MATERI KULIAH
KEPERAWATAN KRITIS
DISUSUN OLEH
IMAM WAKHYONO
KELAS B ALIH JENJANG
NIM : 190203129
Jurnal I Jurnal II
Peneliti 1. Nurlaily Afianti 1. Nahla Shaaban Khalil
2. Ai Mardhiyah 2. Marwa Fathallah
Moustafa
3. Zeinab Mahmoud El-
Bourae
Tahun 2017 2019
Judul Pengaruh Foot Massage Effects Of Non-
Terhadap Kualitas Tidur Therapeutic Measures On
Pasien di Ruang ICU Sleep Quality Among
Critically Ill
Patients, Egypt
Metode Penelitian Metode quasi experiment Metode quasi eksperimen
Waktu Penelitian 2017 2019
Tempat Penelitian Di ruang ICU RSUP. Dr. Di Neuro-Critical Care
Hasan Sadikin Bandung Unit (NCCU), Rumah
Sakit Mansoura New
General, Mesir
Jumlah 24 Responden 66 Sampel
Responden
Kriteria Kriteria inklusi : Kriteria Inklusi :
Responden a). Kesadaran kompos a. Glasgow merekaSkala
mentis, Koma kurang dari 14.
b). Kooperatif, komunikatif b. Mengalami cedera
dan ada kontak mata, telinga / mata
c). Hemodinamik stabil c. Mengeluh pendengaran
sistolik 100-130 mmHg, dan masalah
diastolic 60-100 mmHg penglihatan
dan MAP >65 mmHg
tanpa menggunakan d. Mengalami semua jenis
golongan inotropik dan delirium.
support seperti: e. Kebingungan
dobutamin, dopamin, Kriteria Eksklusi :
epineprin dan berada di bawah
norepineprin, pengaruh sedasi atau
d). Skala nyeri ringan dan obat-obatan narkotika
sedang (skala 1–10), e).
Responden yang
menggunakan ventilator
mode spontan ataupun
yang tidak mengguna kan
ventilator
Kriteria Ekslusi :
a). Responden tidak
menggunakan analgetik
narkotik dan sedatif,
b). Responden yang
mengalami fraktur,
trauma, atau luka pada
kaki,
c). Responden dalam kondisi
gelisah,
d). Responden yang
mempunyai manifestasi
gejala thrombosis vena
dalam.
Instrumen (alat 1. Lembar isian yang berisi 1. Lembar isian data
ukur) data sosial demografi, demografi dan
2. Data klinis responden, Karakteristik klinis
3. protokol perlakuan foot pasien
massage, dan
4. kuesioner penilain 2. Kuesioner tidur ICU
kualitas tidur mengguna yang dikembangkan
kan richard campbell sleep oleh Freedman et
questionnaire (RSCQ) al.,1999. Alat tersebut
mengumpulkan data
tentang berbagai faktor
yang mempengaruhi
kualitas tidur. Alat ini
memungkinkan Pasien
untuk mengevaluasi
sendiri kualitas tidur
mereka pada skala 1
sampai 10 (1 berarti
buruk, 10 berarti luar
biasa).
3. Kuesioner Tidur
Richard Campbell
(RCSQ)
Cara Pengukuran pretest dilakukan Penilaian primer dilakukan
Pengumpulan pada pagi hari jam 07.00 oleh para peneliti pada hari
data WIB, elanjutnya foot pertama untuk semua
massage dilakukan pada neuro-critical pasien sakit
malam hari menjelang pasien melalui pengumpulan data
tidur jam 19.00-21.00 WIB yang berkaitan dengan
selama dua hari berturut- karakteristik dan
turut. Foot massage diberikan lingkungan pasienfaktor
selama 10 menit pada Para peneliti melakukan
masing-masing bagian kaki intervensi memakai
sehingga total lama perlakuan penyumbat telinga dan
20 menit masker mata di antara
merekakelompok belajar
selama tiga malam
berturut-turut sebagai
berikut; masker mata dan
penutup telinga sudah
dipakaipada waktu yang
sama setiap malam dari
jam 10 malam sampai jam
7 pagi. Dalam
mengenakan penutup
telinga, perawat
bergulingpenyumbat
telinga menjadi "ular"
kecil tipis dengan
menggunakan jari
menggunakan salah satu
dari kedua tangan.
Kemudian,perawat
menarik bagian atas
telinga pasien ke atas dan
ke belakang dengan tangan
yang berlawanan untuk
meluruskankeluar dari
liang telinga dan penutup
telinga yang sudah
digulung dimasukkan.
Selanjutnya, penyumbat
telinga ditahan dalam
penggunaan
Halaman 6
Jurnal Akademik
Internasional Kesehatan,
Kedokteran dan
Keperawatan | Volume 1,
Edisi 2, hlm.175-188180 |
P usiajari dan dihitung
sampai 20 atau 30 dengan
keras menunggu
penyumbat telinga
mengembang lagi dan
mengisidi saluran telinga
pasien, suara terdengar
tidak terdengar saat steker
ditutup dengan
baik.Sebagian besar, badan
busa penyumbat telinga
harus berada di dalam
liang telinga. Apalagi
perawatmenangkupkan
tangannya dengan kuat ke
telinga pasien dengan
benar. Jika suara jauh
lebih terdengardengan
tangan di tempatnya,
penyumbat telinga
mungkin tidak menutup
dengan baik dan perawat
melepaspenutup telinga
dan coba lagi. Akhirnya,
perawat melepas penutup
telinga secara perlahan
dengan gerakan
memutaruntuk membuka
segel secara bertahap
untuk menghindari
kerusakan pada gendang
telinga. Penyumbat telinga
itu sekali pakai.Penyumbat
telinga dijaga
kebersihannya dengan
membuang kotoran telinga
dan kotorannya sebelum
dimasukkan
kembali.Selain itu, larutan,
desinfektan, dan bahan
kimia tidak pernah
digunakan (Delfino &
Dowd, 2018
Hasil Dari hasil penelitian adanya Studi saat ini
Pembahasan perbedaan rerata skor kualitas mengungkapkan
tidur pada kelompok kontrol perbedaan statistik yang
tetapi terdapat perbedaan sangat signifikan antara
secara bermakna pada kelompok studi dan
kelompok perlakuan. Foot kelompok kontrol
massage memiliki pengaruh mengenai kualitas tidur di
positif terhadap kualitas tidur malam kedua dan ketiga.
