Critical Care Nursing

Critical Care Nursing


Question:
Discuss about the Critical Care Nursing.

Answer:

Introduction

Critical care units including the ICU and the Emergency Departments form part of the most crucial units of a health care facility. The environment in these units must be fit enough to promote patients’ physical, spiritual, social and psychological healing.  Any compromises in the quality of the environment within these units interrupt the patient’s healing process (Harvey, 2011).   This is because the environmental factors may lead patients into vulnerable positions, making them to be more at risk, due to further deterioration of their health.  Sleeping promotes body healing, rest, and rejuvenation. The main aim of the ICU physicians is to stabilize patients through medication administration and promotion of their healing. Therefore, sleeping patterns are considered to be crucial. A complete sleep cycle requires about 90 to 110 minutes. Lesser amounts as a result of interruptions amount to deprivation of sleep and consequential longer stays in hospitals due to delays in healing. The critical unit environment therefore should be attuned to the needs of a patient including sleep unless there is need for other crucial procedures (Reach, 2013).  This presentation provides the different environmental factors and how they alter the sleeping patterns of patients in critical care units. It also presents the possible interventions that nurses need to provide in order to ensure that these factors are under acceptable levels and/or eliminated.
How The Environmental Factors Related To the Emergency Department OR the Intensive Care Unit Contribute To Alterations in Sleep Patterns for Patients

Noise

Noise is one of the environmental factors that bring about patient alterations in sleep patterns in the ICU while interfering patient’s healing process. Noise remains one of the top challenges in the design and management of critical care units. Nursing beds that are surrounded by a lot of noisy machines among other equipment intimidate patients, their families, and even the novice nurses within the critical care unit (Cai, et al, 2015). Noise is listed among the major environmental hazards in any universal risk management plan, and it leads to discomfort and disruption of sleep among patients. Other consequences of a noisy critical-care-unit include; impaired healing of wounds and the activation of a patient’ sympathetic nervous system. Usually, according to Rashid (2010), moderate levels of noise lead to vasoconstriction. Sometimes, hyperarousal as a result of noises occurs for many days and weeks for those patients that have prolonged ICU stays (Harvey, 2011). Among the listed complaints on noise levels include banging noises, time to time alarms, water sounds including the chest-tube bubbling, and the sounds of doors opening and closing.


The major sources of noise include equipment, telephone, television, hospital alarms, and ventilators staff conversations among others. Mostly, nurses are usually unaware of how loud their conversations could be, including the irritation they create within the minds of minds of their patients (Carling et al, 2010). Decibels are the SI units that measure noise levels. Any increase of noise to 10 decibels makes any noise to be twice as loud. Normally, sleep happens best below noise levels of 35 decibels. According to the Environmental Protection Agency (EPA), there is need, to maintain noise levels below 45 decibels at day and also below 35 decibels during the night (Reach, 2013). A lot of studies that have focused on ICU treatment indicate that there have been noises that even elevate to 80 decibels. Novel technologies also contribute to noise despite the fact that manufacturers are ensuring that they make them to produce lower noises.
It is necessary that a patient’s physical, spiritual, psychological and social health is safeguarded while in the ICU. However, equipment noises and going off of alarms does not only create panic among the family members but also among the patients (Cai, et al, 2015). Panicking patients and family members lead to a deteriorated social interaction between the two, and also create a psychological torture as the patients do not know what could be happening to them. Alarms that reach the extents of over 80 decibels might be interpreted to mean a high possibility of a critical condition.  Patients who get exposed to such an environment are unlikely to rest and sleep. They cannot assume the healing mentality as they are in panic of imminent death and /or deterioration of their health (Rashid, 2010). Music therapy could be an essential means to bring about healing. However, inappropriate music, not chosen by the patient might lead to further torture, especially when they are not able to make a choice of their own.  Sympathetic music could be inappropriate for some patients and may worsen their psychological health (Lai and Bearer, 2008). However, soothing music can bring about sleep and thus promote patient healing, reducing the length of stay in the hospital.

