PORTT ans) Based on the content in this chapter, the reader should be able to: The Patient’s and Family's Experience With Critical Illness 1 Explain the effects of prolonged stress and anxiety and describe measures the nurse can take to minimize the amount of stress and anxiety patients and family members experience. 2 Describe the critical care nurse's role in assisting the family through the crisis. 3 Describe strategies to promote sleep in critically il patients. 4 Discuss alternatives to the use of physical restraints in the critical care unit. Ihe patient's experience in a critical care unit has lasting meaning for the patient and fam- ily. Often, it is the caring and emotional support given by the nurse that is remembered and val- ued. A number of authors have sought to study and describe patients’ experiences related to their stay in a critical care unit. Research has found that although many patients recall negative experiences, they also recall neutral and positive experiences. Negative experiences were related to fear, anxiety, sleep disturbance, cognitive impairment, and pain or discomfort. Positive experiences were related to feelings of being safe and secure and were often attributed to the care provided by nurses, specifi- cally nurses’ technical competence and effective interpersonal skills.’ The need to feel safe and the need for information were predominant themes in other research studies as well. Managing Stress and Anxiety Patients admitted to the critical care unit are sub- ject to multiple physical, psychological, and envi- ronmental stressors, as are their family members. For example, patients and their families frequently 8 perceive admission to critical care as a sign of impending death, based on their own past experi- ences or the experiences of others. In addition, the near-constant noise (eg, from equipment and alarms), bright lights, and lack of privacy in the crit ical care unit are intimidating and stress inducing. ‘The body responds to these stressors by activating the hypothalamic— pituitary-adrenal axis. The resul- tant increase in catecholamine, glucocorticoid, and mineralocorticoid levels leads to a cascade of physi- ological responses known as the stress response (Fig. 2-1). In critically ill patients, prolonged activa- tion of the stress response can lead to immunosup- pression, hypoperfusion, tissue hypoxia, and other physiologic effects that impair healing and jeopar- dize recovery. ‘Anxiety; pain, and fear can initiate or perpetu- ate the stress response. Anxiety is an emotional state of apprehension in response to a real or per ceived threat that is associated with motor tension, increased sympathetic activity, and hypervigilance. Feelings of helplessness, loss of control, loss of function or self-esteem, and isolation can produce anxiety, as can a fear of dying. Left untreated or undertreated, anxiety can contribute to the morbid- ity and mortality of critically ill patients.‘The Patient's and Family's Experience With Critical lines. tIAPTEE ? 9 cognitwe apprisal ne svessor adrenal lena FISURE 2.1. The stress response. Prolonged stress has far-reaching physiotogieal effects that hinder te bodys ably to heal. CRF, corvcttopin releasing factor; ACTH, ‘adrenccarticotropic hormone. AD AIA tne ts @ warnnreeseet physiological and behavioral indicators of anxiety regia ov nn oat eae cmos = Management of stress and anxiety entails elimi- nating or minimizing the stressors. For the critically ill patient, providing supportive care (eg, nutrition, oxygenation, pain management, sedatives, and anx- iolytics) is indicated.’ Mind-body strategies that may be employed to lessen stress and anxiety are summarized in Box 2-1. Often, the way the nurse interacts with the patient and family can have a sig- nificant impact on the amount of stress and anxiety they experience. Positive actions the nurse can take to minimize stress and anxiety include +» Fostering trust. When patients or family mem- bers mistrust caregivers, they are more anxious ney (pearl stmt povaiie bahavoraeaponeae ieratd mortal activity ‘ysonea yperventation gestion ese tenon Saphoross restasoness| ‘ataion oa end aldosterone ¥ fects conte to: ‘ovatod blood possure Gocreased unary output Increased es glcoe= sfc onrute inerated hoa rato ‘Sovated blood posture ‘ised pt sngia, palpaions because they are unable to feel safe and secure. A trusting relationship between the nurse and patient can make a difference in the patient's recov- ery or facilitating a dignified death. Displaying a confident, caring attitude; demonstrating techni- cal competence; and developing effective commu- nication techniques are strategies that help the nurse to foster trusting relationships with both patients and family members. + Providing information. Anxiety can be greatly relieved with simple explanations. Critically ill patients and their family members need to know what is happening at the moment, what will happen to the patient in the near future, how the patient is doing, and what they can expect. 