1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 02: The Patient’s Experience With Critical Illness

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of Hormones Released in Response to Major Stress See Table 2-1.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Evolution of the ICU See Table 2-2.

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a physiological consequence of noise in the ICU environment? A.Increased granulation of a wound B.Activation of the sympathetic nervous system C.Activation of the parasympathetic nervous system D.Longer periods of REM sleep

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Activation of the sympathetic nervous system Rationale: Increased noise levels have been associated with the activation of the sympathetic nervous system, decreased wound healing, and shorter periods of REM sleep.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Anxiety-Producing Experiences Threat of helplessness Loss of control Sense of loss of function and self-esteem Failure of former defenses Sense of isolation Fear of dying

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Creating a Healing Environment Develop a trusting relationship with patient/family. Provide information on an ongoing basis and verify that the patient/family understands, if possible. Help patients to maintain control as much as possible in planning, implementing, and evaluating their care. Be culturally sensitive. Learn your patient/family’s cultural view from their personal perspective. Provide a caring attitude as one human to another.

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cognitive Techniques to Help Handle Anxiety Ask your patient/family to share internal dialogue. Ask your patient/family to substitute constructive positive comments. Help your patient/family to identify strengths and acknowledge accomplishments to help resolve sense of helplessness. Assess the patient’s needs and instruct on techniques available to decrease anxiety: guided imagery, relaxation, deep breathing, music, aromatherapy, therapeutic touch, acupuncture, and pet therapy.

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client who is admitted to the ICU with a diagnosis of brain attack states that he can’t do anything and he is worthless. Your best response is: A.“You can move your right arm above your head and dress yourself, which means you are improving and can do more than you did 2 days ago.” B.“You will be fine once your rehab is over.” C.“You are still alive, so be thankful.” D.“Say to yourself, ‘I can do this, and I am worthwhile.’”

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. “You can move your right arm above your head and dress yourself, which means you are improving and can do more than you did 2 days ago.” Rationale: The client’s statement is an example of external dialogue, and the nurse should point out accomplishments and help the patient to accurately talk about himself. The nurse should not offer false reassurance that the client will be fine once rehab is over. The nurse should not minimize the client’s feelings by telling him he should be glad he is alive. The nurse should not tell the patient how to think and act.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Stages of Sleep See Box 2-2.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategies to Promote Sleep in the Critically Ill Patient

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study When assessing your patient’s sleep for quality and quantity, you note that the patient states she gets only 3 hours of uninterrupted sleep per night and she feels exhausted. She stated that she is awakened at 2400 for assessment and labs. She states that there is excessive chatter from the nurse’s station at 0300. She is awakened for assessment, chest x-ray, and labs at 0400. She is bathed at 0600. What steps should the nurse take to ensure that the patient may receive the rest and sleep that the patient needs?

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Elements of Spirituality Religion Beliefs and values Intuition Knowledge from the unknown Unconditional love A sense of belonging A sense of connection with the universe Reverence for life Personal empowerment

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Fostering a Spiritual Environment Respect and encourage the patient/family to share their spiritual beliefs. Encourage the patient/family to draw strength from their spirituality through prayer, meditation, connection with the universe, etc. Offer spiritual support as appropriate to meet the individual’s needs by calling for spiritual leaders or clergy.

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study A client awaiting a second heart transplant has an infection being treated with antibiotics in the ICU. While assessing his spirituality you find the following. He states that he believes he is his own god, and his strength for life and death comes from within. He believes his purpose is to give back to society while he is on earth, and once he dies he will give back to the earth by enriching the soil. How is the patient’s spirituality different than yours, and what can you do to ensure acceptance? What interventions can you provide to help him draw strength from his spirituality?

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Standard of Care: Proper Use of Physical Restraints in ICU See Box 2-4.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Alternatives to Physical Restraints See Box 2-5.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client is on a mechanical ventilator and has invasive lines in place. The client is restless; respirations, pulse, and blood pressure are elevated. The client is pulling at the covers and trying to get out of bed. The first action the nurse should take is: A.Provide bilateral wrist restraints and obtain an order. B.Assess the client for reasons for the behaviors. C.Provide sedation ordered on a prn basis. D.Request a family member to sit with the patient.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Assess the client for reasons for the behaviors. Rationale: The first action the nurse should take is also the first step of the nursing process: assessment. The nurse assesses whether the behaviors are a result of physical, psychological, or spiritual needs. Based on what the nurse finds as the underlying causes for the behaviors, interventions are provided to meet the client’s needs. The behaviors will become manageable, and the client will remain safe.