pasien di Ruang ICU, hal ini Jadi, subjek kelompok
ditunjukkan dengan belajar yang memakai
meningkatnya skor kualitas masker dan penutup
tidur pada kelompok telinga menunjukkan
intervensi setelah peningkatan rata-rata skor
mendapatkan perlakuan foot kualitas tidur. Temuan ini
massage secara signifikan mungkin relevan dengan
dibandingkan dengan fakta bahwa penggunaan
kelompok kontrol. Hal penyumbat telinga dan
tersebut didukung masker mata eningkatkan
kualitastidur pasien dalam
pengaturan perawatan
oleh adanya perbedaan yang kritis untuk mengurangi
signifikan skor awal pretest kebisingan lingkungan
antara kelompok kontrol yang timbulbanyak
dan kelompok intervensi penyebabnya, begitu juga
dimana kelompok intervensi dengan suara bicara,
memiliki skor kualitas tidur telepon, dan suara
lebih rendah dari skor peralatan yang berasal dari
kualitas tidur kelompok mesin hisap dan alarm
kontrol hal nilah yang ventilator mekanis.
menunjukkan bahwa Satu penjelasan lain yang
foot massage memiliki mungkin untuk temuan itu
pengaruh yang kuat dalam adalah bahwa memakai
membatu memperbaiki masker dan penutup
kualitas tidur pasien di ruang telinga mencegah
ICU RSUP Dr. Hasan Sadikin rangsangan sensorik dan
Bandung. mencegah simpatis
pelepasan adrenalin sistem
saraf dan efek ini membuat
pasien menenangkan dan
jatuh tertidur.
Kelebihan Jurnal Hasil dari penelitian mudah Hasil dari penelitian ini
untuk di implementasikan mudah untuk
baik pada pasien kritis diimplementasikan
maupun untuk pasien non
kritis. Hasil ini juga tidak
dibawah pengaruh analgetik
narkotik dan sedative.
Kekurangan Sampel responden yang Kekurangannya dalam
Jurnal sedikit, dan hanya terbatas studi ini kriteria responden
pada kriteria responden yang berada di bawah pengaruh
kompos mentis, dan pada sedasi atau obat-obatan
narkotika dimana respon
rentang nyeri kecil sampai masing- masing responden
dengan sedang. berbeda, dan dengan
sampel yang terbatas.
Rekomendasi Studi ini sebaiknya Studi ini sebaiknya
direplikasikan pada sampel direplikasikan pada sampel
yang lebih besar. Selanjutnya yang lebih besar dari
mungkin dapat dilakukan berbagai wilayah geografis
pada rsponden tidak sadar dan di unit perawatan
dan dalam skala nyeri berat. intensif umum.
Selanjutnya mempelajari
hambatan yang dihadapi
pasien di unit perawatan
kritis yang menyebabkan
mereka kurang tidur.
Pengaruh Foot Massage terhadap Kualitas Tidur Pasien di Ruang ICU
Abstrak
Gangguan tidur pasien kritis di ruang Intensive Care Unit dapat mengakibatkan terganggunya fungsi kekebalan
tubuh, menurunkan kemampuan otot inspirasi pernafasan, terganggunya sistem metabolisme, terganggunya regulasi
sistem saraf pusat dan kondisi psikologis pasien yang berdampak terhadap waktu perawatan berkepanjangan.
Foot Massage merupakan salah satu terapi komplementer yang aman dan mudah diberikan dan mempunyai efek
meningkatkan sirkulasi, mengeluarkan sisa metabolisme, meningkatkan rentang gerak sendi, mengurangi rasa sakit,
merelaksasikan otot dan memberikan rasa nyaman pada pasien. Tujuan penelitian ini teridentifikasinya perbedaan
pengaruh skor kualitas tidur pada kelompok kontrol dan perlakuan. Penelitian quasi eksperimental ini menggunakan
kelompok kontrol dan kelompok perlakuan dengan masing-masing kelompok dilakukan penilaian pretest dan postest.
Jumlah sampel sebanyak 24 pasien. Instrumen kualitas tidur menggunakan Richard Campbell Sleep Quationare
(RCSQ). Data dianalisis dengan uji t berpasangan dan uji t tidak berpasangan. Hasil penelitian menunjukan pada
kelompok kontrol tidak terdapat perbedaan yang bermakna rerata skor kualitas tidur (p = 0,150), sedangkan pada
kelompok perlakuan, terdapat perbedaan yang bermakna rerata skor kualitas tidur (p=0,002). Adapun selisih skor
kualitas tidur pada kelompok kontrol dan kelompok perlakuan terdapat perbedaan secara bermakna (p= 0,026).
Simpulan penelitian ini skor kualitas tidur pada kelompok intervensi lebih tinggi daripada kelompok kontrol,
sehingga disarankan foot massage dijadikan evidence based di rumah sakit sebagai salah satu terapi komplementer
yang dapat dijadikan intervensi mandiri keperawatan untuk membantu mengatasi gangguan tidur pasien kritis.