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.10 PANT BRE The Concept of Holism Applied to Critical Care Nursing Practice HOWI2: 1 ina-body techniques tor Lessening Anxiety and Strese +Presencing and reassurance. Presencing, or “just being there,” can alleviate distress and anxiety. Nurses practice presencing by adopting a caring attitude, pay- ing attention to the person's needs, and actively listen- ing. Reassurance can be provided verbally or through caring touch, Verbal reassurance is most appropriate for people who are expressing unrealistic or exagger- ated fears. It is not valuable when it prevents a person from expressing emotions or stifles the need for fur- ther dialogue. “+ Reframing dialogue. Highly anxious people tend to sive themselves messages that perpetuate their anxi ety. For example, a patient may be thinking things such as, "Icant stand it in here. I've gat to get out.” ‘The murse encourages the person to share his or her internal dialogue, and then helps the person replace the negative thoughts with constructive, reassuring cones (eg, “Te been in tough situations before, and. ‘Ym capable of making it through this one!”). A simi lar method ean be applied to external dialogues. By speaking accurately about the situation to others, the person's own misconceptions about the situation will be improved. + Cognitive reappraisal. This technique asks the per- son to identify a particular stressor and then reframe his or her perception of the stressor in a more posi- tive light so that the stimulus is no longer viewed as. threatening. + Guided imagery. Guided imagery is a way of purpose- fully diverting or focusing a person's thoughts. Guided imagery can be used to promote relaxation through ‘mental escape. The nurse encourages the person to ‘imagine being in a very pleasant place or taking part in avery pleasant experience. The nurse instructs the per- son to Focus and linger on the sensations that are expe- rienced, prompting with questions if necessary (eg, “What colors do you see?” “What do you hear?” "How does the air smeil2”). Guided imagery can also be used to mentally prepare to mect a challenge (eg, relearning, how to walk) successfully: When applied in this way, the nurse teaches the person to visualize herself mov- ing through the task and successfully completing it. + Relaxation training. In progressive relaxation, the person is directed to find a comfortable position and then to take several deep breaths and let them out slowly. Next, the person is asked to clench a fist or curl the toes as tightly as possible, to hold the position for a few seconds, and then to let go while focusing on. the sensations of the releasing muscles. The person + Ensuring privacy. Ensuring privacy while sensi- tive or confidential information is being exchanged can markedly reduce the anxiety of a patient or family member. Healthcare providers are not always mindful of their surroundings when dis- cussing confidential details of a patient's case. The nurse can direct healthcare providers and family progresses in this way, tensing and releasing the muscles in a systematic manner throughout the body. + Deep breathing. People who are acutely anxious tend to hold their breath, Diaphragmatic (abdominal) breathing may be useful as both a distraction and a coping mechanism. To practice diaphragmatic breath- ing, the person places a hand on the abdomen, inhales deeply through the nose, holds the breath briefly, and exhales through pursed lips. ‘Music therapy. Music therapy can reduce anxiety, provide distraction, and promote relaxation, rest, and sleep. It has also been shown to be effective for relax- ing mechanically ventilated patients. Usually, music sessions are 20 to 90 minutes long, once or twice daily. ‘Most people prefer music that is familiar to them, ‘Humor. Laughter releases endorphins (the body's natural pain relievers) into the bloodstream, and can relieve tension and anxiety and relax muscles. The use ‘of humor, spontaneous or planned, can help reduce procedural anxiety and provide distraction. The nurse takes cues from the person regarding the appropriate use of humor. ‘Massage. Nurses have traditionally used effleurage (low, rhythmic strokes from distal to proximal areas of long muscles such as those of the back or extremi- ties) to promote patient comfort. Massage can be combined with the use of scented oils of lotions (eg, lavender to promote relaxation). Not all patients are good candidates for massage. For example, massage is not appropriate for patients who are hemodynami- cally unstable. + Therapeutic touch. In therapeutic touch, the practi- tioner’s hands move over a patient in a systematic way to rebalance the patient's energy fields. Therapeutic touch as a complementary therapy has been used suc- cessfully in acute care settings to decrease anxiety and promote a sense of well-being. ‘Meridian therapy. Meridian therapy, which originates from traditional Chinese medicine, refers to therapies that involve an acupoint (eg, acupuncture, acupres~ sure, the activation of specific sites with electrical stimulation and low-intensity laser) +Pet (animal-assisted) therapy. Interacting with ani- mals can provide physical benefits (eg, lowered blood pressure), as well as emotional ones (eg, increased self-esteem). Some facilities allow pets to visits their owners, Other facilities participate in formal programs wherein volunteer owner-dog teams visit, patients in the critical eare unit, members to a quiet room away from the general waiting arca to afford privacy when discussing specific patient information. + Allowing control. Nursing measures that rein- force a person’s sense of control help increase autonomy and reduce the overpowering sense of loss of control that can increase anxiety and stress,‘The Patient's and Family's Experience With Critical The nurse can help the patient and family exert more control over the environment by providing, order and predictability in routines; using anti patory guidance; allowing the patient and fam- ily to make choices whenever possible; involving the patient and family in decision making; and explaining procedures thoroughly, including why the procedure is needed. Assisting the Family Through the Crisis A critical illness is a sudden, unexpected, and stress- ful occurrence for both the patient and the family that threatens the equilibrium of the family unit. During the acute crisis, family members often expe- rience stress, disorganization, and feclings of help- lessness that make it difficult for them to mobilize appropriate coping resources.