The Patient's Experience With Critical Illness

15 Pages·2004·0.19 MB·English

chapter
2
The Patient’s Experience
With Critical Illness
KATHRYN S. BIZEK
Perception of Critical Illness objectives
Patients’ Experiences
Based on the content in this chapter, the reader should be able to:
Anxiety
■ Explore relationships among stress, response to illness, and
Causes of Anxiety
anxiety.
Responses to Anxiety
Patterns of Adaptation ■ Construct nursing interventions to assist patients in their
Nursing Assessment adaptation to critical illness.
Nursing Interventions
■ Compare and contrast techniques that the patient and family
Creating a Healing Environment
can learn in an effort to manage stress and anxiety.
Fostering Trust
Providing Information ■ Discuss alternatives to the use of physical restraint in the
Allowing Control intensive care unit.
Cultural Sensitivity ■ Describe the phases of loss and specific nursing interventions
Presencing and Reassurance for each phase.
Cognitive Techniques
■ Develop nursing interventions that foster the ability of patients
Guided Imagery and Relaxation
to draw strength from their personal spirituality.
Training
Deep Breathing ■ Develop strategies to care for patients and their families at the
Music Therapy end of life.
Humor
Massage and Therapeutic Touch
Meridian Therapy
Animal-Assisted Therapy
Restraints in Critical Care
Physical Restraints
Chemical Restraint
Alternatives to Restraints
Loss and Responses to Loss
Shock and Disbelief
Development of Awareness
Restitution
Resolution
Spirituality and Healing
Care at the End of Life
A Good Death
Barriers to Care
Nursing Interventions
12
CHAPTER 2 The Patient’s Experience With Critical Illness 13
The patient’s experience in an intensive care unit (ICU) between 30% to 100% of patients studied could recall all
has lasting meaning for the patient and his or her fam- or part of their stay in the ICU.3 Although many of the
ily members and significant others. Although actual patients recalled feelings that were negative, they also
painful memories are blurred by drugs and the mind’s need recalled neutral and positive experiences. Negative expe-
to forget, attitudes that are highly charged with feelings riences were related to fear, anxiety, sleep disturbance,
about the nature of the experience survive. These attitudes cognitive impairment, and pain or discomfort. Positive
shape the person’s beliefs about nurses, physicians, health experiences were related to feelings of being safe and
care, and the vulnerability of life itself. secure. Often, these positive feelings were attributed to
This chapter describes specific measures that nurses use the care provided by nurses. The need to feel safe and the
to support patients and their families through the stress of need for information were predominant themes in qualita-
crisis and adaptation to illness, death, or a return to health. tive research studies conducted by Hupcey and colleagues.4,5
An understanding and appreciation of the intricate relation- Nurses’ technical competence and effective interpersonal
ships among mind, body, spirit, and the healing process will skills were cited by patients as promoting their sense of secu-
help the critical care nurse provide emotional support to the rity and trust.3–6
patient and family. It is the caring and emotional support
given by the nurse that will be remembered and valued. STRESS
Stress has been defined as a situation that exists when an
organism is faced with any stimulus that causes a disequi-
PERCEPTION OF
librium between psychological and physiological function-
CRITICAL ILLNESS ing. All hormone levels can be altered by stress. Extreme
levels of stress damage human tissue and may interfere with
Admission to a critical care unit (CCU) may signal a threat adaptive responses. If adaptive behaviors are effective,
to the life and well-being of the patient who is admitted. energy is freed and may be directed toward healing. If
Critical care nurses perceive the unit as a place where frag- adaptive behaviors fail or are ineffective, however, the ten-
ile lives are vigilantly scrutinized, cared for, and preserved. sion state is increased, as is the demand for energy. There-
Patients and their families, however, frequently perceive fore, the original stress of illness looms larger (Fig. 2-1).
admission to critical care as a sign of impending death, Hans Selye first described the stress syndrome and the
based on their own past experiences or the experiences of general adaptation syndrome in the 1930s.7
others. Understanding what critical care means to patients
Response to Stress
may help nurses care for their patients. However, effective
communication with critically ill patients is often challeng- The characteristic problems of adapting to limitations
ing and frustrating.1,2Barriers to communication may relate enforced by illness can be understood by exploring the
to the patients’ physiological status; the existence of endo- relationship between the physical and the sociopsycho-
tracheal tubes, which inhibit verbal communication; med- logical response to the illness. There is an observable lag
ications; or other conditions that alter cognitive function. between the physical onset of illness and its emotional
acknowledgment—that is, the patient experiences illness
and disability physically before acknowledging them fully
Patients’ Experiences
on an emotional level. Denial is an example of this lag. Like-
A number of authors have sought to study and describe wise, after physical health has been stabilized, the patient
patients’ experiences related to their ICU stay. In a review still experiences concerns and fears related to acute illness.
of 26 studies, Stein-Parbury and McKinley noted that At this point, the patient is likely to resist independence
Coping
Stress
behaviors
Effective
Increased demand
behaviors
for energy
Ineffective
behaviors
Decreased
tension state
Increased
Free
tension
energy
figure 2-1 Stress and coping.