Abstract
Sleep disorders of critical patients in the Intensive Care Unit can result in impaired immune function, decrease
respiratory muscle capacity, disruption of metabolic system, disruption of central nervous system regulation and
psychological condition of patients impacting on long treatment period. Foot Massage is one of the complementary
therapies that is considered safe and easy to administer and has the effect of improving circulation, removing
the rest of the metabolism, increasing the range of motion of the joints, reducing the pain, relaxing muscles
and providing comfort to the patient. The purpose of this study is to identify differences in the effect of sleep
quality score on control and treatment groups. This quasi experimental study used a control group and a treatment
group where each group performed a pretest and posttest assessment. The sample size was 24 patients. Sleep
quality instrument used Richard Campbell Sleep Questionnaire (RCSQ). Data were analyzed by paired t test
and unpaired t test. The results showed that there was no significant difference in sleep quality score (p = 0,150),
while in the treatment group, showed that there was a significant difference on sleep quality score (p = 0,002).
The difference of sleep quality score in control group and treatment group was significantly different (p = 0,026).
Therefore, it can be concluded that sleep quality scores in the intervention group were higher than in the control
group, thus foot massage is suggested to be used as evidence-based in hospitals as one of the complementary
therapies that can be used as self-care interventions to help overcome patients with critical sleep disorder.
kesehatan, dan dapat digunakan oleh perawat denyut nadi, kelelahan, dan suasana hati
di hampir setiap pelayan perawatan (Kaur, setelah intervensi tersebut dilakukan. Pada
Kaur, & Bhardwaj, 2012). tindakan foot massage berarti sentuhannya
Mekanisme foot massage yang dilakukan dapat merangsang oksitosin yang merupakan
pada kaki bagian bawah selama 10 menit neurotransmiter di otak yang berhubungan
dimulai dari pemijatan pada kaki yang dengan perilaku seseorang, dengan kata
diakhiri pada telapak kaki diawali dengan lain sentuhan merangsang produksi hormon
memberikan gosokan pada permukaan yang menyebabkan perasaan aman dan
punggung kaki, dimana gosokan yang berulang menurunkan stres serta kecemasan (Mac
menimbulkan peningkatan suhu diarea Donald, 2010 & Zak, 2012).
gosokan yang mengaktifkan sensor syaraf Foot Massage adalah manipulasi jaringan
kaki sehingga terjadi vasodilatasi pembuluh ikat melalui pukulan, gosokan atau meremas
darah dan getah bening yang mempengaruhi untuk memberikan dampak pada peningkatan
aliran darah meningkat, sirkulasi darah sirkulasi, memperbaiki sifat otot dan
menjadi lancar (Aditya, Sukarendra & Putu, memberikan efek relaksasi (Potter & Perry,
2013). Foot massage mengaktifkan aktifitas 2011).
parasimpatik kemudian memberikan sinyal Menurut Puthusseril (2006), foot
neurotransmiter ke otak, organ dalam tubuh, massage mampu memberikan efek relaksasi
dan bioelektrik ke seluruh tubuh. Sinyal yang yang mendalam, mengurangi kecemasan,
di kirim ke otak akan mengalirkan gelombang mengurangi rasa sakit, ketidaknyamanan
alfa yang ada di dalam otak (Guyton, 2014). secara fisik, dan meningkatkan tidur
Impuls saraf yang dihasilkan saat melakukan pada seseseorang. Foot massage dapat
foot massage diteruskan menuju hipotalamus memberikan efek untuk mengurangi
untuk menghasilkan Corticotropin Releasing rasa nyeri karena pijatan yang diberikan
Factor (CRF). CRF merangsang kelenjar menghasilkan stimulus yang lebih cepat
pituitary untuk meningkatkan produksi sampai ke otak dibandingkan dengan rasa
Proopioidmelanocortin (POMC) sehingga sakit yang dirasakan, sehingga meningkatan
medulla adrenal memproduksi endorfin. sekresi serotonin dan dopamin. Sedangkan
Endorfin yang disekresikan ke dalam efek pijatan merangsang pengeluaran
peredaran darah dapat mempengaruhi endorfin, sehingga membuat tubuh terasa
suasana hati menjadi rileks (Ganong, 2008). rileks karena aktifitas saraf simpatis menurun
Menurut Aziz (2014) Gelombang alfa (Field, Hernandez-Reif, Diego, & Fraser,
akan membantu stres seseorang, sehingga 2007; Gunnarsdottir & Jonsdottir, 2007).
stress akan hilang dan menjadikan orang Morton dan Fonatin (2009) menunjukkan
tersebut merasa rileks dan membantu bahwa penanganan gangguan tidur saat ini
kontraksi otot untuk mengeluarkan zat bisa menggunakan terapi nonfarmakologi.
kimia otak (neurotransmitter) menstimulasi Perawat dituntut agar dapat memberikan
RAS (Reticular Activating System) untuk perawatan nonfarmakologi yang tidak
melepaskan seperti hormone serotin, memiliki pengaruh negatif dan dapat
asetilkolin dan endorphine yang dapat melengkapi terapi farmakologi yang selama
memberikan rasa nyaman dan merelaksasi. ini sudah diberikan dalam perawatan pasien.
Kemudian rasa rileks dan perasaan nyaman Untuk kondisi pasien di ruang ICU
yang dirasakan dapat menurunkan produksi intervensi foot massage menjadi pilihan
kortisol dalam darah sehingga memberikan karena kaki mudah diakses tanpa memerlukan
keseimbangan emosi, ketegangan pikiran reposisi dari pasien dan juga massage pada
serta meningkatkan kualitas tidur (Azis, kaki, selain merangsang sirkulasi dapat
2014). menurunkan edema dan latihan pasif
Kaur, Kaur, dan Bhardwaj (2012) untuk sendinya, serta melalui intervensi ini
menyatakan bahwa foot massage yang perawat dapat memberikan rasa nyaman dan
dilakukan selama 5 menit pada pasien sakit kesejahteraan bagi pasien (Puthuseril, 2006;
kritis dapat memberikan efek meningkatkan Prapti, Petpichetchian & Chongcharoen,
relaksasi karena adanya perubahan pada 2012). Tindakan foot massage memiliki
tekanan darah sistolik, tekanan darah diastolik, pertimbangan biaya rendah, kemungkinan
komplikasi yang sedikit dan prosedur yang pasien yang dirawat diruang ICU RSUP. Dr.