* The critical care nurse plays a key role in assisting the family through this stress response and helping them to adapt to the critical care environment. When caring for the fam- ily, the nurse seeks to (1) provide a human, caring presence; (2) acknowledge multiple perceptions; (3) respect diversity; and (4) value each person within the context of the family. ‘The way a family reacts to a crisis is difficult to categorize because reactions depend on the different coping styles, personalities, and stress management techniques of the family. ‘However, the following generalizations usually hold true: * Whether people emerge stronger or weaker as a result of a crisis is based not so much on their character, as on the quality of help they receive during the crisis. + People are more open to suggestions and help during an actual crisis. * With the onset of a crisis, old memories of past crises may be evoked. If maladaptive behavior was used to deal with previous situations, the same type of behavior may be repeated in the face of a new crisis. If adaptive behavior was used, the impact of the crisis may be lessened. + The primary way to survive a crisis is to be aware of it, ‘The nurse's initial interaction with family members is extremely important because it helps establish a foundation of trust and respect between the nurse and family, Taking a few minutes to learn the names of family members and their relationship to the patient signifies respect and begins to build a thera- peutic and trusting relationship. The primary goal of the nurse is to assist the family as they deal with the crisis phase of this illness by providing con- sistent and accurate information about the condi- tion of their loved one. Research has demonstrated that up-to-date information is the highest priority for family members who are coping with critical illness.” yess CuurTin? 14 Frequently, the period of illness extends well beyond the initial crisis phase and creates additional burdens for the patient and the family. The patient may experience a slow and unpredictable course with periods of organ compromise or failure. Recovery is measured in small changes that occur over days and weeks. Over time, it may become increasingly diffi- cult for the family to obtain information and patient status reports from the healthcare team. Often, phy- sician schedules are unpredictable and physician visits may not coincide with family member avail- ability. With protracted critical illness, many fami lies struggle to keep the lines of communication ‘open to the extended family, creating opportunities for conflict and misinformation. Throughout the patient's illness, itis vitally important for the critical ‘care nurse to maintain a link with the family. RED FLAG! The time the critical care nurse can spend with the family is often limited because of the crucial physiological and psychosocial needs of the patient. Therefore, itis important to make every interaction with the family as useful and therapeutic ‘as possible, Identifying and Meeting Family Needs Nursing assessment of the family secks to identify the family's strengths as well as the problems they are facing. The nursing assessment is comprehen- sive, exploring family members’ physiological, psy- chological, and spiritual responses to crisis, as well as social, environmental, cultural, and economic factors that influence the family. The family history provides insight into the family's past experience with critical illness, and is helpful for identifying family roles and relationships. Identifying a formal or informal leader of the family facilitates decision making and communication about legal matters (eg, obtaining consent, withdrawing life support) Numerous assessment tools, such as the Critical Care Family Needs Inventory (CCFND), are available to aid the nurse in determining the needs and prob- lems the family faces. Nursing research using these tools reveals a great deal of consistency in what needs are important to family members (Box 2-2) ‘Nursing interventions that help to address the needs of afamily in crisis are given in Box 2-3. An approach to assisting the family with problem-solving is given in Box 2-4 Some families will benefit from a referral to another objective professional with experience in critical illness and its impact on the family (eg, a mental health clinical specialist, a social worker, a psychologist, or a chaplain). Many critical care units have such resources available on a 24-hour, ‘on-call basis to ensure prompt interventions. The nurse can best encourage the family to accept help from others by acknowledging the difficulty and complexity of the problem and providing contact