14 PART 1 THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE
and be reluctant to cooperate with increased expectations Responses to Anxiety
for activity and self-care. Preparation for return to health,
PHYSIOLOGICAL RESPONSES
acknowledgment of concerns about increased activity, and
the reassurance of watchful eyes help alleviate anxiety as The physiological responses of rapid pulse rate, increased
the patient progresses. blood pressure, increased respirations, dilated pupils,
If different responses of patients to illness could be dry mouth, and peripheral vasoconstriction may go un-
plotted on a graph, they would show both common and detected in a seemingly cool, calm, self-contained patient.
unique points, just as electrocardiograms (ECGs) from These autonomic responses to anxiety are frequently the
different people show common characteristics and indi- most reliable index of the degree of anxiety when behav-
vidual differences. The time and congruence between ioral and verbal responses are not congruent with the
physical and sociopsychological responses vary, but the circumstances.
stages occur predictably. Like the electrical events of the
heart, response to illness, both adaptive and maladaptive, SOCIOPSYCHOLOGICAL RESPONSES
can be anticipated. The nurse has several responsibilities: Behavioral responses indicative of anxiety are often
family-based and culturally learned. They vary from
■ Anticipate, assess, and monitor the response to illness.
quiet composure in the face of disaster to panic in the
■ Recognize and support effective behaviors.
presence of an innocuous insect. Such extremes of con-
■ Minimize and redirect ineffective behaviors.
trol and panic use valuable energy. If this energy is not
directed toward eliminating or adapting to the stressor,
ANXIETY
it only perpetuates the discomfort of the tension state.
The goal of nursing care is always to promote physio-
Causes of Anxiety logical and emotional equilibrium.
Any stress that threatens one’s sense of wholeness, contain-
ment, security, and control causes anxiety. Illness is one Patterns of Adaptation
such stress. A common cause of anxiety is a sense of isola-
Figure 2-2 demonstrates one pattern of adapting to vari-
tion. Rarely is one lonelier than when in the midst of a
ous stages of illness. During stress, the patient regresses in
socializing crowd of strangers. In such a situation, people
an attempt to conserve energy. During times of acute
attempt to include themselves, remove themselves, or emo-
exacerbation or heightened expectations, or during any
tionally distance themselves. The sick person surrounded
significant change, the initial response is regression to an
by active and busy people is in a similar situation but with
few resources available to reduce the sense of isolation. earlier emotional position of safety. Weaning from a res-
Hospital staff who ignore the presence of a patient, regard- pirator, removal of monitor leads, increased activity, and
less of the patient’s alertness, contribute to the patient’s reduction in medication often trigger anxiety and regres-
sense of isolation. Including the patient in conversations sion. This regression may even include a retreat into
about treatment and providing a reassuring touch at fright- increased dependency, depression, and anger. At such
ening moments can reduce this sense of isolation. times, the patient may find comfort in regressing to a state
Serious illness and the fear of dying also separate the that has already been mastered. Behavior at this time may
patient from his or her family. The immediate development seem peculiar or irrational to the nurse. The regression is
of dependent and intimate relationships with strangers is usually temporary and brief and can be used to identify the
required. The reassuring cliche, “You’ll be all right,” often cause of anxiety. Nurses may become disappointed, anx-
meant to comfort, only reinforces the patient’s sense of dis- ious, or angry with the patient’s regression and may want
tance. It shuts off the expression of fears and questions to retreat. It is more helpful, however, to acknowledge
about what is to come next. The efficiency and activity that that regression is inevitable and to support the patient
surround the patient increase the sense of separateness.
Another category of anxiety-provoking stimuli includes
those that threaten the individual’s security. Admission
to the ICU dramatically confirms for the family and
patient that their security on all levels is being severely
threatened.
After the patient is admitted to the unit, the initial inse-
Wellness Transition Acceptance Convalescence
curity undoubtedly concerns life itself. Later, questions
to illness
regarding such issues as length of hospitalization, return
to work, financial implications, well-being of the family,
and permanent limitations arise. The patient’s insecurity
continues and needs to be sensitively considered. Level of physical well being
Anxiety occurs when a person experiences the following: Degree of sociopsychological response
figure 2-2 One pattern of adapting to various stages of illness.
■ Threat of helplessness
The darkly shaded areas represent transition into and out of illness
■ Loss of control
and show the disparity between actual health and the person’s per-
■ Sense of loss of function and self-esteem
ception of his or her health. During transition to illness, there is
■ Failure of former defenses denial. During the acceptance phase, physical and mental well-
■ Sense of isolation being are congruent. During the convalescence phase, an emotional
■ Fear of dying lag exists between physical and emotional well-being.
CHAPTER 2 The Patient’s Experience With Critical Illness 15
with interventions appropriate to earlier stages. The nurse promote adaptation in critically ill patients. Often a com-
helps the patient understand what is happening by bination of interventions is used.
explaining the emotional lag phenomenon.
Creating a Healing Environment
NURSING ASSESSMENT
Florence Nightingale is considered the founder of modern
nursing. She often wrote about the nurse’s role in creating
Often it is not possible for the nurse simply to remove the
an environment to allow healing to occur.8,9She empha-
stimuli that cause anxiety. In these circumstances, the nurse
sizedholism in nursing—that is, caring for the whole per-
must assess the effectiveness of the patient’s behaviors and
son. In today’s technological age, critical care nurses are
either support them, help the patient modify them, or teach
challenged to create an environment of healing. These
new behaviors. Frequently, levels of anxiety are so high that
environments must allow critically ill patients to have
the anxious state becomes the stimulus that demands addi-
their psychological needs as well as physical needs met.
tional coping responses. After assessing coping behaviors
Manipulating the milieu may involve timing interventions
for effectiveness, the nurse has several choices:
to allow adequate sleep and rest, providing pain-relieving
■ Support the behaviors. medication, playing music, or teaching deep-breathing
■ Help the patient modify behaviors. exercises.