mudah sehingga foot massage dianjurkan Hasan Sadikin Bandung. Sedangkan sampel
untuk perbaikan kualitas tidur (Oshvandi, penelitian ini adalah yang memenuhi kriteria
Abdi1, Karampourian, Moghimbaghi & penelitian, kriteria inklusi: a). Kesadaran
Homayonfar, 2014). kompos mentis, b). Kooperatif, komunikatif
Upaya memperbaiki kualitas tidur dengan dan ada kontak mata, c). Hemodinamik
menggunakan Foot Massage di ruang ICU stabil sistolik 100-130 mmHg, diastolik
dimana secara kultur budaya massage 60-100 mmHg dan MAP >65 mmHg tanpa
dapat diterima, dan foot massage aman menggunakan golongan inotropik dan support
diberikan pada pasien di ruang ICU, selain seperti: dobutamin, dopamin, epineprin dan
tidak perlu merubah posisi pasien, massage norepineprin, d). Skala nyeri ringan dan
ini dapat memberikan rasa aman karena sedang (skala 1–10), e). Responden yang
kehadiran perawat yang kontak langsung menggunakan ventilator mode spontan
skin to skin terhadap pasien, sehingga hal ataupun yang tidak menggunakan ventilator
tersebut melandasi penulis untuk melakukan dan kriteria Ekslusi: a). Responden tidak
penelitian tentang pengaruh foot massage menggunakan analgetik narkotik dan sedatif,
terhadap kualitas tidur pada pasien di ruang b). Responden yang mengalami fraktur,
ICU RSUP Dr. Hasan Sadikin Bandung. trauma, atau luka pada kaki, c). Responden
Tujuan penelitian ini adalah untuk mengetahui dalam kondisi gelisah, d). Responden yang
pengaruh foot massage terhadap kualitas mempunyai manifestasi gejala trombosis
tidur pasien di ruang ICU RSUP Dr. Hasan vena dalam.
Sadikin Bandung. Besar Sampel pada penelitian ini Mengacu
pada penelitian yang dilakukan oleh
Oshvandi, Abdi, Karampurian, Homayonfar
Metode Penelitian (2014), maka besar sampel untuk tiap
kelompok adalah 11,5 dibulatkan menjadi 12
Rancangan penelitian yang digunakan dalam responden sedikitnya jumlah sampel untuk
penelitian ini adalah Quasi Experiment setiap kelompok. Dengan demikian maka
dengan pendekatan Pretest and Posttest besar sampel yang dipakai dalam penelitian
Control Group Design. Metode quasi ini adalah 24 responden, dengan uraian 12
experiment merupakan metode penelitian responden untuk kelompok intervensi dan 12
eksperimen dengan menggunakan kelompok responden untuk kelompok kontrol.
kontrol. Pada rancangan ini responden Penelitian ini dilaksanakan di ruang
penelitian dibagi secara acak menjadi dua Intensive Care Unit (ICU) RSUP Dr.
kelompok. Satu kelompok adalah kelompok Hasan Sadikin Bandung. Peneliti memilih
perlakuan, sedangkan kelompok lain adalah rumah sakit ini sebagai tempat penelitian
kelompok kontrol sebagai penguat (Dharma, dikarenakan Rumah Sakit Umum Pusat Jawa
2011). Barat merupakan rumah sakit rujukan tipe A
Pada rancangan ini sebelum peneliti terbesar di Jawa Barat dan memiliki fasilitas
melakukan intervensi pada semua kelompok atau ruang perawatan intensif dewasa
dilakukan pengukuran awal (pretest) untuk tersendiri. Ruang perawatan yang dipakai
mengetahui kualitas tidur awal responden penelitian adalah ruang perawatan General
sebelum diberikan intervensi. Selanjutnya Intensive Care Unit (GICU) lantai 2.
pada kelompok intervensi dilakukan foot Pengukuran pretest dilakukan pada pagi
massage sesuai dengan langkah-langkah hari jam 07.00 WIB, selanjutnya foot massage
yang telah direncanakan, sedangkan pada dilakukan pada malam hari menjelang pasien
kelompok kontrol tidak dilakukan foot tidur jam 19.00-21.00 WIB selama dua
massage. Setelah intervensi diberikan hari berturut-turut. Foot massage diberikan
dilakukan pengukuran akhir (posttest) pada selama 10 menit pada masing-masing bagian
semua kelompok untuk menentukan efek kaki sehingga total lama perlakuan 20 menit.
foot massage terhadap kualitas tidur pada Analisis uji homogenitas pada penelitian ini
responden (Dharma, 2011). berdasarkan usia, jenis kelamin, lama hari
Populasi dalam penelitian ini adalah rawat, riwayat gangguan tidur, nyeri, tingkat
3 Pegang semua jari-jari kaki oleh tangan kanan, dan tangan kiri menopang
tumit pasien, kemudian peneliti memutar pergelangan kaki tiga kali
searah jarum jam dan tiga kali ke arah berlawanan arah jarum jam selama
15 detik.
4 Tahan kaki di posisi yang menunjukkan ujung jari kaki mengarah keluar
(menghadap peneliti), gerakan maju dan mundur tiga kali selama 15
detik. Untuk mengetahui fleksibilitas.
5 Tahan kaki di area yang lebih luas bagian atas dengan menggunakan
seluruh jari (ibu jari di telapak kaki dan empat jari di punggung kaki)
dari kedua belah bagian kemudian kaki digerakkan ke sisi depan dan ke
belakang tiga kali selama 15 detik.
