Posted: June 27th, 2015

Stressors Experienced by Critically Ill Patients

Patients who are critically ill are mostly treated in the specialized health care departments which offer intensive care. These include intensive care unit-ICU, critical care unit-CCU, intensive treatment unit-ITU and intensive therapy unit-ITU. The environment presented by the above units is stressful for nurses, patients as well as their families/guardians (Brysiewicz & Bhengu 2010). Some factors contribute to enhancing the stress in these environments, for instance, strange machinery presence, the absence of privacy, separation from loved ones and immobility amongst others (Omari 2009). These factors are termed to as stressors. The main stressful factor is pain especially from the illness which make the patient to be in the ICU in the first place. In addition, offensive smells, lightings-all day and night, unfamiliar machinery and uncomfortable tubes, invasive procedures, lack of privacy, separation from family, dependency-loss of control, and fear of death are other ICU stressors (Almerud, Alapack, Fridlund & Ekebergh, 2007; Hweidi, 2007). The patient is deprived of the usual lighting, deafening and unknown noises, harmful smells, invasive interventions, sensory stimuli and so forth (Vandall-Walker et al. 2007). The subjection to these stresses may elicit reactions to the stress thereby triggering ICU syndrome. Above 5 million adult patients from the United States are admitted annually in ICU of which half of them later experience Post-ICU syndrome attributed to the stress (Robert Wood Johnson Foundation, 2010). Despite the identification of these stressors, disagreement have risen concerning the factors which cause more stress for the critically ill patient. Conference connections (2011) described some of the stressors as being more significant for the ICU patient: loud noises, communication breakdown, depersonalization, and immobilization. The increase in stress stimulates the sympathetic nervous system, which emerge as raised heart rate, bleed pressure, and respiratory rate, possibly resulting in the critical anxiety syndrome. In this respect, there is need for interventions to control these stressors. Mostly, pharmacological interventions are employed in controlling the distress, although they are costly with regards to complications when administering since they result to increased hospital care expenses. Therefore, non-pharmacological interventions particularly music ought to be used instead since they decrease such expenses at the same time enhancing the comfort of critical patients. Music therapy is important because of its healing influence on patients as it alleviates the physiological and psychological reactions hence raising patients’ comfort. In this regard, the paper aims to identify and critically analyze the stresses experienced by critically ill patients in the critical care setting. The impact of these stressors on psychological well being and the strategies that can be used to promote coping and recovery.

According to Hamaideh and Ammouri (2011) a stressor refers to the factor causing psychological or physical demand besides the norm and depict the disparity amid the existence and what is optimal. Stressors in the ICU occur in three groups namely physical, psychological, and environmental (Soh et al. 2008). Wade (2011) revealed that about 84% of those who survive from the ICU suffer physical as well as psychological difficulties that consequently manifest as post-traumatic stress disorder (PTSD) whereas Griffins et al (2008) estimated that 5% to 64% suffer PTSD or its related symptoms for a number of years after surviving from the ICU. However, reports about the PSTD rates and symptoms varied considerably in terms demographic factors, methods and timing of the assessment. In most cases, PSTD is portrayed as the long term psychological disturbances.

Moreover, Hweidi (2007) further defined physical stressors as medical device applied on the patient, for instance tubes put in the nose and mouth, ventilators used, and pain as well as discomfort experience. Relative to psychological stressors, he described that they occur when the patient is restrained and confused (Hweidi, 2007). Furthermore, environmental stressors are defined as the things or states like uncomfortable bed, extreme cold or being hot, noise, absence of privacy, and constant lighting (Hweidi, 2007; Soh et al, 2008). Amongst the three groups, the most common in the Post-ICU syndrome are the psychological stress. The syndrome occurs 48 hours after being in the ICU. It impairs the patient’s mental functioning, which resumes normality following discharge. Nevertheless, the syndrome derails the recovery process thereby prompting a larger stay in the ICU as well as increased risk of complications (Thungjaroenkul & Kunaviktikul 2006). As earlier mentioned, close to about half os the US patients admitted annually in the ICU experience this syndrome which continued even after they were discharged (Robert Wood Johnson Foundation, 2010). Landro (2011) further stipulated that between 50% and 80% of patients develop psychological impairment, whereas 30%, clinical depression and 15% to 40%, PSTD (Myhern, et al. 2010).