■ Teach new behavior.
Coping behaviors may be directed either toward elim- Fostering Trust
inating the stress of illness or toward eliminating the anx-
Almost every nurse in critical care can relate stories of
iety state itself. The nurse must evaluate each behavior as
special bonds that formed with individual patients and
to whether it helps restore a steady state. Behaviors that
families. They can describe special situations where a
promote movement toward a steady state can then be sup-
trusting relationship developed and they made a differ-
ported and encouraged. The nurse may also need to help
ence in the patient’s recovery or even dignified death. In
the patient modify or find substitutes for behaviors that
contrast, patients have related to us, through research,
are disruptive or threatening to homeostasis. At times, the
that when they mistrust their caregivers, they are more
nurse must introduce new behaviors to facilitate equilib-
anxious and more vigilant of staff behaviors, and lack the
rium and promote health.
feeling of safety and security. Our goal, then, is to dis-
Examples of nursing diagnoses associated with critical
play a confident, caring attitude, demonstrate technical
illness and injury can be seen in Box 2-1.
competence, and develop effective communication tech-
niques that will foster the development of a trusting
NURSING INTERVENTIONS relationship.6
Whenever possible, stress must be reduced or eliminated
Providing Information
for critically ill patients. If this can be accomplished, the
problem is quickly resolved, and the patient is returned to Besides the need to feel safe, critically ill patients iden-
a state of equilibrium. Usually, however, the stress is not tify the need for information as having a high priority.
eliminated so easily because many other stressors are This need to know involves all aspects of the patients’
introduced by attempts to remedy the original problem. If care. They need to know what is happening at the
adaptive behaviors are effective, anxiety is reduced, and moment. They also need to know what will happen to
energy is directed toward rest and healing. A number of them, how they are doing, and what they can expect.
nursing interventions may be used to reduce anxiety and Many patients also need frequent explanations of what
happened to them. These explanations reorient them,
sort out sequences of events, and help them distinguish
real events from dreams or hallucinations.4,5Anxiety can
box 2-1 Examples of Nursing Diagnoses and be greatly relieved with simple explanations. Consider
Collaborative Problems for the Patient With the patient, for example, who was being weaned from the
Critical Illness or Injury ventilator who just needed reassurance that if he did not
breathe, the machine would do it for him.10Families, too,
■ Anticipatory Grieving have identified the need for information as a high prior-
■ Anxiety ity. This is followed closely by the need to have hope.
■ Body Image Disturbance Most families identify physicians as the primary source
■ Impaired Verbal Communication for information. It is important for nurses to be mindful
■ Ineffective Denial of patient confidentiality issues when speaking to family
■ Fear members. Nurses should have the patient’s permission
■ Risk for Loneliness before giving confidential medical information to family
■ Powerlessness members. If that is not possible because of the patient’s
■ Self-Esteem Disturbance condition, a family spokesperson should be identified as
■ Spiritual Distress the person who may receive confidential information.
■ Potential for Enhanced Spiritual Well-Being This information should be recorded in the patient’s
medical record.
16 PART 1 THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE
Allowing Control at the patient and his or her needs or feelings. Snyder and
colleagues describe a higher level of presence called tran-
Nursing measures that reinforce a sense of control help
scendent presence, which conveys an energy exchange
increase the patient’s autonomy and reduce the overpower-
between the nurse and the patient that has a spiritual qual-
ing sense of a loss of control. The nurse can help the patient
ity.12Quinn describes the concept of intentionality in the
to feel more control over his or her environment by:
development of the use of self as healer. This means one
■ Providing order and predictability in routines makes a conscious effort to use all of one’s capacity, includ-
■ Using anticipatory guidance ing eyes, voice, energy, and touch, in a more intentionally
■ Allowing the patient to make choices whenever healing way.13Reassurance can be provided to the patient
possible in the form of presencing and caring touch. Reassurance
■ Involving the patient in decision-making can also be verbal. Verbal reassurance can be effective for
■ Providing information and explanation for procedures patients if it provides realistic encouragement or clarifies
misconceptions. Verbal reassurance is not valuable, how-
Providing order and predictability allows the patient to
ever, if it prevents a patient from expressing his or her
anticipate and prepare for what is to follow. Perhaps it cre-
emotions or stifles the need for further dialogue. Reassur-
ates only a mirage of control, but anticipatory guidance
ance is intended to reduce fear and anxiety and evoke a
keeps the patient from being caught off-guard and allows
calmer, more passive response. It is best directed at patients
the mustering of coping mechanisms.
expressing unrealistic or exaggerated fears.
Allowing small choices when the patient is willing and
ready increases the patient’s feeling of control over the
environment. Would the patient prefer to lie on his or her Cognitive Techniques
right or left side? In which arm should the intravenous
Techniques that have evolved from cognitive theories of
(IV) line be placed? What height is preferred for the
learning may help anxious patients and their families.
head of the bed? Does the patient want to cough now or
They can be initiated by the patient and do not depend on
in 20 minutes after pain medication? Any decisions that
complex insight or understanding of one’s own psycho-
afford the patient a certain amount of control and pre-
logical makeup. They can also be used to reduce anxiety
dictability are important. These small choices may also
in a way that avoids probing into the patient’s personal
help the patient accept lack of control during procedures
life. Furthermore, the patient’s friends and family mem-
that involve little choice.
bers can be taught these techniques to help them and the
patient reduce tension.