information for several professionals who will be able to assist.12 PAT ORE The Concept of Holism Applied to Critical Care Nursing Practice [BUWI:2 commontytentined Needs o ‘amily Members in Crisis ‘+The need to feel satisfied with the care given * The need for courteous caregivers who show an. interest in how the family is doing +The need to receive information about the patient at least once a day, and assurance that someone will call the family with any changes «The need to see the patient frequently and be in close proximity to the patient ‘+The need for honest information about the patient’s condition, including information about the patient's prognosis ‘The need to have understandable explanations of why things are being done ‘The need to have physical needs met (eg, a comlort- able place to wait with easy access to refreshments, and bathroom facilities) ‘+ The need to have emotional needs met (eg, the need’ to feel that there is hope, the need to share negative feelings) Fa ting Visitation Policies regarding visiting hours should be evalu- ated periodically. Family presence at the bedside has been shown to decrease patient and family anxi- ety, and can have a positive effect on the patient’ physiological parameters (eg, intracranial pressure) as well. Novel approaches to visitation (eg, chil- dren accompanied by an adult, animals as part of [BOX 2-3 nursing interventions for Care of the Family in Crisis + Convey feelings of hope and confidence in the family's ability to deal with the situation, «Try to perceive the feelings that the crisis evokes in the family, ‘Demonstrate concern about the patient and family and a willingness to help. + Speak openly to the patient and the family about the critical illness, ‘Discuss all issues as they relate to the patient specifi- cally, avoiding generalizations. ‘Be realistic and honest about the situation, taking care not to give false reassurance ‘Ensure that the family receives information about all, significant changes in the patient's condition. + Mitigate feelings of powerlessness and hopelessness by involving families in decision making and patient care. + Advocate for the adjustment of visiting hours to ‘accommodate the needs of the family. ‘Locate space near the unit where the family can be alone and have privacy. + Recognize the patients and familys spirituality, and sug- gest the assistance of a spiritual advisor if there isa need. [BOX/2-4 Assisting the Family in Crisis with Problem-Solving 1. Identify the problem. Families in crisis are often overwhelmed and immobilized by acute stress and. anxiety, Helping the family to articulate the immedi- ate problem reduces anxiety by giving family mem- bers a clearer understanding of what is happening, and facilitates the planning of goal-directed activities 2. Identify available support systems. Asking fam- ly members to identify the person to whom they usually tum when they are upset, and encouraging them to seck assistance from that person now, helps direct the family back to the normal mechanisms for handling stressful issues. Few families are truly without resources; rather, they only have failed to recognize and call on them, 3. Focus on feelings. During the difficult days of the critical illness, the family may become dependent on the judgment of professionals. It is important that the nurse acknowledges the familys feelings and rec- ‘ognize the complexity of the problem, while empha- sizing the responsibility each member of the family has for his or her feelings, actions, and decisions. ‘The nurse encourages family members to rellect on their feelings and practices by using active listening. 4. Identify steps. Once the problem has been defined and the family begins goal-directed activities, he nurse may help further by asking the family members to identify the steps that they must take to achieve those goals. For example, sometimes the muarse must help family members recognize that returning home to rest is an important step for maintaining their own health and ability to help the patient. an animal-assisted therapy program) have also been shown to have positive effects on patients, including increased feelings of happiness and calmness and reduced feelings of loneliness.* These findings sup- port the need for less restrictive and individualized visiting policies for patients and families. The nurse prepares family members for the ini- tial visit to the unit by providing explanations of the functions of monitors, IV drips, ventilators, and other equipment, as well as the meaning of alarms, before and during the visit. The nurse also introduces the family to the members of the healthcare team involved in the patient's care, providing names, titles, and an explanation of responsibilities. Encouraging family members to provide direct care to the patient (cg, assistance with grooming, cating, or hygiene), if they are interested, can help decrease anxiety and provide the family with some sense of control. Managing Family Presence During Invasive Procedures and Resuscitation Efforts Although controversial, family presence dur ing invasive procedures’ and resuscitation efforts‘The Patient's and Family's Experience With Critical is becoming more common. In light of current research, it has demonstrated positive benefits for family members. When family members were inter- viewed, 97.5% believed that family presence was a ight, 100% said they would repeat family presence in the same situation again, 95% believed that their presence helped the patient, even if the patient was unconscious, and 95% said it helped them real- ize the seriousness of the patient's condition? In the event of the patient's death, family members have reported that being present during resusci- tation efforts was helpful during the bereavement process? However, many healthcare providers are uncom- fortable with family presence during resuscitation efforts, due to concerns about litigation, making a mistake, or that caring for family members may take time’ and attention away from the patient. ‘The American Association of Critical-Care Nurses (AACN) recommends that each facility establish pol- icies and procedures for handling family presence during resuscitation.