7 Pegang kaki kanan dengan kuat dengan menggunakan tangan kanan pada
bagian punggung kaki sampai ke bawah jari-jari kaki dan tangan kiri yang
menopang tumit. genggam bagian punggung kaki berikan pijatan lembut
selama 15 detik.
8 Posisi tangan berganti, tangan kanan menopang tumit dan tangan kiri yang
menggenggang punggung kaki sampai bawah jari kaki kemudian di pijat
dengan lembut selama 15 detik.
9 Pegang kaki dengan lembut tapi kuat dengan tangan kanan seseorang di
bagian punggung kaki hingga ke bawah jari-jari kaki dan gunakan tangan
kiri umtuk menopang di tumit dan pergelangan kaki dan berikan tekanan
lembut selama 15 detik.
12 Tangan kanan memegang jari kaki dan tangan kiri memberikan tekanan
ke arah kaki bagian bawah kaki menggunakan tumit tangan dengan
memberikan tekanan lembut selama 15 detik
Tabel 2 Distribusi Rerata Skor Kualitas Tidur Kelompok Kontrol pada Pretest dan Posttest di
Ruang ICU RSUP Dr. Hasan Sadikin Bandung
Kualitas Tidur Mean SD SE p value N
Pre 49,76 10,281 2,968 12
0,150
Post 52,49 7,940 2,292 12
Tabel 3 Distribusi Rerata Skor Kualitas Tidur Responden Pretest dan Posttest pada Kelompok
Intervensi Foot Massage di Ruang ICU RSUP Dr. Hasan Sadikin Bandung
Kualitas Tidur Mean SD SE p value N
Pre 47,09 11,586 3,344 0,002 12
Post 60,69 8,861 2,558 12
Tabel 4 Analisis Perbedaan Rerata Skor Kualitas Tidur Pada Responden Kelompok Intervensi
dan Kontrol Di Ruang ICU RSUP Dr. Hasan Sadikin Bandung
Kualitas Tidur Mean SD SE p value N
Postest
Kontrol 52,49 6,1305 1,7697 12
0,026
Intervensi 60,69 11,5323 3,3291 12
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2523-5508
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INTRODUCTION
Sleep deprivation is a major concern in intensive care unit (ICU) critically ill patients and is
characterized by low subjective quality of sleep and lack of circadian rhythms (Huang et al.,
2015). Up to 40% of hospitalized patients suffer from impaired quality of sleep and in
adequate sleep duration, in neurological patients it is associated with higher dependency rates
at the time of initiation and may be at six months (Sweity et al., 2019).
The adverse outcomes of impaired sleep quality in ICU patients are seemly clear. They
include decreased inspiratory muscle endurance, and thus a negatively affected weaning from
mechanical ventilation, diminished immune function, and may have related to incidence of
delirium (Hu, Jiang, Zeng, Chen & Zhang, 2010). Also, the impact of poor sleep on the
duration of mechanical ventilation, immune function, metabolism, and quality of life after
admission to ICU setting is also questionable but wasn’t definitely proven (Demoule et al.,
2017).
Several physiological, psychological and environmental factors can contribute to sleep
disruption for the NICU patients. The key physiological causes include pain, medicine, and
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illness, as well as stress and worry (Dave, Qureshi, Gopichandran& Kiran, 2015). While
patient-related factors are likely to play a major role in sleep disruption, it is not possible to
neglect the impact of the ICU environment. ICU noise comes from multiple sources,
including alarms, mechanical ventilators, conversations with staff, visitors and television
(Pisani et al., 2015).
Moreover, interventions for sleep promotion include both the therapeutic and non-
therapeutic interventions (Kanji et al., 2016). Despite widespread use of medications, they
may produce adverse effects, such as negative effects on breathing, a reduced ability to think
clearly, and they can also affect normal sleeping patterns and lead to a risk of tolerance or
drug dependency (Morin, Beaulieu-Bonneau & Cheung, 2019). However, the minimizing the
voices and light during the night is difficult to reach in the ICU settings due to increased
human movements during night such as admission of new patients. Moreover, the voice of
alarms cannot always be lowered or turned off. Another way to keep patients safe from noise
and light is earplugs and eye masks. Earlier studies have recommended that this alternative
strategy could improve the quality of sleep in patients who exposed to a high level of noise
and light that unexpectedly be faced in an ICU (Hu et al ., 2010).
Accordingly, non-therapeutic interventions such as noise and light reduction, social support,
music therapy, and alternative therapies are recommended for improving sleeping quality in
critically care settings (Hu et al., 2015). In addition, many non-therapeutic measures have
also been tested to enhance the sleep quality of hospitalized patients, including earplugs and
eye masks, although there is no evidence of their benefits or risks. (Sweity et al., 2019).
Therefore, the current study was carried out to study the effectiveness of this therapeutic
intervention that predicted that earplugs and eye masks can improve sleep quality in critically
ill patients for three consecutive nights after the start of the intervention.
AIM OF THE STUDY
This study aimed to evaluate the effects of non-therapeutic measures such as earplugs and eye
masks on sleep quality among critically ill patients.
RESEARCH HYPOTHESIS
H1: Use of non-therapeutic measures such as earplugs and eye masks during the three
consecutive nights improves sleep quality among critically ill patients.
SUBJECTS AND METHODS
Research Design
Quasi-experimental study design was used to apply this study. So, the patients were assigned
either study or control groups, that considered the gold standard for assessing causality and,
were the first choice for most intervention research (Campbell & Stanley, 2015).
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Study Setting
The study was done at the Neuro-Critical Care Unit (NCCU), Mansoura New General
Hospital. That unit admits almost 40 patients monthly from Mansoura city and adjacent cities
around Mansoura city.
Subjects
A convenient sample of 66 patients admitted to the previously mentioned setting was enrolled
in this study. The exclusion criteria included who were less than 18 years old, their Glasgow
Coma Scale less than 14, having ear / eye injuries on admission, complained of hearing or
vision problems, having any type of delirium, confusion or sleeping problems on admission,
as well as patients who were under sedation or narcotic drugs during the study.
