一例机械通气伴意识障碍患者眼部并发症的循证护理

目的为l例机械通气伴昏迷患者眼部并发症制定循证护理方案。方法按PICO原则,针对患者临床表现提出问题,计算机检索Cochrane图书馆(2011年第12期)、PubMed(1980.1～2011.10)、EMbase(1974～2011)及CBM(1978～2011),搜集有关危重患者眼部护理的临床指南、系统评价和随机对照试验。对其进行证据的真实性、重要性和适用性评价后,将最适证据应用于该例患者并观察患者疗效。结果共纳入3篇临床指南、2篇系统评价和9篇RCT。当前证据表明:眼部清洁是危重患者眼部护理的重要内容,常用的擦拭或冲洗液为生理盐水和无菌水;预防角膜干燥常采用保湿膜覆盖及应用润滑眼液/膏,聚乙烯保湿膜能有效防止角膜损伤的发生,而润滑眼液/膏则有利于眼部观察,应用时应结合患者病情酌情选择。护士需每日评估患者眼睑闭合能力并帮助患者眼睑闭合,但被动性眼睑闭合预防角膜损伤效果明显比人工泪液软膏差,保持眼睑闭合及形成眼球保湿腔室综合干预能更有效预防眼部并发症的发生。我们参照上述循证医学证据,并根据患者的具体情况,制定如下眼部护理方案:应用0.9%生理盐水纱布擦拭眼睑及周围皮肤,使用无菌聚乙烯薄膜(透明敷贴内含无菌纱布衬垫)覆盖双眼,周围用抗过敏胶带粘贴加固,每12小时更换一次(污染、破损或敷贴卷边时及时更换),每日观察眼睑闭合情况。实施7天后,该患者眼部症状出现明显好转,分泌物明显减少,无球结膜充血及水肿,荧光素染色检查阴性。结论眼部清洁能有效去除分泌物及微生物,而聚乙烯薄膜能防止泪液蒸发并充分发挥泪液免疫功能,减少感染风险,眼睑保持闭合及局部的湿润环境有利于角膜上皮的修复。

Evidence-Based Nursing for an Unconscious Patient Undergoing Mechanical Ventilation with Eye Complication

Objective To formulate an evidence-based nursing scheme of eye care for an unconscious patient undergoing mechanical ventilation with eye complication. Methods Under the principle of PICO, the issue was put forward aiming directly at patient’s clinical manifestations, and the following databases as The Cochrane Library (Issue 12, 2011), PubMed (January 1980 to November 2011), EMbase (1974 to 2011) and CBM (1978 to 2011) were searched. Results A total of 3 guidelines, 2 systematic reviews and 9 randomized controlled trials (RCTs) were included. The evidence showed that eye cleaning was the very important part of eye care, and the commonly-used cleaning or rinsing solutions were saline and sterile water. Both moist cover and lubricating eye drops/ointment were used to prevent dryness in the eyes. For instance, polyethylene moisture covers could effectively prevent corneal abrasion, and lubricating eye drops/ointment were beneficial to eye observation, so these two methods needed to be properly selected in combination with patient’s conditions. Nurses had to assess the ability of the patient to close eyelids daily and helped the patient to close eyes, but the passive eyelids closure was inferior to the artificial tear ointment in the effect on preventing corneal abrasions; the integrated intervention of maintaining eyelids closure and forming eyeballs moisture chamber was more effective to prevent eye complications. According to the available evidence mentioned herein and the patient’s conditions, the following nursing scheme of eye care was formulated: cleaning the eyelids and peripheral skin using 0.9% saline gauze, covering the eyes with sterile polyethylene films which were fixed by anti-allergic adhesive tapes, changing the dressing every 12 hours, and observing closure of the eyelids every day. Seven days later, eye symptoms got obviously improved, with decreasing secretion, without congestion and chemosis, and negative results of fluorescein staining test. Conclusion Eye cleaning removes secretion and bacteria from the eyes. Polyethylene film prevents tear from evaporation and fully promotes the immune function of tears which can reduce the risk of infection. Eyelids closure and local moisture environment benefit the corneal epithelial repair.