* Every effort must be made to have a knowledgeable person present to explain to the family what measures are being implemented and the rationale. Protocols must also be in place to escort family members from the room if the health- care team cannot perform resuscitative measures effectively. Facilitating Family Conferences As a patient and family advocate, the nurse pro- vides accurate information and shares the plan of care with the family. The nurse may arrange for a family conference to provide a forum for health- care providers and family members to share infor- mation in an organized way. During the family conference, the healthcare team provides infor- mation about the condition of the patient and the patient's prognosis and reviews recommendations for care. Family conferences facilitate open com- munication and are often useful for dispelling misinformation and misconceptions about the patient's progress. Family conferences also serve as a forum for exploring how family members may wish to participate in determining treatment goals for the patient.* ‘Consensus among providers is an important step before presenting treatment options and recommendations.’ Providing conflicting informa- tion creates confusion for everyone involved and may lead families to request nonbeneficial inter- ventions. Box 2-5 describes the nurse’s role before and after the family conference’ and Box 2-6 describes how to facilitate communication during a family conference. Encouraging the family to be active participants during the family conference increases their level of satisfaction and improves the quality of communication among providers and families.” wees CHANT? 19 [FOX 2-5 the nurse's Rote Before and After the Family Conference Betore the Conference ‘Explain the medical equipment and therapies that ‘are being used in the care of the patient to the farnily. ‘*Tell the family what to expect during their confer- ‘ence with the healthcare team members, ‘*Talk with the family about their spiritual or religious needs and take actions to address unmet spiritual or religious needs. “Talk with the family about specific cultural needs and take actions to address unmet cultural needs, ‘= Talk with the family about what the patient values in fe. ‘*Talk with the family about the patient’ illness and ‘treatment, ‘Talk with the family about their feclings. + Reminisce with the family about the patient. ‘Tell the family it is all right to talk to and touch their loved one. ‘Discuss with the family what the patient might have wanted if he or she were able to participate in the ‘treatment decision-making process. * Locate a private place or room for the family to talk. among themselves. After the Conference + Talk with the family about how the conference went. Talk with any other healthcare team members ‘who were present at the conference about how the conference went, + Ask the family if they had any questions following the conference, ‘Talk with the family about their feelings. ‘Talk with the family about any disagreement among the family concerning the plan of care. Talk with the family about changes in the patient’ plan of care as a result of the conference. ‘* Support the decisions the family made during the conference, ‘*Reassure the family that the patient will be kept comfortable. ‘Tell the family itis all right to talk to and touch their loved one. + Locate a private place or room for the family to talk, among themselves. From Curtis JR Patrick Dl, Shavsnon SB, etal The family com- ference asa focus to improve communication about end-of-life ‘are in the intensive care unit: Opportunities for improvement. (Crt Care Med 28(2 suppl):N26-N33, 2001 permission before giving confidential medical Information to family members. If that is not possible ‘because of the patient's condition, the patients next of kin should be identified as the person who ‘may receive confidential information. The names of those family members approved to receive medical information about the patient should be recorded in the patient's medical record ® RED FLAG! The nurse should have the patient's14 PAT ONE The Concept of Holism Applied to Critical Care Nursing Practice Before the Conference ‘Review previous knowledge of the patient and family. + Review previous knowledge of the family’ attitudes and reactions. + Review your knowledge of the disease—prognosis, treatment options. “+ Examine your own personal feelings, attitudes, biases, ‘and grieving. ‘Plan the specifics of location and setting: a quiet, private place, + Discuss with the family in advance about who will be present, During the Conference ‘Introduce everyone present. ‘If appropriate, set the