Sample and Sampling Technique
The Sample size was calculated depending on the following measurements; Population size
(80 patients, all patients admitted to Neuro Critical Care Unit (NCCU), Expected frequency
(20%), Margin of error (5%), confidence coefficient (95%), and minimum sample size (61
patients). The sample was estimated according to Epi Info 7 sample size estimation program
2013 using the following parameter:
N = (Z1-a / 2 + Z1- b )2s1s 2 / d 2 Z1-a / 2 = 1.96
Z1- b = 0.842
Where: σ1 σ2 = SD for each group; δ = Expected difference to be detected between 2 groups
α = Level of acceptability of a false positive result (level of significance=0. 05); β =
Level of acceptability of a false negative result (0. 20) 1-β = power (0. 80)
The sample size was 66 patients. Those 66 patients were divided equally and equitably into
the study and control groups. Each group included 33 patients; the control group included
patients who didn’t wear the earplugs or the eye masks at night during sleep, while the study
group included patients who wore them at night. The two groups continued participation in
the study for at least 3 nights.
Tools of Data Collection
Tool I: Patients' demographics and clinical Characteristics
This tool was elaborated by the researchers: it included demographic, health-relevant data.
disruption, 10 means significant disruption). These stimuli contained; pain, noise, light,
nursing interventions (giving care or exercises, bathing, etc.), diagnostic tests as chest
radiographs, vital signs evaluation, blood sampling, and medications administration.
finger and counted till 20 or 30 loudly waiting for the earplug to expand again and fill in the
patient's ear canal during which, the voice sounded inaudible when the plug sealed well.
Mostly, the foam body of the earplug must be inside the ear canal. Moreover, the nurse
cupped her hands firmly over the patient's ears properly. If sounds were much more audible
with hands in place, the earplug may have not been sealing well and the nurse removed the
earplug and tried again. Finally, the nurse removed the earplug slowly with a twisting motion
to gradually break the seal to avoid damage to the eardrum. That earplug was disposable.
Earplugs were maintained clean by removing the earwax and discharges before re-insertion.
As well, solutions, disinfectants, and chemicals were never used (Delfino & Dowd, 2018).
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Concerning the wearing of eye masks, the patients wore the eye masks through the
following steps: first; the nurse fitted the mask comfortably over the head, and the colored
side of the mask faced outwards. Second; the elastic bands or strings were positioned
appropriately to keep the mask definitely in place around the head. Third; the nurse wore
his/her patient eye mask firmly, and not too tight or not too loose. Finally, the nurse ensured
that no light penetrated the patient's eye (Bruder, 2017).
Regarding the implementation of the traditional procedure of the control group, the nurse
performed the following actions as follows; the patients were left all the three nights of the
study period without using earplugs or eye masks, and they were observed by the nurse
researchers throughout the study period utilizing sleep assessment tools.
Evaluation
After completion of both interventions in the study and control groups, the researcher
carried out a comparison between both groups to ascertain that the combined use of earplugs
and eye masks have an impact on the quality of sleep.
Data Analysis
Data were analyzed utilizing SPSS version 22. Data were represented in the form of means,
frequencies, and percentages. Chi-square was used for comparison and correlation between
quantitative data. Moreover, t-test was calculated to compare the quantitative data between
groups.
RESULTS
Table 1 revealed the mean age of both study and control groups were 35.42 ±14.02 & 34.48
±14.04 respectively. Almost half of the study group (51. 5%) was male and (48.5%) were
female in the control group. However, no significant differences were found between them
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Table 2 revealed that 12.1% of the study group had a diagnosis of acute subdural
hemorrhage (ASDH), dorsal fracture and Pneumocephalus. On the other hand, 12.1% and
15.2% of patients in the control group had a diagnosis of hemorrhagic brain contusion
(HBC) and chronic subdural hemorrhage (CSDH). A statistically significant difference was
detected between the study and the control group in relation to the length of hospitalization.
Regarding the Glasgow Coma Scale scores for patients throughout three consecutive days,
there were no significant differences were found between the two groups.
