Page 131 - ACCCN's Critical Care Nursing

108 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

EYE ASSESSMENT benefit from regular 4-hourly administration of artificial
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Eye assessment should be undertaken at least every 12 tears to lubricate the eyes, although this may be unneces-
hours, even for the conscious patients who are able to sary while they are sleeping.
blink spontaneously and usually require minimal eye Dawson offers an eye care protocol for critically ill
care. The risk of corneal abrasion or iatrogenic trauma is patients, which clarifies the type of eye care required
greatest when patients are unable to close their eyes spon- according to the patient’s ability to maintain eye closure.
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taneously, so these patients are at greatest risk of injury. The protocol requires an assessment to be made once per
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The second at-risk group is those patients receiving posi- shift. Initially, eye closure is assessed to determine whether
tive pressure ventilation, who may develop conjunctival it is complete or whether the conjunctiva and/or the
oedema (chemosis), sometimes referred to as ‘ventilator cornea are exposed. Suggested treatment is 1–4-hourly
eye’. Third, patients who are exposed to high flows of air/ eyedrops, with further assessment to exclude keratitis or
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oxygen, such as that with continuous positive airway conjunctivitis. Unconscious or paralysed patients are
pressure (CPAP) systems, may be vulnerable to its drying likely to require more eye care than conscious patients.
effects. Finally, all patients are at risk of eye inflammation Basic eye care consists of cleaning the sclera and sur-
and infection. Serious infections with bacteria such as rounding tissue and moistening the eyes by administer-
pseudomonas can progress rapidly, resulting in blindness ing artificial tears.
if not treated promptly.
For at-risk patients, the general consensus is that eye care
Initial assessment should focus on whether the patient should be performed using a sterile technique, cleansing
belongs to an at-risk group. Most critically ill patients are the eye from the inside to the outside usually with saline
at some risk, but particularly those who are unable to and gauze; however, eye care regimens have not been
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close their eyes adequately. If the cornea is exposed, the rigorously researched. Cotton wool is not recommended
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patient is considered to be in a high-risk group. Based because of the presence of particulates that may cause
on the groups identified above, initial assessment should corneal abrasions. Eyedrops should be administered
help determine how often eye assessment and eye care is gently, inserting the drop in the uppermost part of the
required. opened eye and as close to the eye as possible without
The general principles of eye assessment are shown in touching it. Sometimes eyedrops can sting, so it is advis-
Table 6.4, which should include a full examination of the able to warn the patient of this possibility. Regular sche-
eye’s external structure, colour and response. A number duled eye care with an ocular lubricant plus eye closure
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of assessment tools have been developed for this purpose. with tape or wrap is used to reduce the potential for
Thorough eye assessment should assess appearance corneal abrasions or subsequent corneal ulceration or
(which may provide indications of disease or trauma) infection in patients who are either paralysed or heavily
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and physical and neurological functions. If there is sedated.
concern about any aspect of a patient’s eyes, a referral for
assessment should be made to an ophthalmologist.
Practice tip
ESSENTIAL EYE CARE Another source of irritant to the eyes can be the constant air
The goals of eye care are to provide comfort and protect flow from air-conditioning vents or fans, so check that your
the eyes from injury and infection. Eye care and the patient at risk is not positioned directly in line with these vents
administration of artificial tears should be provided as or poorly-positioned fans.
required, if the patient complains of sore or dry eyes, or
if there is visible evidence of encrustation. If a patient is
receiving high-flow oxygen therapy via a mask, they may Conjunctival Oedema (Chemosis)
Conjunctival oedema (chemosis) is a common problem
associated with positive pressure ventilation, high posi-
tive end-expiratory pressure (PEEP) above 5 cmH 2 O and
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TABLE 6.4 Assessment of the eyes prone positioning. While the oedema itself usually
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resolves without treatment when ventilation is discontin-
External structure Colour Reaction ued, it may be advisable to seek an ophthalmic opinion
● Is it bulging or ● Is the sclera its ● Is the blink if there is concern. The literature is inconclusive concern-
misshapen? normal reflex ing the best method of treatment for conjunctival oedema,
● Is the pupil circular? off-white present? but evidence supports the use of artificial tear ointment
● What size are the colour or is ● Do both and maintaining eye closure as effective measures to
pupils? there evidence pupils react 9
● Are both pupils the of jaundice or to light with reduce corneal abrasions.
same size? haemorrhage? equal speed? Severe oedema often results in the patient’s inability to
● Is the pupil clear? ● Does it look red ● Is there a
● Is there any visible and inflamed? composite maintain eye closure. Under such circumstances, the
trauma? reaction to majority opinion is that eye closure may be maintained by
● Is it weeping? light in the applying a wide piece of adhesive tape horizontally to the
● Does it look dry or opposite eye? upper part of the eyelid. This usually anchors the lid in
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moist?
the closed position, while allowing the eyelid to be opened