To begin with, pain is a significant psychological ICU stressor amongst the many existing stressors. It is an internal stressor which results from the disease itself or the medical interventions used on the patient (Chanques et al. 2009). Chanques et al. (2006) postulated that the obstacles to measuring pain in the ICU patients are caused by the impaired verbal communication resulting from the use of endotracheal tubes (ET), medications, and the patients’ consciousness levels. Additionally, Young et al, (2006) added that other obstacles include lack of effective assessment, improper documentation, improper method of analgesia prescription, which are used frequently (Young et al. 2006). Therefore , the patient can not communicate the need for control of the pain under these obstacles. Other causes of pain are disruptive interventions, trauma, and surgical incisions (Pang & Suen 2008). Pain being a significant ICU stressor, there is need to consider it due to the impact it has on critically ill patients.

Sleep disturbance or lack is another psychological stressor (Friese et al, 2007). Sleep is a significant part of recovering from severe sickness and lack may damage the repair of tissues as well as general cellular immune functioning. Nevertheless, Rowe (2008) study indicated that the quality and adequate sleep is hard to obtain in a critical care setting although nurses are use strategies to enhance sleep in the ICU. Noise is regarded a significant environmental cause of sleep interruption in the ICU. The required sound pressure levels to sleep should be less than 40 as proven by Friese et al. (2007) study. However, this is not observed and background noise is a common phenomenon in the ICU. The Major sources of noise are talking telephone, television, and alarm among others (Weinham & Pittard 2009), which Rowe (2008) agreed that patients in the ICU do not sleep properly. Most of them are awake 30-40% of their sleep time and have their sleep distributed as well as fragmented all through the day and night. They experience a decrease in slow wave as well as rapid eye movement (REM) sleep (Borthwick et al, 2006). In septic patients, the sleep/wake statuses may be indefinable. However, Conference Connections (2011) claimed that only 30% of awakenings can be attributed to sound peaks, and light is not a disturbance. For the patient’ disease, at least sepsis totally puts off usual sleep that affects patients sleep. Contrary, sleep is also affected by extreme light and temperature conditions. Therefore, these factors that cause sleeping problems to critically ill patients have to be eliminated and by so doing their psychological stress is reduced.

Another stressing factor is light and temperature; these are external factors. The cycle of sleep wake moments is connected to the environment. This is possibly the most dominant connecting factor along with sounds and social cues. If the linking factors are altered, the cycle can be extended and in certain ICUs, the risk is not subjected to some natural light (Wenham and Pittard 2009). Day et al (2009) asserted that the Patients’ inability to differentiate day from light may cause, and in support, Wenharn and Pittard (2009) suggested that dazzling lights originating from the nurses’ working position may disrupt the patient to sleep, even if the ICU’s light intensity depicts a 24 hours circadian rhythm. Turning lights on at night is disruptive to the patients’ sleep. On the other hand, ambient temperature influences sleep prominently. Low temperatures disrupts sleep whereas higher enhance sleep. The sensitivity to temperature varies with individual’s optimal temperature for sleeping (Wenharn and Pittard 2009). However, controlling light intensity and temperature ranges is crucial in enhancing the psychological well being of critically ill patients.

Limitations in communication, mobility, and social interactions also add to the ICU patients’ stress. These are external factors. Mechanically ventilated patients are largely affected by the inability to speak (Wenham and Pittard 2009). Omari ( 2009) stipulated that these patients do not comprehend why they are unable to speak and they fear that they may never speak thereby compounding their condition. In addition, Johnson et al. (2007) explained that this is because they are stressed by the fact of not being understood. They waste energy trying to communicate and their message is received inaccurately most of the times. Additionally, Privacy is an issue because the ICU patients are helpless and must be helped even to dress, feed, and change bed positions. This is stressing because they lack dependency, which they previously had. Truong et al (2009) lamented that being stuck in bed without movement and the lack of dependency makes the patient feel the lack of control to their fate, and Day et al. (2009) revealed that it makes the patients to be socially isolated, especially where the person is physically isolated because of their condition thereby limiting friends as well as family to visit them. The emotional reaction to this isolation may obstruct weaning from the ventilator.