Table 2: Frequency distribution of the studied sample by their health relevant data
(n=66)
Study group Control group
(n= 33) (n= 33)
Variables Test
No % N %
Diagnosis
Acute Sub-dural hemorrhage 4 12. 1 2 6. 1
Space Occupying Lesion 2 6. 1 3 9. 1
Depressed skull fracture 2 6. 1 3 9. 1
Lumbar Disc Prolapse 1 3. 0 1 3. 0
Depressed skull fracture + Hemorrhagic 3 9. 1 1 3. 0
Brain Contusion
Hemorrhagic Brain Contusion 3 9. 1 4 12. 1
Depressed fracture 3 9. 1 1 3. 0
X2=11.986
Pneumocephalus 4 12. 1 3 9. 1
P= 0. 85
Chronic Sub-Dural Hemorrhage 1 3. 0 5 15. 2
Dorsal fracture 4 12. 1 3 9. 1
Cervical fracture 2 6. 1 2 6. 1
Dorsal tumors 1 3. 0 1 3. 0
Extra Dural Hemorrhage + Hemorrhagic 1 3. 0 1 3. 0
Brain Contusion
Extra Dural Hemorrhage + 1 3. 0 1 3. 0
Pneumocephalus
Length of hospitalization
3 days 23 69. 7 11 33. 3
X2=10.028
4 days 10 30. 3 19 57. 6
P= 0.007*
5 days 0 0. 0 3 9. 1
Glasgow coma score
1st day
X2= 1.158
14 6 18. 2 3 9. 1
P= 0. 28
15 27 81. 8 30 90. 9
2nd day
14 1 3. 0 2 6. 1 X2= 0.349
15 32 97. 0 31 93. 9 P= 0. 55
3rd day
14 0 0. 0 3 9. 1 X2= 3.143
15 33 100.0 30 90. 9 P= 0.08
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From table 3 it was noticed that, the control group subjects complained from many factors
more than the participants in the study group particularly experiencing pain, noise, light,
and alarms
Table 3: Comparison of factors affecting sleep quality between the study and control
groups (n= 66)
Variables Study group Control group t-test p-value
(n= 33) (n= 33)
Mean ± SD Mean ± SD
Pain 8. 03 ± 0. 73 8. 39 ± 0. 75 -2. 002 0. 05*
Noise 2. 88 ± 0. 60 7. 64 ± 0. 70 -29. 670 0. 000**
Light 2. 70 ± 0. 59 7. 61 ± 0. 83 -27. 834 0. 000**
Nursing interventions 3. 70 ± 0. 64 4. 97 ± 0. 85 -6. 899 0. 000**
Diagnostic testing 4. 15 ± 0. 67 5. 09 ± 0. 63 -5. 878 0. 000**
Vital signs measurement 4. 39 ± 0. 61 4. 61 ± 0. 49 -1. 551 0. 13
Blood samples 5. 21 ± 0. 65 6. 0 ± 0. 56 -5. 280 0. 000**
Administrating medications 5. 06 ± 1. 12 5. 79 ± 0. 74 -3. 120 0. 003*
Alarms 2. 61 ± 0. 56 8. 0 ± 0. 87 -30. 114 0. 000**
O2 finger probe 3. 15 ± 0. 62 4. 18 ± 0. 68 -6. 425 0. 000**
Talking 2. 21 ± 0. 42 3. 36 ± 0. 55 -9. 613 0. 000**
Nurses and doctors' phones 2. 00 ± 0. 25 3. 06 ± 0. 56 -10. 00 0. 000**
Table 4 revealed no significant statistical differences were found in the total score of sleep
quality between the study and control group on the first night. However, significant
differences were found in some sub-items of sleep questionnaire such as awakening and
sleep depth. So, most of the study group subjects (84.8%) awaked very little during night
versus (45.5%) in the control group. As well, more than two thirds of the study group
patients experienced deep sleep (69.7%) versus (45.5%) in the control group.
Table 4: Frequency distribution of the studied sample regarding their sleep quality in
the first night (n= 66)
Study group Control group
Item (n= 33) (n= 33) Test/ p value
No % No %
Sleep depth
Light sleep 10 30. 3 18 54. 5
t= 2. 02; p=0. 04*
Deep sleep 23 69. 7 15 45. 5
Mean ± SD 69.69 ± 46.67 45.45 ± 50.564
Sleep latency
Just never could fall asleep 18 54. 5 11 33. 3
Fell asleep almost 15 45. 5 22 66. 7 t= -1. 750; p=0. 09
immediately
Mean ± SD 45.45 ± 50.564 66.67 ± 47.87
Awakenings
Wake up the whole night 5 15. 2 18 54. 5 t= 3. 632; p=0.
Awake very little 28 84. 8 15 45. 5 001*
Mean ± SD 84.85 ± 36.41 45.45 ± 50.56
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Returning to sleep
Could not return to sleep 24 72. 7 13 39. 4
t= -2. 852; p=0.
Got back to sleep 9 27. 3 20 60. 6
01*
immediately
Mean ± SD 27.27 ± 45.23 60.61 ± 49.61
Sleep quality
A bad night's sleep 3 9. 1 7 21. 2
t= 1. 372; p=0. 18
A good night's sleep 30 90. 9 26 78. 8
Mean ± SD 90.91 ± 29.19 78.78 ± 41.51
Total sleep quality
Good 30 90. 9 27 81. 8
Poor 3 9. 1 6 18. 2 t= 1. 411; p=0. 16
Mean ± SD 318.18 ± 63.51 296.96 ± 58.55
Table 5 showed high significant improvement in the total sleep quality in the second night,
So, all the patients in the study group demonstrated good sleep quality (100%) versus
(15.3%) of patients in the control group.
Table 5: Frequency distribution of the studied sample regarding their sleep quality in
the second night (n= 66)
Study group Control group
Test
Variables (n= 33) (n= 33)
No % No %
Sleep depth
Light sleep 4 12. 1 27 81. 8
t= 7. 8; p=0. 000
Deep sleep 29 87. 9 6 18. 2
Mean ± SD 87.88 ± 33.14 18.18 ± 39.1
Sleep latency
Just never could fall asleep 2 6. 1 12 36. 4
Fell asleep almost 31 93. 9 21 63. 6 t=3.19; p=0.002
immediately
Mean ± SD 93.94 ± 24.23 63.64 ± 48.8
Awakenings
Wake up the whole night 2 6. 1 31 93. 9
Awake very little 31 93. 9 2 6. 1 t= 14. 7; p=0. 000
Mean ± SD 93.94 ± 24.23 6.06 ± 24.2
Returning to sleep
Could not return to sleep 20 60. 6 6 18. 2
Got back to sleep 13 39. 4 27 81. 8
t= -3. 8; p=0. 000
immediately
Mean ± SD 39.39 ± 49.61 81.81 ± 39.1
Sleep quality
A bad night's sleep 3 9. 1 26 78. 8
t= 7. 8; p=0. 000
A good night's sleep 30 90. 9 7 21. 2
Mean ± SD 90.91 ± 29.19 21.21 ± 41.5
Total sleep quality
Good 33 100. 0 5 15. 2
t= 14; p=0. 000
Poor 0 0. 0 28 84. 8
Mean ± SD 406.06 ± 60.93 190.90 ± 63
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Table 6 showed high significant improvement in the total sleep quality in the third night, So,
almost all the patients in the study group demonstrated good sleep quality (97%) versus
(6.1%) of patients in the control group.