tone in a nonthreatening way! “This is @ conversation we have with all families...” ‘Discuss the goals of the specific conference. ‘Find out what the family understands. ‘Review what has happened and what is happening to the patient. + Discuss prognosis frankly in a way that is meaningful to the family, + Acknowledge uncertainty in the prognosis. + Review the principle of substituted judgment: "What ‘would the patient want?” Facilitating Communication During a Family Conference ‘Support the family’s decision. ‘Do not discourage all hope; consider redirecting. hope toward a comfortable death with dignity if appropriate ‘Avoid the temptation to give too much medical detail. + Make it clear that withholding life-sustaining treat- ‘ment is not withholding caring. ‘Make explicit what care will be provided including symptom management, where the care will be deliv- cred, and the family’s access to the patient. + If life-sustaining treatments will be withheld or with- drawn, discuss what the patient's death might be like. + Use repetition to show that you understand what the patient or family is saying + Acknowledge strong emotions and use reflection to ‘encourage patients or families to talk about these emotions, *Tolerate silence, At the Conclusion of the Conference + Achieve common understanding of the disease and. treatment issues. ‘Make a recommendation about treatment. ‘Ask if there are any questions. ‘Review the lollow-up plan and make sure the family knows how to reach you for questions. From Curtis JR, Patrick DI, Shanon SE, etal: The family conference asa focus to improve comm: ication about end-of-life care in the intensive care unt: Opportunities for improvement. Crit Care Med 29/2 suppl}:N26-N33, 2001 Practicing Cultural Sensitivity Culturally competent nursing care is defined as being sensitive to issues related to culture, race, gender, sexual orientation, social class, and eco: nomic situation.’ In addition, culturally competent nursing considers the family’ structure and gender role as it relates to the patient. Health and illness beliefs are deeply rooted in culture, How a patient or family member responds to the diagnosis or a pro- posed treatment may be strongly influenced by his or her values and culture. During initial assessment, the critical care nurse obtains several key pieces of information regarding the patient's cultural beliefs (Box 2-7). Astuteness and sensitivity on the part of the critical care nurse are required to ensure that the highly technologic, illness-focused critical care environment does not clash with the patient’ and family’s cultural beliefs and values. Because individ- ual responses and values may vary within the same culture, the nurse takes care to recognize the patient and family members as individuals within the cul- tural context. Supporting Spirituality Spirituality speaks to the manner by which a person. seeks meaning in his or her life, and experiences connectedness with the universeat large. Spirituality is intrinsically related to a person's beliefs and val- ues, and for some people, it has a religious compo- nent. The nurse assesses the patient's and family's spiritual belief systems and assists the patient and family in recognizing and drawing on the values and beliefs they already hold, Critical illness may [OW 2-7 ‘key Pieces of information to Obtain Bereta Sut aneesement '=Place of birth, ‘Length of time in this country © Does the patient live in an ethnic community? © Who are the patient's major support people? Primary and secondary languages (speaking and reading ability) + Religious practices ‘+Health and illness beliefs and practices + Communication practices (verbal and nonverbal) '* How decisions are made in the context of the patient and family Adapted from Lipson JG: Culturally competent reusing care. In Lipson JG, Dibble SI, Mainarik PA (eds): Culture and Nursing ‘Care: A Pocket Guide. San Francisco, UCSF Nursing Press, 2005, ppt-6.‘The Patient's and Family's Experience With Critical deepen or challenge existing spirituality. During these times, it may be useful to call on a spiritual or religious leader, hospital chaplain, or pastoral care representative to help the patient and family make meaningful use of the critical illness experience Preparing the Patient and Family for Discharge As the patient's condition improves and plans for transfer to a lower acuity area are discussed with the healthcare team, the critical care nurse must prepare the patient and family for the eventual dis- charge from the unit. This milestone in recovery is typically viewed by the patient and family in one of two ways. If the patient and family believe that the patient's condition has improved sufficiently and that the intensity of critical care is no longer nec- essary, then this step is viewed in a positive light. However, if they believe that the depth of nursing support and level of monitoring on a lower acu- ity unit are inadequate to meet the needs of the patient, there may be resistance to the transfer pro- cess. Providing information about the new unit's routine, staffing patterns, and visiting hours before making the transfer can help mitigate some of the negative feelings and anxiety associated with the change.’ ‘Once the transfer has been made, it is important that the receiving nurse further assist the patient and family with adjusting to the new routine. The nurse begins by acknowledging the normal anxi- ety that accompanies the transfer process, and emphasizes that the transition is a positive stage in the recovery process. The nurse also reassures the patient and family that even though the inten- sity of treatment has changed, staff members are trained to anticipate the patient's needs and will respond appropriately to changes in the patient's status, Once the patient's and family’s initial anxiety diminishes, the nurse can begin to set new self-care goals and expectations based on assessment of the patient. Promoting Rest and Sleep for the Critically Ill Patient Sleep deprivation is common in critically ill patients, due to environmental factors, anxiety, pain, medi- cation side effects, and therapeutic interventions that disrupt sleep. Secretion of melatonin (a hor- mone that facilitates sleep) is inhibited by light and stimulated by darkness; the constant, high-intensity lighting typical of the critical care unit disrupts this normal rhythm, Sleep deprivation contrib- utes to stress and, if prolonged, can lead to altered cognition, confusion, and difficulty with ventilator weaning. wees CHINTIN? 18 [HONT2°8 seursing interventions tor Promoting Sleep ‘= Ensure the patient is comfortable (eg, manage pain, use pillows to ensure a comfortable position). '*Schedule care and procedures (eg, labs, x-rays) to disrupt sleep as little as possible. ‘Try to orient the patient to normal sleep-wake cycles ‘as much as possible, Provide large clocks and calen- dars, and dim the lights at bedtime. ‘+ Make an effort to control noise, especially during the evening hours: decrease noise from televisions and talking, post signs to alert others to the need to be quiet (¢g, “Patient Sleeping”). + Ensure privacy by closing the door and pulling the curtains (if possible). + Institute a bedtime routine (eg, brushing teeth, ‘washing face). As part of the bedtime routine, consider providing a 5-minute massage. ‘*At bedtime, provide information to lower anxiety. Review the day together, remind the patient of prog- ress made toward recovery, and explain what to expect for the next day. + Employ anxiety-reducing strategies (eg, relaxation, techniques, guided imagery, music therapy). ‘The nurse assesses the amount and quality of the patients sleep, and intervenes to facilitate rest and sleep (Box 2-8). The patient's own report of sleep quality is the best measure of sleep adequacy. A visual analog scale is recommended to evaluate sleep quality in select patients at high risk for sleep disruption owing to an extended stay on the critical care unit.’ Some situations (eg, mechanical ventila- tion) make a self-report of sleep quality difficult to obtain. If a self-report is unobtainable, systematic observation has been shown to be somewhat valid and reliable.* Using Restraints in Critical Care Physical restraints must occasionally be used for patients in critical care to prevent potentially seri- ‘ous disruptions in therapy resulting from acciden- tal dislodgment of endotracheal tubes, IV lines, and other invasive therapies; to prevent falls; and to manage disruptive behavior. However, the use of restraints can increase agitation and puts the patient at risk for other potentially serious inju- ries, including falls, fractures, and strangulation. Altematives to physical restraints must always be sought and tried first (Box 2-9). Standards on phys- ical restraint use are published and monitored by the Joint Commission and the Centers for Medicare and Medicaid Services. These standards are sum- marized in Box 2-10.16 PINT ONE The Concept of Holism Applied to Critical Care Nursing Practice [HOYI2=0|antematives to physical restraints Environmental Modification: ‘Keep the bed in the lowest position, ‘Minimize the use of side rails to what is needed for positioning, + Optimize room lighting. “Activate bed and chair exit alarms where available. “+ Remove unnecessary furniture or equipment, ‘Ensure that the bed wheels are locked, + Position the call light within easy reach. ‘+ Ensure that the patient has needed vision and hearing. aids. ‘Therapeutic Interventions «Frequently assess the need for treatments and discon- tinue lines and catheters at the easliest opportunity + Orient the patient to invasive medical equipment. Help the patient explore the equipment by guiding the patient's hand over it. Explain the purpose of the equipment, as well as the meaning of any alarms that may sound. “Disguise treatments, if necessary (eg, keep IV solution bags out of the patient’ field of vision, apply a loose stockinette or long-sleeved gown over IV sites). [BOX 2-10 summary of Care Standards Regarding Physical Restraints Initiating Restraints ‘Restraints require the order ofa licensed indepen- dent practitioner who must personally see and evalu- ate the patient within a specified time period, “Restraints are used only as an emergeney measure or after restraint alternatives have failed. (The restraint alternatives that were tried and the patient's responses to them are documented.) + Restraints are instituted by staff who are trained and competent to use restraints safely. (A comprehensive training and monitoring program must be in place.) ‘Restraint orders must be time limited. (A patient must not be placed in a restraint for longer than 24 hours, ‘with reassessment and documentation of continued need for restraint at more frequent intervals.) «Patients and families are informed about the ratio- nnale for the use of the