الفهرس 
I. IntroductionOnly 14 pages are availabe for public view
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Abstract
Mechanical Ventilation (MV) is a lifesaving intervention often used to protect vital pulmonary capabilities necessary for the maintenance and preservation of lifesustaining metabolic processes (Dweekat, 2020). However, MV is associated with serious complications. These complications may be related to the direct mechanical effects of the intra thoracic pressures generated by the ventilator, to alveolar and systemic inflammation, or to neural stimulation (Blanch & Quintel, 2017). Also, MV has been associated with respiratory muscle dysfunction and weaning difficulties (Dres et al., 2017). Mechanically ventilated patients’ treatment requires sedation, prolonged bed rest and treatment that results in physical immobility (Dweekat, 2020). Prolonged immobility can lead to the development of some complications, such as physical functional impairment, cognitive dysfunction, neuromuscular weakness and neuropsychiatric dysfunction (Wang et al., 2020). After a short period of immobility, muscles rapidly undergo disuse atrophy and lose mass. Disuse of skeletal muscles rapidly leads to a loss of lean muscle mass. This loss of muscle mass is accompanied by a 12% decline in skeletal muscle strength per week (Jiricka., 2009) or even up to 40% decline within the first week of immobility (Topp et al., 2002). Muscle protein degradation starts early during the course of the disease reflected by a shift in protein homeostasis towards breakdown on the first day after ICU admission. It has been reported that starting physical therapy early to reduce the duration of immobilization may improve muscular strength and patients’ outcomes (Puthucheary et al., 2013). Mechanically ventilated patients need analgesic and sedative medications for comfort and safety; however, over-sedation can lead to delirium, delayed mobilization, and cognitive impairment (Schefold et al., 2020). Delirium is a common complication among critically ill patients on MV with high incidence ranged from70 to 80% but it is mostly preventable (Zhang et al., 2021) Implementation of early mobility protocol has been proven to be safe and feasible and is associated with improvement in physical function and mobility levels, significant reductions in both ICU and hospital length of stay, ventilation days and a reduction in both the incidence and duration of delirium (McWilliams et al., 2018). The main goal of early mobility is to prevent loss of muscle function, promote mobility recovery, and help patients regain pre-hospital functional capabilities.
Aim of the study The aim of the study was to examine the effect of early mobility protocol on physical function, muscles strength and delirium among mechanically ventilated patients. Research Design: - A quasi-experimental design (study /control) was utilized.
Setting: - The current study conducted in the Emergency and Anesthesia Intensive Care Units at Menoufia University hospital, Menoufia Governorate, Egypt.
Sample: - A convenient sample of 60 adults patients was recruited. Patients were approached over a 12 months period from the biginning of February 2021 to the end of January 2022. Patients who met the study inclusion criteria including: a) Adults, age 18- 65 years and b) Mechanically ventilated via endotracheal tube. Patients were excluded from participation in the study if they have any of the following conditions: a) Preadmission immune-compromised status (taking corticosteroids for more than two weeks), because of the potential difficulty in assessing muscle strength in patients on long term corticosteroids; b) A history or acute diagnosis of myopathy, neuropathy, neurologic or orthopedic injury due to the inability to participate in progressive mobility protocol (Acute stroke, Hip fracture, unstable cervical spine or pathologic fracture); c) Mechanical ventilation 48 hours before transfer from an outside facility, current hospitalization or transferring hospital stay72 hours because the protocol began within 24 to 48 hours of intubation .