Table 6: frequency distribution of the studied sample regarding their sleep quality in
third night (n= 66)
Variables Study group (n= Control group (n= Test
33) 33)
No % No %
Sleep depth
Light sleep 2 6. 1 31 93. 9 t= 14. 7; p=0.
Deep sleep 31 93. 9 2 6. 1 0
Mean ± SD 93.94 ± 24.2 6.06± 24.2
Sleep latency t= 6. 1; p=0.
Just never could fall asleep 0 0. 0 18 54. 5 00
Fell asleep almost 33 100. 0 15 45. 5
immediately
Mean ± SD 100 ± 0.0 45.45 ± 50.5
Awakenings t= 8. ; p=0. 0
Wake up the whole night 2 6. 1 25 75. 8
Awake very little 31 93. 9 8 24. 2
Mean ± SD 93.93 ± 24.2 24.24 ± 43.5
Returning to sleep t= 0. 5; p=0.
Could not return to sleep 10 30. 3 12 36. 4 61
Got back to sleep 23 69. 7 21 63. 6
immediately
Mean ± SD 69.69 ± 46.6 63.64 ± 48.8
Sleep quality t= 11.
A bad night's sleep 4 12. 1 31 93. 9 4;p=0.0
A good night's sleep 29 87. 9 2 6. 1
Mean ± SD 87.88 ± 33.1 6.06 ± 24.2
Total sleep quality t= 18; p=0. 0
Good 32 97. 0 2 6. 1
Poor 1 3. 0 31 93. 9
Mean ± SD 445.45± 66.5 145.4± 61.6
DISCUSSION
The present study aimed to evaluate the effects of non-therapeutic measures such as earplugs
and eye masks on sleep quality among critically ill patients. Despite, the sample was smaller
than required, worthy recognitions about the impact of non-therapeutic measures such as
earplugs and eye masks on the quality of sleep were detected. The current study revealed
highly significant statistical differences between the study and control group concerning the
quality of sleep in the second and third nights. So, the study group subjects who wore the eye
mask and earplugs showed an increased mean of sleep quality scores.
This finding may have relevant to the fact that using earplugs and eye masks improves
patients' sleeping in critical care settings to reduce the environmental noise that arises from
many causes, as well as talking, phone sounds, and equipment sounds originated from suction
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machines and mechanical ventilators' alarms. One other possible explanation for that finding
is that wearing mask and earplugs prevent sensory stimulation and prevent the sympathetic
nervous system's release of adrenalin and these effects make the patient soothing and falling
asleep. Similar to the current study, recently done studies on the efficacy of earplugs and eye
masks for promoting sleep quality in critical ill adults by Scharf, Kasinathan & Sunderram,
(2019); Sweity et al., (2019) &Su& Wang, (2018) found some evidence that these
interventions can deliver some advances in subjective measures of sleep quantity and quality.
On the other hand, Le Guen, Nicolas-Robin, Lebard, Arnulf & Langeron, (2013), assessed
the effect of earplug and eye blinders on sleep quality in patients in the post-anesthetic care
unit, and proved that earplugs increased overall sleep quality, but had no effect on the depth
of sleep. Regarding sleep latency, the present study findings is consistent with another study
done by Huang et al., 2015; who detected statistically significant decreases in onset of sleep
latency (71.4 min, 46.6 min, P = 0.01) when providing earplugs and eye masks during ICU
nights. Furthermore, Bajwa, Saini, Kaur, Kalra & Kaur, (2015) concluded that applying
earplug and eye mask showed significant effects in enhancing the sleep latency of critically-
ill patients admitted to ICU’s than control group and is well thought-out as economical and
uncomplicated method which can enhance pattern of sleep in ICU’s patients.
Concerning awakenings, our study findings showed highly statistically significant differences
between the study and control group. So, most of the patients in the study group experienced
very little awake during night in the three days when compared in the control group. In a
study by Longley et al., (2018), it was discussed that patients in a surgical, trauma, and burn
when exposed to the ordinary non-simulated ICU environment, appeared to fall asleep
relatively well, but were awakened and had difficulty returning to sleep. Scores indicated that
the depth of patients’ sleep and quality of sleep were not sufficient. In contrast, a study by
Demoule et al., 2017 who concluded that prolonged awakening times were smaller in the
intervention group than in the control group.
Moreover, the present findings revealed significant differences between both groups in
relation to returning to sleep after awakening in the first and second nigh but there was no
statistically significant difference between the intervention and control groups on the third
night. Our findings are agreed with another similar study done by Bani Younis et al., 2019
who found a significant statistical difference between both groups regarding returning to
sleep after awakening. Also, Huang et al., 2015 in their study reported that those who wore
earplugs and eye masks had less awakenings and shorter sleep latency.
On the other hand, our study finding is contradicted with Arttawejkul & Chirakalwasan
(2018) who found that using non-therapeutic measures in medical ICU patients during the
first night was associated with an improvement in sleep quality. As well, the present finding
is not congruent with Demoule et al., 2017 who proved that there was no statistic difference
between the intervention group and control group in terms of quality of sleep following the
first night. That study rationalized that participants of the study group who used earplugs only
for a short time of night had more worse quality of sleep than patients in the control group.
This was due to their poor tolerance of the devices provided. Generally, earplugs and eye
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masks represent cost-effective methods that can be applied in all ICUs to enhance quality of
sleep.. Despite, most participants in this study who used earplugs and eye masks considered
this strategy as effective and beneficial.
CONCLUSION
Non-therapeutic measures such as earplugs and eye masks significantly reduced the
environmental stressors at night and also, using them improved sleep quality among
critically ill patients.
RECOMMENDATIONS
Replication of the study on a larger sample from different geographical regions of Egypt and
in general intensive care units is recommended. Furthermore, studying the barriers facing
patients in critical care units and lead them to sleeping deprivation. Also, evidence-based
care protocols or bundles for promoting sleep should be integrated into ICUs to improve
patients' quality of life.
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