restraint. Monitoring Patients in Restraints * The patient’ rights, dignity, and well-being are protected. + The patient is assessed every 15 minutes by trained and competent staf. “The assessment and documentation must include evaluation of the patient's nutrition, hydration, hygiene, elimination, vital signs, circulation, range ‘of motion, injury due to the restraint, physical and psychological comfort, and readiness for discontinu- ance of the restraint, + Ensure comfort by meeting the patient's physical needs (eg, frequent toileting, skin care, pain manage- ‘ment, hypoxemia management, positioning). ‘Mobilize the patient as much as possible. ‘Allow the patient to make choices and exert some degree of control when possible, Diversionary Activities ‘Enlist family members or volunteers to provide company and diversion. + Facilitate solitary diversionary activities (eg, music, videos or television, audio books). ‘Therapeutic Use of Self “Use calm, reassuring tones. ‘Introduce yourself and let the patient know he or she is safe. + Find an effective method of communicating with intubated or nonverbal patients. + Rcorient patients frequently by explaining treatments, medical devices, care plans, activities, and unfamiliar sounds, noises, or alarms, (DASE stuby Ms. J. is a 40-year-old pregnant woman who is admitted to the hospital at 34 weeks, 5 days of gestation with complaints of vaginal bleeding, painful contractions, and nausea and vomiting, Until this time, she has received routine prenatal care, and the pregnancy has been uneventful Before her admission to the hospital, she was eating lunch at work when she felt a “pop” in her abdomen; shortly afterward, her symptoms began. ‘She states that the last time she felt fetal move- ‘ment was earlier in the morning. At the hospital, an external fetal monitor and portable ultrasound detect no fetal heart tones. There is blood in the vaginal vault and no active bleeding, and the cervix is long and closed. Ms. J.is admitted to the labor and delivery unit with the diagnosis of a fetal death in utero, prob- ably due to an abruption of the placenta, and the plan is to deliver her by induction of labor. Shortly after admission, she complains of increasing pel- vic pressure. Examination reveals that she is fully dilated, and she spontaneously delivers a stillborn male child. Delivery of the placenta, as well as a 250-mL clot, follows, confirming the diagnosis of placental abruption. Despite administration of med- ications to assist the uterus to contract and control bleeding, Ms. J. begins to bleed steadily. Clinicians decide to perform dilation and curettage (D&C).‘The Patient's and Family's Experience With Critical Following the D&C, Ms. J’s uterus becomes well contracted, bleeding decreases, and coagulation parameters begin to improve. Her estimated blood Toss is 8000 mL. Ms. J. begins to bleed again later that evening and is again transferred to the operating room, where a uterine artery embolization is performed. Ventilation becomes difficult, and she is intubated. She is transferred to the critical care unit for closer surveillance, ventilatory support, and fluid resuscitation. Clinicians make an additional diag- nosis of disseminated intravascular coagulation (DIC). Ms. J's husband stays with Ms. J. through- ut the night during her first 2 days the critical care unit. On day 3, Ms. J. is extubated and is hemodynamically stable. She is transferred to the progressive care unit after she is weaned from. the ventilator. 1. Mr. J. stayed at his wife's bedside throughout her first 2 days in the critical care unit. How does this demonstrate the critical care staff's commitment to meeting both the patient's and the family’s needs? 2. Desoribe actions the critical care nursing staff ‘can take to ensure that Ms. J. and her husband view this difficult time in their lives in the most positive way possible, wees CHANT? 47 References 1, Curtis R, White D: Practical guidance for evidence based ICU family conference. Chest 134(4):835-843, 2008 2, Borges K, Mello M, David C: Patient lamilis in ICU: Describing their strategies to face the situation. Cit Care 15:P527, 2011 3, Davidson J, etal: Clinical practice guidelines for support of famaly in patient centered intensive care unit: An American Collegeof Critical Care Medicine Task Force 2004-2005. Crit Care Med 35(2)605-622, 2007 4, Miracle V-A closing word: Critical care visitation, Dimens Crit Care Nurs 24(1)48.49, 2005 Curtis JR, Patrick DL, Shannon SE, etal: The family confer: lence asa focus to improve communication about end-of-life ‘care inthe intensive care unit: Opportunites for improve tment. Crit Care Med 29(2 suppl):N26-N33, 2001 6, American Association of Critical-Care Nurses: Family presence during CPR and invasive procedures. Practice Alert. Retrieved October 20, 2006, from hitp-/wwwaacn. ‘OrAACN/practice Alert nsiFilesFPSfle/Farilye20 Presence%-20During%20CPR5:201 1-2008 pat 7. Nelson J: Family meetings made simpler: A toolkit for ICU, J Crit Care 2462607-627e14, 2009 8, Jansen MPM, Schmitt NA: Family-focused interventions Crit Care Nuts Clin N Am 15(3):347-284, 2003 9. Dogan O, Ertckin 5, Dozan S: Sleep quality in hospitalized patients. J Clin Nars 14107-113, 2005 ‘Wantto know more? Awide aretyofresourcestoenhance yourlearn- ing and understanding ofthis chapter are available on w»Pal-s. Visit hitp:/Ahepoint.tww.com/MortonEsste to access chapter review ‘questions and more?