Lights and Color

Light remains a powerful environmental synchronizer which entrains sleep through promoting normal circadian sleep and wakefulness cycle. A strongly lit environment in the ICU and the Emergency Department affects the sleep patterns of patients and thus interferes with their healing process, leading to longer stays in the hospital (Lee, 2016). Where patients are treated to a view of natural scenery and lighting, studies indicate that lesser pain medication is used and patient hospital stays are usually shorter. Other studies indicate that patients suffer impaired cognition in health units that are windowless. Therefore, critically ill patients find it difficult trying to figure out the people around and the procedures in progress.
In most hospitals artificial light by fluorescent tubes creates a very harsh type of light which brings about visual fatigue and repeated headaches among patients unless they are shielded. The resulting visual fatigue and headache interferes with sleep among patients as they feel pain and look options to for relieve. Glare also occurs whenever light reflects off the environmental surfaces within the hospital such as glass, mirrors among other polished finishes (Lai and Bearer, 2008). Glares are usually troublesome to elderly patients in critical units. Sometimes bright lights are left on for long hours in the ICUs despite the fact that there is no direct patient care going on at the time.  Patients get frustrated especially when they have no control over the artificial lighting. On the other hand, time to time interruptions in the normal light–dark patterns disrupt patient usual physiological processes. Further, the colors within the ICU may psychologically affect some patients (Lee, 2016).  Art works on the walls of critical care units depict a lot of different cultures, including peaceful nature. However, unmuted bright colors that also reflect off light to patients interfere with elderly patient vision and sleep patterns. Therefore, hospital personnel need to understand the need for healing and patient preferences in regard to the ICU experience.

Clinical Interactions Effects

Since a lot of assessments need to be done on ICU patients including for instance hourly checks on fluid balance and administration of medication, it is most likely that patients’ sleep patterns will be interrupted.  These interventions when combined with other basic care needs for a patient in critical unit brings about de-prioritization of sleep (Esen, 2015).  In fact, an ICU design may even compound issues, especially when it is designed as an open plan where patients are separated from each other but can still are within a common room.  Studies indicate that each sleep cycle needs between 90 and 110 minutes to be completed. In critical units where there are constant clinical interactions, patients are unlikely to acquire quality sleep and this, impacts on their healing process (Lai and Bearer, 2008). Once a patient is woken up for medication, it remains difficult for them to fall back to sleep, more so when they are experiencing pain result of a surgery for instance.  Disruptions for patients who are on mechanical ventilation have been reported to be higher, meaning that they might be among those that are the most sleep-deprived ICU patients. 
Ways Through Which Nurses Can Provide Holistic Person-Centered Care To Minimize The Impact Of The Environment And Put The Patient In The Best Possible Condition For Self-Healing

Controlling Excessive Noise and Lights

Noise is one of the major physical environmental factors that need to be controlled in the ICU to boost patient’s healing process by preventing alterations in patient sleeping patterns. Nurses should provide willing patients with headsets and make time-to-time assessment of noise levels, so that there is a quiet environment for patients (Duffy et al, 2012). They should ensure that any noise generating nursing equipment that is not in use is put off. On the other hand, natural lighting is encouraged although it should be at the comfort of the patient in that it is not too intense. Nurses need to ensure that they help in regulating the light for example by using slightly tinted and/or reflective glasses in the ICU. This reduces glare and any heat that may be generated due to natural sunlight. Nurses need to ensure that they only set the maximum light intensity to be the 6.5 foot-candles (continuous lighting) while 19 foot-candles (short-period lighting) during the night in the ICU (Collinsworth et al, 2014).  Even further, nurses need to just switch off useless lights unless the patient requests otherwise. Patient preference for lighting options should be considered so that their sleeping patterns are not interrupted.

Omission of Unnecessary Nocturnal Clinical Interaction

According to Lindberg et al (2015), a percentage of nocturnal interactions can safely be omitted so that the excessive disturbance to patients’ sleep patterns is curtailed. It has been observed severally in different studies on critical care that several nursing activities are carried out merely as routine. They are not actually based on the clinical evidence available, and necessity for patient service.  In this regard, there is need for the hospital clinical staff to be able to evaluate critically the need for some of the care services offered. Consideration on coming up with necessary adjustments on the workflow so as to promote patient nocturnal sleep can is imperative (Esen, 2015). Once the interactions that are unnecessary are omitted, it is likely that most patients will have more time to sleep. This will translate into faster healing and reduced stays in hospital for patients.