Last is depersonalization, which is a stressor denoting the lack of use of patient names when issuing care and treatment. Evidently, this causes the lack of a rapport and understanding with the patient’s family as well as the patient’s inability to relax. Unlike the cases where nurses refer to patients as diagnosis, the failure to use names causes inability to relate with the patients and their families, thus making it hard to cope with the situation (Taylor 2010). However, Jennifer et al. (2012) claimed that the use of the name may be unhelpful for critically ill patients when unconscious, but help the family identify their patients’ records. Moreover, these ICU stresses make the lives of the critically ill difficult because of the psychological effects they have on the patients’ well being. They compound the recovery process thereby prolonging the stay at the ICU (Wenham and Pittard 2009).

Psychological effects

The stress experienced by patients in the ICU impacts differently on their psychological well being. Most notably, it results to delusion, hallucination, anxiety and death fear. The psychological set up of a patient often determines the effect of the care and medication given to them. In most instances, patients tend to respond positively to medication when they are psychological state of an individual usually denotes their mental as well as emotional state (Molter 2007). This can be categorized into the impacts these stressors have on their mental emotional as well as physical desires. In communicating with critically ill, nurses are usually expected to adapt the use of uncomplicated words especially when elucidating the patient condition (Workman 2007) which is supported by Jennifer et al (2012) because simple words help the patient understand the medication plus his or her situation in the ICU. According to Rushton et al (2007) immobilization influences more on the physical needs of the patients in which Ramsey (2012) explained it was because of the tube insertions made on the patients. Overly, this stressor tends to restrict the patient’s movements by confining them to one position. In such cases, the patient feels helpless and over dependent on the nurses and family members. Psychologically, most patients tend to be unease and angry with their situation. Reportedly, there are times when patients have been counseled by psychiatrists to prevent these stresses from worsening their condition (Ramsey 2012).

Depersonalization, which is an external stressor, influence more on the psychosis state (inability to distinguish reality and imagination) of the patients. This is a delusional disorder as a result of psychological stress. Patients start misinterpreting perceptions/experiences which are overexaggerated like you are deceived, not loved, and so forth. This is because mostly patients are isolated or given less time with their family and friends. As Landy & Conte (2009) described this notably creates a detachment from the patients and they are often filled with insecurity and unease of their condition (Carayon, 2011). However, people with delusion can still socialize and fuction normally as well. Therefore, nurses are required to handle them with great care and approach like using the patient’s name which makes the patients and families feel at harmony with the medical staff. This makes a positive impact on the patient by enabling them to interact freely and embrace the care given to them. When patients are at peace with the care they receive, they enable the medication to work in their favor. Reportedly, addressing them as human via the use of their preferred name helps them to be receptive and reduces the effects of the stresses on their condition (Puntillo et al. 2010). Nevertheless, Rathmell et al. (2006) stated that poor management of patients may lead to psychological stress, difficulty in sedation, postoperative complications, incidence of metabolic as well as endocrine reactions, and emergence of chronic pain, which Chanques et al (2006) agreed with.

Poor or lack of sleep is psychologically damaging and may result in conditions, such as delirium (Borthwick et al, 2006). Rowe (2008) acknowledges that 80% of patients admitted to the ICU develop delirium, Weinham and Pittard (2009) agreed that sleep disruption might be related to mental changes as well as delirium thereby detrimentally affecting recovery. Some characteristics of delirium include irregular mental status, disoriented thinking and vision, inattentiveness, as well as the varied consciousness level, which mostly is followed by hallucination. The condition is categorized into hyperactive and hypoactive which involves hearing of voices and sounds, seeing patterns and feeling sensations which are not real. Most hallucinations are associated with their departed loved ones. The latter although unrecognized at times has a bad diagnosis. It is illustrated by retardation of psychomotor featured by a still manifestation, inattentiveness, and reduced mobility. The former is characterized by aggressiveness, combative behavior, as well as continuous confusion and happens despite the use of sedatives. Weinharn and Pittard (2009) add that improper sleep may impair the formation of memory and the resulting amnesia may enhance delirium. Relative to hallucinations emanating from the departed loved ones, critically ill patients are filled with fear of death. As studies have proved, majority of critically ill patients claim that their departed loved ones keep on appearing implying they have come back for them.

