge, the current study’s findings indicated that the occurrence of
eye discharge decreased significantly among patients in the intervention group compared to the
control group. It is noticeable that 24% of the patients in the control group and 14% of the
patients in the intervention group showed first degree of eye discharge from the 2nd day with no
significant difference between the two studied groups (p=0.202).But on the 7th day of the
study,72% of patients in the control group had developed grade 3 eye discharge compared with
only 14% of patients in the intervention group. Furthermore, this table reflects that there was a
highly significant difference (p<0.001) between the two studied groups from the 3rd to the 7th
day of the study about grade 3 of eye discharge.
Conclusion
The current study demonstrated a positive effect of implementing the nurse - led eye care
protocol on decreasing the incidence and severity of overall ECs including eye dryness,
periorbital edema, conjunctival injection and eye discharge among mechanically ventilated
patients.
Recommendations
• The nurse - led eye care protocol should be incorporated into ICU nurses’ daily routine
care for mechanically ventilated patients.
• The nurse - led eye care protocol should be started on admission to decrease the incidence
and severity of ECs.
• The nurse - led eye care protocol should be tailored based on policies and available
resources in clinical settings.
• The incidence and severity of ECs should be assessed daily using ECs development
scales.
• In service educational programs and workshops should be conducted to raise CCNs’
awareness regarding the correct and effective implementation of the nurse led eye care
protocol.
• An educational handout about the nurse led eye care protocol must be provided to the
CCNs to be used as a reference guide in their practice.
• Hospital budget should be directed to provide the needed equipment and supplies for
application of the nurse led eye care protocol.
• ECs assessment scales should be included in nursing flow sheets.
• Replication of this study on large sample is needed for generalization of results.
• Consider further research about identification of barriers to the application of the nurse
led eye care protocol among mechanically ventilated patients.