Other Ways of Promoting Sleep

Studies indicate that it remains difficult for most patients to catch sleep while in the ICU as a result of not only the pain they undergo, but environmental factors that hinder them from doing so. One of the other approaches that nurses can use to promote sleep includes doing a 5-minute back rub to the patients, with their permission (Lindberg et al, 2015). Music therapy could still be an option in promoting patient sleep. However, it has been proved that 5-minute long slow back massage on a patient promotes increased speed of sleep by an hour (Esen, 2015). The nurses should however use soothing and slow-stroke back massage in a situation where the nurse centers themselves to be sincerely present with such patients.
Alternative non-pharmacological approaches that can make patients relax and sleep, are important in the ICU. The nurses therefore need to assess the patient’s readiness according to Lee (2016), to utilize alternative non-pharmacological approaches such as relaxation, music therapy and guided imagery. These approaches can negate for drugs which form part of the ICU environment or more importantly, reduce the dosages for the same. Even so, allowing patients to choose the best option from a list of non-pharmacological approaches available remains imperative. They can be allowed to choose the kind of music and the sound volume of the music, an approach that might have worked for them in other situations (Kanhere et al, 2012). Music promotes both spiritual and psychological healing and makes patients even go into sleep voluntarily despite the painful injuries they might have. Nurses should provide music therapy as it reduces stress and/or anxiety among patients that have suffered acute myocardial infarction, cardiac surgery, and patients on mechanical ventilators. Further, music lowers the heart rate, patient’s BP, and induces better breathing patterns due to its effect of relaxation.
Despite the fact that a nurse is a gatekeeper that needs to protect their patient sleep time in the ICU, it will still be difficult to fulfill this because of escalations in patient–nurse ratios according to Hurley (2010). Even so it should remain the nurse’s responsibility to protect their patient’s sleep.  Nurses also need to work in shifts to avoid sleep deprivation, a factor that boosts their compassionate care and patient experience in the ICU (Mosleh et al, 2015).  They should care for themselves so that they can be able to meet the demands of their patients, colleagues and their families effectively. This is because, a stressed nurse may be irritable and thus have little time to ensure that patient’s health services are adequately administered.
In conclusion therefore, there is need for nurses and health care providers in general to ensure that the environmental factors that alter patients’ sleeping patterns .are omitted and/or reduced effectively. This presentation includes the different environmental factors that lead to alteration in patient sleep patterns. The discussion involves the different effects of these factors such as noise, bright lights, and clinical interactions between care-givers and patients. Different ways in which nurses can control the amount the extent of these factors and their effect on patient sleeping patterns have been discussed.  Among the solutions include using natural lighting, using light blinders, reduction of noise levels, switching off useless noisy devices, promoting sleep, and omission of unnecessary clinical interactions with patients.

References

Cai, X., Robinson, J., Muehlschlegel, S., White, D., Holloway, R., Sheth, K., Fraenkel, L. and Hwang, D. (2015). Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocritical Care, 23(1), pp.131-141.
Carling, P., Parry, M., Bruno-Murtha, L. and Dick, B. (2010). Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission*. Critical Care Medicine, 38(4), pp.1054-1059.
Collinsworth, A., Priest, E., Campbell, C., Vasilevskis, E. and Masica, A. (2014). A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. Journal of Intensive Care Medicine, 31(2), pp.127-141.
Duffy, D., Garbash, M., Sharland, M. and Kennea, N. (2012). Surveillance swabbing for MRSA on neonatal intensive care units - is weekly nasal swabbing the best option?. Journal of Infection Prevention, 13(4), pp.120-124.
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Esen Yildiz, I. (2015). Evaluation of Prevention Bundle Application for Ventilator-Associated Pneumonia in Intensive Care Units. JFMHC, 1(2), p.27.
Harvey, M. (2011). Palliative care makes intensive care units intensive care and intensive caring units*. Critical Care Medicine, 39(5), pp.1204-1205.
Hurley, J. (2010). Individual patient data meta-analysis in intensive care medicine and contextual effects. Intensive Care Med, 36(5), pp.903-904.
Kanhere, M., Kanhere, H., Cameron, A. and Maddern, G. (2012). Does patient volume affect clinical outcomes in adult intensive care units?. Intensive Care Med, 38(5), pp.741-751.
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Lai, T. and Bearer, C. (2008). Iatrogenic Environmental Hazards in the Neonatal Intensive Care Unit. Clinics in Perinatology, 35(1), pp.163-181.
Lee, H. (2016). Pre-heart transplant patient autonomy. Australian Critical Care, 29(2), p.121.
Lindberg, C., Sivberg, B., Willman, A. and Fagerstr̦m, C. (2015). A trajectory towards partnership in care РPatient experiences of autonomy in intensive care: A qualitative study. Intensive and Critical Care Nursing, 31(5), pp.294-302.
Mosleh, S., Alja’afreh, M. and Lee, A. (2015). Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units. Intensive and Critical Care Nursing, 31(6), pp.366-374.
Pileggi, C., Bianco, A., Flotta, D., Nobile, C. and Pavia, M. (2011). Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Critical Care, 15(3), p.R155.
Rashid, M. (2010). Environmental Design for Patient Families in Intensive Care Units. Journal of Healthcare Engineering, 1(3), pp.367-397.
Reach, G. (2013). Patient autonomy in chronic care: solving a paradox. Patient Preference and Adherence, p.15.
Richards, K. and Raby, S. (2016). Co-trimoxazole-induced hypoglycaemia in an immunosuppressed intensive care patient. Journal of the Intensive Care Society.

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