Exposing ICU patients to noise is annoying and a major stressor in the ICU. Noise is an external stressor and most related to anxiety. The reaction is individualized, subjective, as well as depictions of variable response. Uncontrolled noise may contribute to stress induced by noise. Exposure to noise may prompt a reaction of the sympathetic nervous system, which increase the working of the cardiac and can possibly affect the function of respiratory muscle adversely. Extreme noise may arise the necessity for sedation, impair communication, and play a part in loss of hearing. The loss of hearing is an extra predisposition to delirium. However, Wenham and Pittard (2009) argue that the loss of hearing may not necessarily result in delirium. Additionally, separation from loved ones who provide a feeling of security cause anxiety. Furthermore, PSTD is form anxiety that emante from earlier trauma from severe situations or occurrences.

Strategies

Dealing with critically ill individuals calls for careful and feasible application of strategies. This is because handling critically ill patients usually demands the need for special care as compared to other illnesses (Omari 2009). Management using sedation is a fundamental part of the care of the ICU patient. Practitioners administer the sedative agents in a trial to alleviate anxiety and enhance comfort. Distress as well as anxiety may result from the continuously noisy environment, technology, intrusive stimuli, invasive procedures, as well as unknown routines, which characterize the ICU environment (Wenham & Pittard 2009). In such an environment, sedation depresses the patients’ knowledge of the surroundings and decreases their reaction to external stimulus. Sedation functions significantly in the care of the ICU patients and includes varied symptom control, which differ amid patient and individuals during the course of their disease (Rowe 2008). However on regards to sedation, Wenham and Pittard (2009) claimed that sedatives must be used in the ICU despite the variations. On the contrary, little comprehension exist in the manner which nurses in the ICU formulate resolutions concerning the evaluation of the amount of sedatives to use on a patient and the proper sedative agents administration (Egerod et al, 2006; Mehta et al, 2006). Application of guideline for formal sedation to raise steadiness and promote communication amid clinicians is still infrequent. Nevertheless, it is widely agreed the appropriate level ought to be made for the individual patient’s requirements. The ideally factors, for example, clinical state, present goals for treatment, as well as patients past record ought to be applied to enlighten the resolution. However, inadequate sedation may result in negative psychological scale, for instance, anxiety in addition to physical issues like self-extubation or physical injury (Sessler &Wilhelm 2008). Despite these issues, Wenham and Pittard (2009) insist on the use of sedative in the ICU. In addition, the physiological reactions are autonomic tone transformation, raised myocardial workload, raised coagulability, raised metabolism with a succeeding rise in oxygen need, as well as immunocompromise (Pandharipande et al, 2007). These transformations are likely to influence recovery negatively. Therefore, there should be an accurate assessment of the sedatives administered to ICU Patients to optimize sedation management. Payen et al. (2009) claims that assessing pain is linked to reduced time of mechanical ventilation in the ICU. Moreover, to manage delirium, neuropleptic are used, which are believed to function by applying a balancing influence on the role of the cerebral, lower hallucinations, fantasy, as well as non-configured pattems of thought (Wenham & Pittard 2009). Haloperidol is a safe pharmacodynamic profile and therefore preferred to chlipromazine (Erman, et al, 2006).

 

Apart from sedation, other strategies exist including pharmacological and non-pharmacological approaches. As earlier mention, non-pharmacological are preffered to pharmacological on the basis of cost. One of the most used non-pharmacological strategy is music therapy. The latter entails adjustments of the local environment of patients to reduce unnecessary noise (Wenham and Pittard, 2009). Music usually has a soothing effect. According to Rowe (2008) best sleep occurs under less than 35 dB and an 80 dB noise level regardless if it is music will lead to arousal from sleep. Sleep can be encouraged by good music which the patients likes and is within the a good noise level. In addition, objected music therapy may reduce heart rate, the frequency of ventilation, anxiety scores, and myocardial oxygen requirement thereby improving sleep. On the other hand, aromatherapy is a strategic means of raising the value of sensory input, which patients obtain and lowering stress as well as anxiety (Horwitz, 2011). However, Horwitz (2011) argues that despite the prevailing anecdotal evidence supporting the above claims, few studies have objected to assess the influence on stress reduction. According to Wray (2011) using aromatherapy including essential oils is crucial in reducing anxiety and lowers the requirement for pain medication. Horwitz (2011) supported that the use of essential oils because they influence the limbic system of the brain through the olfactory nerve resulting in a calming as well as relaxing effect.