Instruments In order to achieve the purpose of the present study, the following instruments were used: I: A Semi Structured Demographic and Clinical Data Questionnaire II: The Physical Function ICU Test-Scored (the PFIT-s) III: Medical Research Council Manual Muscle Testing (MRC-MMT) scale IV: Confusion Assessment Method in the ICU (CAM-ICU) V: Acute Physiology and chronic Health Evaluation II (APACHE II) VI: The charlson Co-morbidity Index Ethical consideration After approval of the Research Committee in the Faculty of Nursing, an official permission was obtained from the hospital director to carry out the study. An oral consent was obtained from relatives of the patients to participate in the study. The procedure was explained to the patients` relatives. Patients’ information was kept confidential. The questionnaires did not harm the participants physically or emotionally. Data Collection Procedure Data were collected over 12 months period from the biginning of February 2021 to the end of January 2022. The participants were recruited the first day of admission to the ICU. The participants were matched against the study inclusion criteria. The researcher handled the control group first to prevent contamination of data. This group followed the usual hospital care. Study group received early mobility protocol intervention daily. Result • The mean age of the participants in the study and the control group was (51.96±12.02) and (54.66±8.88) years old respectively. Regarding gender, more than half of the participants in both study and control groups were male (66.7%) and (33.3%) respectively. Concerning ICU diagnosis, the highest percentage of the participants in both study and control group has COPD and respiratory failure (53.3%), (50.0%). There was no statistically significant difference in the demographic characteristics between both groups regarding the demographic data. • The mean APACHE II score was (10.56±3.14) (10.16±3.36) in the study and the control group respectively with no statistically significant difference (P < .636). About 16.7% and 10.0% of the participants in the study and the control groups have APACHE II score ranged from 15 to 19 which indicate a 25% mortality risk. 0.0% and 3.3% of the participants in the study and the control groups have APACHE II score ranged from 20 to 24 which indicate a 40% mortality risk. • The total mean score of the charlson Comorbidity Index was (12.23±1.25and 2.93±1.89) in the study and the control group respectively with no statistically significant difference (P < .096).• There is a highly statistically significant increase in the mean score of the Physical Function in the study group (8.90±2.15) compared with the control group (6.76±2.45) P< 0.001 post intervention. • There is a highly statistically significant increase in the mean score of muscle strength in the study group (51.70±7.66) compared with the control group (45.13± 8.82) P< 0.000 post intervention. • There is a highly statistically significant improvement of muscle strength. 60.0 % of the participants in the study group have muscle weakness pre intervention. This percent declined to 20.0 % of the participants have muscle weakness post intervention (p< 0.002). • There is a highly statistically significant decrease in the total mean days of delirium in the study group (2.73±1.78) compared with the control group (3.90±2.11) (p< .051) and there was a statistically significant reduction in the mean duration of mechanical ventilation in the study group (6.00±1.84) days compared to (7.46±1.94) days in the control group post intervention p< 0.05). In addition, there is a highly statistically significant decrease in the mean score of the hospital length of stay in the study group (10.46±3.41) compared with the control group (12.63±4.18) post intervention (P< 0.001). • There is a statistically significant reduction in the amount of prescribed Sedation to the study group (104.50±55.37 mg /kg) compared with the control group (136.0±53.49 mg/kg) (P< 0.000) and r = -.509 respectively (P< 0.004) which indicated that there was improvement in physical function when APACHEII score was low. • There is a positive relationship between the delirium and the total APACHE II score between the study and the control groups post intervention with r =0. 586 (P< 0.000) and r=0. 370 respectively (P< 0.008) which indicated that when APACHEII score was high, delirium increased. • There is a statistically significant negative correlation between physical function ICU test score and the comorbidities score between the study and the control groups post intervention with r = -.305 (P< 0.031) and r = -.509 respectively (P< 0.004) which indicated that there was improvement in physical function when comorbidities score was low. • There is a statistically significant negative correlation between muscle strength and the comorbidities score between the study groups post intervention with r = -.413 (P< 0. 003) which indicated that there was improvement in muscle strength when comorbidities score was low. • There is a positive relationship between the delirium and the total comorbidities score between the study and the control groups post intervention with r =0. 275 (P< 0. 053) and r =0.585 respectively (P< 0.001) which indicated that when comorbidities score was high, delirium increased. Conclusions The present study findings supported the use of early mobility protocol in clinical practice as an effective, safe and feasible nursing intervention to improve physical function, muscle strength, reduce delirium duration, increase ventilator free days and reduce hospital and ICU length of stay among mechanically ventilated patients. Recommendations Early mobility protocol should be incorporated as a routine practice in the ICU to promote patient’s mobility and prevent the serious side effects of immobility. Also, to provide the assistance needed to recover from the pathophysiological processes that affected mortality. Implications for Nursing Practice • The findings of the current study could significantly influence nursing practice and reduce the ICU cost through decreasing duration of mechanical ventilation and the ICU and hospital length of stay. Early mobility protocol as a non-pharmacological treatment has yielded improvement in delirium incidence and duration.• Educating critical care nurse and healthcare providers is crucial to improving patient outcomes in critical care. Thus, continuous training for critical care nurses to practice early mobility protocol as a routine care of mechanically ventilated patients is crucial. Implication for Future Research • There is a need for more randomized controlled trials to validate the positive effect of the early mobility protocol at a large scale studies. • Replicate the study with some methodological changes such as, random selection to achieve appropriate representation of the population and using a large sample size from multiple sites.