Cultural Sensitivity
INTERNAL DIALOGUE
Interventions for individual patients must be contextually
Highly anxious people are most likely giving themselves
based and culturally sensitive. Transcultural nursing refers
messages that increase or perpetuate their anxiety. These
to a formal area of study and practice that focuses on pro-
messages are conveyed in one’s continuously running
viding care that is compatible with the cultural beliefs, val-
“self-talk,” or internal dialogue. The patient in the ICU
ues, and lifestyles of individuals. A cultural assessment
may be silently saying things such as, “I can’t stand it in
includes the patient’s usual response to illness as well as his
here. I’ve got to get out.” Another unexpressed thought
or her cultural norms, beliefs, and world views. Because
might be, “I can’t handle this pain.” By asking the patient to
individual responses and values may vary within the same
share aloud what is going on in this internal dialogue, the
culture, the patient should be recognized as an individual
nurse can bring to awareness the messages that are dis-
within the cultural context. Exploring the meaning of the
tracting the patient from rest and relaxation. Substitute
critical event with the patient, family members, and sig-
messages should be suggested to the patient. It is important
nificant others may give clues to the patient’s perception
to ask the patient to substitute rather than delete messages
of what is happening. In addition, the nurse may ask if
because the internal dialogue is continuously operating and
there is a particular ethnic or religious group with which
will not turn off, even if the patient wills it to do so. There-
the patient identifies and if there is anything the nurses
fore, asking the patient to substitute constructive, reassur-
may do to provide care that is sensitive to individual val-
ing comments is more likely to help the patient significantly
ues or norms while the patient is hospitalized. Awareness
and acceptance are the heart of cultural competence.11 reduce his or her tension level. Comments such as, “I’ll
handle this pain just one minute at a time” or “I’ve been in
tough spots before, and I am capable of making it through
Presencing and Reassurance this one!” will automatically reduce anxiety and help the
patient shape coping behaviors accordingly. Any message
Presence, or just “being there,” can in itself be a meaning-
that enhances the patient’s confidence, sense of control, and
ful strategy for alleviating distress or anxiety in the critically
hope and puts him or her in a positive, active role, rather
ill patient. Presencing is the therapeutic use of self, adopt-
than the passive role of victim, will increase the patient’s
ing a caring attitude, and paying attention to an individual’s
sense of coping and well-being.
needs. This presence implies more than just a physical pres-
The nurse helps the patient develop self-dialogue
ence, however. It means giving one’s full attention to the
messages that increase:
person, focusing on the person, and practicing active lis-
tening. When a nurse uses presence, the focus is not on a ■ Confidence
task or outside thoughts. Energy and attention are directed ■ Sense of control
CHAPTER 2 The Patient’s Experience With Critical Illness 17
■ Ability to cope Deep muscle relaxation may reduce or eliminate the use
■ Optimism of tranquilizing and sedating drugs. In progressive relax-
■ Hope ation,the patient is first directed to find as comfortable a
position as possible and then to take several deep breaths
EXTERNAL DIALOGUE and let them out slowly. Next, the patient is asked to
clench a fist or curl toes as tightly as possible, to hold the
A similar method can be applied to the patient’s external
position for a few seconds, then to let go while focusing on
conversation with other people. By simply requiring
the sensations of the releasing muscles. The patient should
patients to speak accurately about themselves to others,
practice this technique, beginning with the toes and mov-
the same goals can be accomplished. For example, patients
ing upward through other parts of the body—the feet,
who exclaim, “I can’t do anything for myself!” should be
calves, thighs, abdomen, chest, and so on. This procedure
asked to identify the things that they are able to do, such
is done slowly while the patient gives nonverbal signals
as lifting their own bodies, turning to one side, making a
(e.g., lifting a finger) to indicate when each new muscle
nurse feel good with a rewarding smile, or helping the
mass has reached a state of relaxation. Extra time and
family understand what is happening. Even the smallest
attention should be given to the back, shoulders, neck,
movement in the weakest of patients should be acknowl-
scalp, and forehead, because many people experience
edged and claimed by the patient. This technique is use-
physical tension in these areas.
ful in helping patients correct their own misconceptions
Once a state of relaxation is achieved, the nurse can
of themselves and the way others see them. This reduces
suggest that the patient fantasize or sleep as deeply as the
the patients’ sense of helplessness and therefore their
patient chooses. The patient must be allowed to select and
anxiety.
control the depth of relaxation and sleep, especially if the
fear of death is prominent in the patient’s mind. A mod-
COGNITIVE REAPPRAISAL
erately dark room and a soft voice facilitate relaxation.
This technique asks the patient to identify a particular
Asking the patient to relax is frequently nonproductive
stressor and then modify his or her response to that stres-
compared with directing him to release a muscle mass
sor. In other words, the patient reframes his or her per-
actively, let go of tension, or imagine tension draining
ception of the stressor in a more positive light so that the
through the body and sinking deeply into the mattress.
stimulus is no longer viewed as threatening. The patient
Again, the patient is assisted to take an active rather than
is given permission to take personal control of responses
passive role by the nurse’s careful use of language.
to the stimulus. This technique may be combined with
guided imagery and relaxation training.
Deep Breathing
Guided Imagery When acutely anxious, the patient’s breathing patterns
and Relaxation Training may change, and the patient may hold his or her breath.
This could be physically and psychologically detrimental.