On the other hand, good communication can also crucial. Non-medical talk is part of noise disruption and be discouraged. By embracing good behavior especially in communication helps much in recovery process. This can do by implementing a behavior modification program to create awareness concerning the problem followed by limiting noise measures. Besides eliminating uncessary noise to some extent, communication helps to improve the relationship between the patient and nurses which enhances cooperation. Although some medications are unavoidable, the nurse should sympathize with the patients’ need. Pain ought to be eased and interventions maintained at a minimum (Erman, et al, 2006). Day et al. (2009) postulated that a resting atmosphere should be provided and the nurse should pressure as well as comfort the patient, while Gay et al. (2012) asserted that such an atmosphere would aid healing. To improve communication, employment of pen and paper, word charts, as well as compute voice synthesizers may help. The hearing aids ought to be on and consultations made with the families concerning past communication problems. The multidisciplinary team should offer extra information to the patients where possible and patients should take part in their clinical management as well as made to feel engaged in the progression (Day et al. 2009).

On the noise coming from other sources like trolleys by the bedside, volume of telephones, alarms, as well as intercoms should be monitored and reduced to reduce noise pollution in the ICU. The ring tone may be replaced with flashing lights or a vibration system. Squeaky doors as well as trolleys should be oiled to decrease the levels of sound pressure. The bins should be made of cushioned and automatic slowly closing covers. The ICU design could be created with materials that absorb sound, such as ceiling soffits. The best achievement will be having a single room for every ICU patient to promote privacy, confidentiality, as well as dignity. Such as setting would be less noisy although the patient’s safety provisions would be problematic and promote isolation (Kellum et al. 2007) however, Wenham and Pittard (2009) noted that noise reduction may not factor in when the patient is unconscious. (Gwen 2009). Lighting the bed space to imitate the day-night course also assists. Dimmed lights may benefit the patients as well. However, Rowe (2008) claimed that there is no much prove on this benefit, but it presumably works. Finally, encouraging family and friends visits is very vital. At such moments when one is critically ill, he/she feels insecure, hated, weak and so forth. The presence of loved ones helps to boost the morale of the patents.

Besides all the above strategies as described above, they correlate in one way or the other. However, sedation strategy is the best in reducing psychological impact. This is because when a patient is sedated he/she does not encounter most of the psychological streessors which could affect him/her such as pain, noise, fear amongst others. Additionally, it enhances patients psychological stability which facilitates their recovery promting they to be transferred from the ICUs. Studies have proved that a patients who recover from sedation outside ICU have high survival rate and less psychological effect as well (Wenham and Pittard, 2009). On the contrary, sedation has contributed in worsening the situation of some patients (Egerod et al, 2006; Mehta et al, 2006). In spite of this, it is the best option due it more benefits as opposed to other ways. Therefore, proper and appropriate administration of sedatives should be facilitated to avoid the minimal unfortunate cases (Wenham and Pittard, 2009).

In summary, the ICU is a highly stressful setting for the seriously sick patient. The major stressors include noise, pain, Immobility, communication breakdown, depersonalization, and lack of sleep among others. The pain mostly results from the disease itself, invasive medical procedures, ET tubes, and surgical incisions among others. Noise in the ICU comes from talking, alarms, television, and noisy doors and trolleys. Immobility is because of confinement in the bed due to disease, equipment, and drug. The stresses are compounded by the inability to talk or poor communication. This makes the patients feel isolated and less important because of lack of self-dependence. These stresses are psychologically stressing to the patients’ as well being. For instance, noise disrupts the sleeping patterns thereby compounding the situation because poor sleep leads to delirium and compromises the immune response. Delirium compounds the disease thereby prolonging the stay in the ICU. The psychological effects cause issues even after discharge with most patients developing PTSD. Some strategies are necessary to fight the stressors and their effects. The ICU design ought to be relaxing for the patient, for instance, the use of noise absorption material for construction, use of vibrating devices instead of ring tones, and baffles to discard echoed noise among others. Other noise control measures are behavioral, such as avoidance of non-medical talk in the ICU. The pain is mostly controlled using sedatives, which helps the patient to spend most of his/her ICU time asleep. However, sedatives have negative effects if used in wrong does. Therefore, practitioners should ensure the use of correct sedation levels. Communication is notably important in order to understand the patient. This is helpful and methods such as use of charts or letters can help the patients to feel part of the treatment process. Therefore, coping efforts in the ICU should be directed to ensuring the comfort and quick recovery of the critically ill patients

 

 

 

 

 

 

 

 

 

 

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