These are two useful techniques that can be taught to
Teaching diaphragmatic breathing, also called abdominal
the patient to help reduce tension. The nurse can encour-
breathing,to the patient may be useful as both a distraction
age the patient to imagine either being in a very pleasant
and a coping mechanism. Diaphragmatic breathing can be
place or taking part in a very pleasant experience. The
taught easily and quickly to the preoperative patient or to
patient should be instructed to focus and linger on the sen-
a patient experiencing acute fear or anxiety. The patient
sations that are experienced. For example, asking the patient,
may be asked to place a hand on the abdomen, inhale
“What colors do you see?” “What sounds are present?”
deeply through the nose, hold briefly, and exhale through
“How does the air smell?” “How does your skin feel?” “Is
pursed lips. The goal is to have the patient push out his
there a breeze in the air?” helps increase the intensity of
own hand to demonstrate the deep breath. The nurse may
the fantasy and thereby promote relaxation through men-
demonstrate the technique and perform it along with the
tal escape.
patient, until the patient is comfortable with the technique
Guided imagery also can be used to help reduce unpleas-
and is in control. The mechanically ventilated patient may
ant feelings of depression, anxiety, and hostility. Patients
be able to modify this technique by concentrating on
who must relearn life-sustaining tasks, such as walking and
breathing and on pushing out the hand. Mechanically ven-
feeding themselves, can use imagery to prepare mentally to
tilated patients experiencing severe agitation may not be
meet the challenge successfully. In these instances, patients
able to respond to this technique.
should be taught to visualize themselves moving through
the task and successfully completing it. If this method seems
trivial or silly to the patients, they can be reminded that this
Music Therapy
method demands concentration and skill and is commonly
used by athletes to improve their performance and to pre- Music therapy has been used in the critical care environ-
pare themselves mentally before an important event. ment as a strategy to reduce anxiety, provide distraction,
Guided imagery is a way of purposefully diverting or focus- and promote relaxation, rest, and sleep.15 The patient is
ing the patients’ thoughts and has been shown to empower provided with a choice of specially recorded audiotapes
patients, improving their satisfaction and well-being.14 and a set of headphones. Usually, music sessions are 20 to
The nurse can also use techniques that induce deep 90 minutes long, once or twice daily. Music selections may
muscle relaxation to help the patient decrease anxiety. vary by individual taste, but the most commonly used
18 PART 1 THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE
selections have a tempo of 60 to 70 beats, a simple, direct Healing touch involves a number of full-body and local-
musical rhythm, and a low-pitched sound with primarily a ized techniques to balance energy fields and promote heal-
string composition. Most patients prefer music that is ing.18Implementation of healing touch therapy involves a
familiar to them. formal educational program for healers, and its potential
benefits are under active investigation.
Humor
Meridian Therapy
A good belly laugh produces positive physiological and
psychological effects. Laughter can increase the level of Complementary and alternative medicine (CAM) is a
endorphins, the body’s natural pain relievers, which are phrase used to describe an array of nontraditional heal-
released into the bloodstream. Laughter can relieve ten- ing approaches. Meridian therapy refers to therapies that
sion and anxiety and relax muscles. The use of humor by involve an acupoint, such as acupuncture, acupressure,
nurses in critical care can help reduce procedural anxiety and the activation of specific sites with electrical stimula-
or provide distraction. Once again, the humor must be tion and low-intensity laser.19Meridian therapy originates
compatible with the context in which it is offered and with from traditional Chinese medicine. Meridians are complex
the individual’s cultural perspective. Many nurses report energy pathways that integrate into intricate patterns.19
using humor cautiously after they have established a rap- These pathways contain sensitive energy points that are
port with the individual. Nurses also report that they are amenable to stimulation to relieve blockages that affect
able to take cues from the patient and visitors regarding various physiological functions. Research has demon-
the appropriate use of humor. Patients have reported that strated the effectiveness of meridian therapy for pain
nurses who have a good sense of humor are more approach- relief, postoperative nausea, and other functions. Cur-
able and easier to talk with. In an effort to incorporate the rently, research is underway to validate acupoint sites.
positive effects of humor into health care settings, some Meridian therapy should be performed only by profes-
institutions have developed humor resource rooms or sionals with specialized training.
mobile humor carts. These provide patients with a variety
of lighthearted reading materials, videotapes, and audio-
Animal-Assisted Therapy
tapes. Also included on the cart may be games, puzzles,
and magic tricks. Some nurses have created their own The human–animal bond has been well documented. Pet
portable therapeutic humor kits. Use of humor by patients ownership has been linked to higher levels of self-esteem
may help them reframe their anxiety and channel their and physical health. Pet therapy (or, more broadly, animal-
energy toward feeling better. Appropriate use of humor assisted therapy) has had measurable benefits for school
can relieve stress among critical care nurses who work in children and residents of nursing homes. More recently,
complex, challenging environments with significant eco- this concept has been introduced to the acute and criti-
nomic pressures.16 cal care settings with positive results. In one California
hospital, a formal program exists in which volunteer
Massage and Therapeutic Touch owner–dog teams visit patients in the hospital on a vari-
ety of units.20In a small pilot study, Cole and Gawlinski
Massage is the purposeful stroking and kneading of muscles described patients’ delight in having fish aquariums
with the goal of providing comfort and promoting relax- placed in their rooms while they were awaiting heart
ation.17Nurses have traditionally used effleurage for back transplantation.20
rubs for patient comfort. Effleurage uses slow, rhythmic
strokes from distal to proximal areas of long musclessuch
as the back or extremities. Consistent, firm yet flexible RESTRAINTS IN CRITICAL CARE
hand pressure is applied with all parts of the hand to con-
form to body contours. Lotion may be used to decrease
Physical Restraints
friction and add moisture. Massage has been effective at
reducing anxiety and promoting relaxation.17Patient selec- Historically, physical restraints have been used for
tion is an important consideration when electing massage patients in critical care to prevent potentially serious dis-
as a therapeutic intervention. Patients who are hemo- ruptions in patient care through accidental dislodgment
dynamically unstable, for example, would not be appro- of endotracheal tubes or life-saving IV lines and other
priate candidates. In addition, nurses require additional invasive therapies. Other reasons that have been cited for
training in massage therapy to effectively incorporate use of restraints include the prevention of falls, behavior
more advanced massage techniques such as petrissage or management, and avoidance of liability suits due to
pressure points into plans of care for critically ill patients. patient injury. However, research related to restraint
Therapeutic touch is a set of techniques where the use, especially in the elderly, has demonstrated that
practitioner’s hands move over a patient in a systematic these reasons, although well-intentioned, often are not
way to rebalance the patient’s energy fields.18An impor- valid.10,21–24Patients who are restrained have been shown
tant component of therapeutic touch is compassionate to have more serious injuries secondary to falls as they
intent on part of the healer. Therapeutic touch as a com- “fight” the device that limits their freedom. In addition,
plementary therapy has been used successfully in acute there are reportedly a greater number of lawsuits related
care settings to decrease anxiety and promote a sense of to improper restraint use than to injuries sustained when
well-being. It is a foundational technique of healing touch. restraints were not used.25,26 Critically ill, intubated
CHAPTER 2 The Patient’s Experience With Critical Illness 19
patients have been known to self-extubate despite the use Chemical Restraint
of soft wrist restraints.21, 23–24, 27
Chemical restraint refers to pharmacological agents that
The forced immobilization that results from restrain-
are given to patients as discipline or to limit disruptive
ing a patient can prolong a patient’s hospitalization by
behavior. Medications that have been used for behavior
contributing to skin alterations, loss of muscle tone,
control include, but are not limited to, psychotropic drugs
impaired circulation, nerve damage, and pneumonia.25,28
such as haloperidol, sedative agents such as benzodi-
Restraints have been implicated in accelerating patients’
azepines (e.g., lorazepam, midazolam), or the anticholin-
levels of agitation, resulting in injuries such as fractures or
ergic antihistamine, diphenhydramine.29 This definition
strangulation.
does notapply to medications that are given to treat a med-
Physical restraints include any device that is used to
ical condition.29The use of sedative, analgesic, and anxi-
restrict the patient’s mobility and normal access to his or
olytic medications is an important adjunct in the care of
her body. These may include limb restraints, mittens with
the critically ill patient. Documentation of the use of these
ties, vests or waist restraints, geriatric chairs, and siderails.
medications should include the indication for the drug and
Siderails are considered a restraint if used to limit the abil-
the patient’s response.
ity of the patient to get out of bed rather than to help him
Delirium is a common phenomenon in the ICU and
or her get up.26
may be related to sleep disturbance, the person’s under-
Standards on restraint use are published and moni-
lying medical condition, the unfamiliar environment,
tored by the Joint Commission on Accreditation of
medication side effects, or a combination of these factors.
Healthcare Organizations (JCAHO) and the Centers for
Elderly patients are especially vulnerable. Delirium is a
Medicare and Medicaid Services (formerly known as the
reversible cognitive disturbance associated with confu-
Health Care Financing Administration). A summary
sion, inappropriate behavior, decreased attention span,
of these standards is given in Box 2-2. These standards
short-term memory impairment, and altered percep-
may be viewed on the respective agency’s website. Many
tions.30Dementia, however, is generally considered to be
hospitals have revised their policies, procedures, and
a progressive disease associated with mild to severe cogni-
documentation of the use of restraints to comply with
tive impairment.
the most recent revision of these standards, effective
Care must be taken to provide adequate comfort for
January 2001.
patients experiencing life-threatening illnesses and a vari-
ety of noxious interventions. It is desirable to use the least
amount of medication as feasible to achieve the goals of
patient care because all medications have potential side
effects and adverse reactions. Patients must be continually
box 2-2
assessed for adequacy of comfort. Behaviors that seem
Summary of Care Standards Regarding
to indicate pain may actually indicate a change in the
Physical Restraints
patient’s physiological status. Agitation, for example, may
be a sign of hypoxemia. Caution must be exercised when
Initiating Restraints
using as-needed (PRN) medications to reduce pain and
■ Restraints require the order of a licensed independent
promote comfort. Without consistency in assessment,
practitioner who must personally see and evaluate the
goal setting, and administration, PRN dosing may inad-
patient within specified time periods.
vertently lead to overmedication or undermedication in
■ Restraints are used only as an emergency measure or
the critically ill patient. In addition, these medications can
after treatment alternatives have failed. (Treatment
have rebound effects if abruptly withdrawn. Weaning a
alternatives and patient responses are documented.)
patient from analgesic or sedative medication may be as
■ Restraints are instituted by staff who are trained and
important as weaning a patient from a mechanical ventila-
competent to use restraints safely. (A comprehensive
tor. Many CCUs incorporate assessment tools for patient
training and monitoring program must be in place.)
comfort on their daily flow sheets.30
■ Restraint orders must be time-limited. (A patient must
not be placed in a restraint for longer than 24 hours,
Alternatives to Restraints
with reassessment and documentation of continued
need for restraint at more frequent intervals.)
What, then, is the well-meaning nurse to do when a patient
■ Patients and families are informed about the reason/
is experiencing confusion or delirium and is pulling at his
rationale for the use of the restraint.
or her lifesaving devices and tubes? Remember that phys-
Monitoring Patients in Restraints ical restraint is the last resort, to be used only when the
■ The patient’s rights, dignity, and well-being are to be patient is a danger to himself or others and when other
protected. methods have failed. Restraints may actually potentiate the
■ The patient will be assessed every 15 minutes by dangerous behavior. Rather, the nurse should attempt to
trained and competent staff. identify what the patient is feeling or experiencing. What
■ The assessment and documentation must include evalu- is the meaning behind the behavior? Is he cold? Does she
ation of adequate nutrition, hydration, hygiene, elimina- itch? Is the person in pain? Does the person know where
tion, vital signs, circulation, range of motion, injury due he or she is and why he or she is there? Sometimes address-
to the restraint, physical and psychological comfort, and ing the patient’s needs or concerns and reorienting the
readiness for discontinuance of the restraint. patient is all that is needed to calm him or her. Other inter-
ventions may include modifying the patient’s environment,
20 PART 1 THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE
providing diversionary activities, allowing the patient more iar self-image and its replacement with an altered one. All
control or choices, and promoting adequate sleep and losses include at least a temporary phase of lowered self-
rest24,29,31(Box 2-3). esteem. Regardless of the nature of the loss, the dynamics
of grief present themselves in some form. The response to
loss can be described in the following four phases:
LOSS AND RESPONSES TO LOSS
■ Shock and disbelief
■ Development of awareness
The threat of illness precipitates coping behaviors associ-
■ Restitution
ated with loss. Patients must adjust to the loss of health or
■ Resolution
loss of a limb, a blow to self-concept, or a necessary change
in lifestyle. Dying patients must adapt to the loss of life. All Each phase involves characteristic and predictable
these events require a change—that is, a loss of the famil- behaviors that fluctuate among the various phases in an
unpredictable way. Through recognition and assessment
of the behaviors and an understanding of their underlying
dynamics, the nurse can plan interventions to support the
box 2-3 healing process.
Alternatives to Physical Restraints
Shock and Disbelief
Modifications to Patient Environment
■ Keep the bed in the lowest position. In the first stage of response to loss, patients demonstrate
■ Minimize the use of siderails to what is needed for behaviors characteristic of denial. They fail to comprehend
positioning. and experience the rational meaning and emotional impact
■ Optimize room lighting. of the diagnosis. Because the diagnosis has no emotional
■ Activate bed and chair exit alarms where available. meaning, patients often fail to cooperate with precaution-
■ Remove unnecessary furniture or equipment. ary measures. For example, patients may attempt to get out
■ Ensure that the bed wheels are locked. of bed against the physician’s advice, or they may deviate
■ Position the call light within easy reach. from the prescribed diet and assert, “I am here for a rest!”
Denial may go so far as to allow patients to project diffi-
Modifications to Therapy
culties onto what is perceived as ill-functioning equipment,
■ Frequently assess the need for treatments and dis-
mistaken laboratory reports, or, more likely, the sheer
continue lines and catheters at earliest opportunity.
incompetence of physicians and nurses.
■ Toilet patients frequently.
When such blatant denial occurs, it is apparent that the
■ Disguise treatments, if possible (e.g., keep intravenous
problem is so anxiety provoking to the patient that it
[IV] solution bags behind patient’s field of vision, apply
cannot be handled by the more sophisticated mental
loose stockinette or long-sleeved gown over IV sites).
mechanisms of rational problem solving. The stressor is
■ Meet physical and comfort needs (e.g., skin care,
temporarily obliterated. This phase of denial may be the
pain management, positioning wedges, hypoxemia
period during which the patient’s resources, briefly blocked
management).
by the shock, can be regrouped for the battle ahead. There-
■ When possible, guide the patient’s hand through
fore, stripping away denial may render the patient helpless.
exploration of the device or tube, and explain the pur-
Furthermore, although denial has its obvious hazards, it has
pose, route, and alarms of the device or tube.
been associated with higher rates of survival after myocar-
■ Mobilize the patient as much as possible (e.g., con-
dial infarctions.
sider physical therapy consult, need for cane or
walker, reclining chairs, or bedside commode).
NURSING INTERVENTIONS
Involvement of the Patient and Family in Care
The principle of intervention consists not of stripping away the
■ Allow patient choices and control when possible.
defense of denial but of supporting the patient and acknowledg-
■ Family members or volunteers can provide company
ing the situation through nursing care.
and diversionary activities.
The nurse recognizes and accepts the patient’s illness
■ Consider solitary diversionary activities (e.g., music,
by watching the monitor or changing the dressings. In
videos or television, books on tape).
these ways, the nurse communicates acceptance of the
■ Ensure that the patient has needed glasses and hear-
patient through tone of voice, facial expression, and touch.
ing aids.
The nurse must reflect statements of denial back to the
Therapeutic Use of Self patient in a way that allows the patient to hear them—and
■ Use calm, reassuring tones. eventually to examine their incongruity and apply reality.
■ Introduce yourself and let the patient know he or she For example, the nurse may say something such as, “In
is safe. some ways you believe that having a heart attack will be
■ Find acceptable means of communicating with intu- helpful to you?” The nurse can also acknowledge the
bated or nonverbal patients. patient’s difficulty in accepting restrictions by making
■ Reorient patients frequently by explaining treatments, comments such as, “It seems hard for you to stay in bed.”
devices, care plans, activities, and unfamiliar sounds, By verbalizing what the patient is expressing, the nurse
noises, or alarms. gently confronts behavior but does not cause anxiety and
anger by reprimanding and judging. In this phase, the
CHAPTER 2 The Patient’s Experience With Critical Illness 21
nurse supports denial by allowing for it but does not per- pital, or his or her own actions. A nondefensive, accepting
petuate it. Instead, the nurse acknowledges, accepts, and attitude will decrease the patient’s sense of guilt, and the
reflects the patient’s new circumstance. expression of anger will avert some of the depression.
When the patient is in denial, the nurse demonstrates Later, when the patient apologizes for an irrational out-
acceptance in several ways: burst, the nurse can interpret the patient’s need to make
this kind of verbalization as a necessary step toward reha-
■ Tone of voice
bilitation and health.
■ Congruent facial expression
■ Use of touch
■ Use of reflection of inaccurate statements Restitution
■ Avoiding joking with patient about serious issues
In this stage, the griever puts aside anger and resistance and
begins to cope constructively with the loss. The patient tries
Development of Awareness new behaviors that are consistent with the new limitations.
The emotional level is one of sadness, and timespent cry-
In this second stage of grief, the patient’s behavior is char-
ing is useful. As the patient adapts to a new image, con-
acteristically associated with anger and guilt. The anger
siderable time is spent going over significant memories
may be expressed overtly and may be directed at the staff for
relevant to the loss. Behaviors in this stage include the ver-
oversights, tardiness, and minor insensitivities. In this
balization of fears regarding the future. Often these go
phase, the ugliness of reality has made its impact. Displace-
unexpressed and undetected because they are unbearable
ment of the anger onto others helps soften the impact of
for the family to hear. Furthermore, after severe trauma,
reality on the patient. The expression of anger gives the
which may have resulted in scarring or removal of a body
patient a sense of power in a seemingly helpless state. A
part or loss of sensation, patients may question their sexual
demanding manner and a whining tone often characterize
adequacy. They worry about the future response of their
this stage and represent the patient’s primitive attempts to
mates to their changed bodies. The patient probably also
regain the control that appears to have been lost. However,
questions a new role in the family. Most likely, the patient
such behavior often alienates the nurse and other person-
has a variety of concerns that are specific to his or her
nel. The patient who does not demand or whine has prob-
lifestyle. Therefore, in the mourning process, such mani-
ably withdrawn into depression because of anger directed
festationsas reminiscing, crying, questioning, expressing
toward self rather than toward others. This patient will
fears, and trying out new behaviors help the patient mod-
demonstrate verbal and motor retardation, will likely have
ify the old self-concept and begin working with and expe-
difficulty sleeping, and may prefer to be left alone.
During this phase, the nurse is likely to hear irrational riencing a revised concept.
expressions of guilt. Patients seek to answer the question,
NURSING INTERVENTIONS
“Why me?” They attempt to isolate their human imper-
fections and attribute the cause of the malady to them- During restitution, nursing care should again be support-
selves or their past behavior. Patients and their families ive so that adaptation can occur. Listening to the patient
may look for a person or object to blame. for lengthy periods of time is necessary. If the patient is
Guilt feelings concerning one’s own illness are difficult able to verbalize fears and questions about the future, he
to understand unless one examines the basic dynamic of or she will be better able to define the anxiety and solve
guilt. Guilt arises when there is a decrease in the feeling new problems. Furthermore, hearing oneself talk about
of self-worth or when the self-concept has been violated. fears helps put a person into a more rational perspective.
In this light, the nurse can understand that what is behind The patient may require privacy, acceptance, and encour-
an expression of guilt is a negatively altered self-concept. agement to cry so that respite from sadness can be found.
Blame therefore becomes nothing more than projection During this stage, the nurse may have the patient con-
of the unbearable feeling of guilt. sider meeting someone who has successfully adapted to
similar trauma. This measure provides the patient with a
NURSING INTERVENTIONS
role model as a new identity is assumed, which often occurs
During the patient’s development of awareness, nursing after the crisis period. Many support groups of recovering
intervention must be directed toward supporting the people with all types of illnesses and injuries will send
patient’s basic sense of self-worth and allowing and encour- someone to support and be a role model for patients and
aging the direct expression of anger. Nursing measures that families.
support a patient’s sense of self-worth are numerous and The patient, with appropriate support from the nurse,
include calling the patient by name; introducing strangers, begins to identify and acknowledge changes arising from
particularly if they are to examine the patient; talking to, the adaptation to illness. Relationships can and do change.
rather than about, the patient; and, most important, pro- Friends may respond differently to the patient who has suf-
viding for and respecting the patient’s need for privacy and fered a permanent disability, causing the patient to believe
modesty. The nurse needs to guard against verbal and non- that the attitudes and feelings of others have changed as a
verbal expressions of pity. It is more constructive and pro- result of the injury or illness.
ductive to empathize with the patient’s specific and During this time, the family has also been going through
temporary feelings of anger, sadness, and guilt rather than a similar process. They too have experienced shock, dis-
with a condition. belief, anger, and sadness. After they are ready to try to
The nurse can create an outlet for anger by listening solve their problems, their energies are directed toward
and by refraining from defending the physician, the hos- wondering how the changes in the patient will affect their