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Critically-ill patients

James Saunders, age 41, was rushed to the intensive care unit as conscious but unresponsive following a care accident that left him critically wounded and his fiancee dead. His chief injuries included chest wounds and significant blood loss. The critical care doctors at the hospital successfully stabilized his condition, but despite morphine being delivered intravenously every four hours to control his pain, the patient remained exceedingly restive, often attempting to rip out his own wrist restraints.

His condition continued to worsen and eventually he was placed on a ventilator. Anxiety is often difficult to detect in patients receiving mechanical ventilation because clinical signs are not as readily detectable or visible as they normally are and patients often cannot respond to measures commonly used to detect anxiety. Research indicates that critically-ill patients often report that they experienced psychological distress, including anxiety and fear, during treatment in an ICU.

These reports were obtained from patients after being discharged, however; learning about patient anxiety levels during critical illness through observational studies is also considered invaluable in attempting an understanding of this problem in its entirety. Evidence indicates that the emotions fear and anxiety are associated with physiological responses, such as changes in tone, increased myocardial workload and reduced immune response.

This may well interfere with patients’ recovery and, as such, their detection and reduction in critically-ill patients is important as clinical goals for Intensive Care Unit staff. Nursing interventions may be successful in the following ways: 1. ) The assessment of anxiety in ICU patients by observation of physiological and behavioral signs such as heart rate, blood pressure, muscle tension, facial expression, and restlessness; 2. ) By measurement of cortisol and catecholamine levels, which are increased during a stress response;

By patients’ self-reports of the extent to which the patients are feeling anxious, tense, or fearful. Objective signs as measures of stress are difficult to interpret and may be unreliable in critically-ill patients because their values may be the result of physiological stressors ot psychological stress. Therefore, attempts to use nursing interventions to control anxiety concurrently with critical illness will general rely upon patients’ self-reports of anxiety levels.

Despite its promise, this approach presents other difficulties. Critically-ill patients are often limited in their ability to response to standard means of assessing anxiety because these means generally involve cognitive efforts and verbal responses that are prohibitive due to respiratory ventilation. The negative ways in which emotional discomfort manifests itself are far too serious to be ignored.

A popular and effective means of providing palliative care to ICU patients is the concurrent use of benzodiazepine sedatives include Diazepam (Valium), Clonazepam (Klonopin), and Alprazolam (Xanax). Sedation is a primary component of medical treatment of intensive care patients and is essential to relieving procedural discomfort and anxiety caused by respiratory ventilation, suction and physiotherapy. Irritation and agitation, such as that displayed by Mr. Saunders, are both minimized through sedation, which also lends to proper rest and sleep.

Sedation via benzodiazepine sedatives and opioid analgesia greatly mollifies the attendant suffering of surgery and trauma. A proper balance of sedation and analgesia is essential, as too much of either can cause complications such as hypotension, delayed recovery time, nausea, immunosuppression, hypertension, tachycardia, increased oxygen consumption, ventilator tube intolerance and infection.

The nursing interventions involved with sedation in the ICU vary widely from aiding patients that are completely unconscious to caring for those whoare awake yet uncomfortable. If the ICU nurses charged with the care of ICU patients accurately and precisely recognize and report the pain and anxiety their patients are experiencing, an ideal regimen to maximize patient comfort can easily be achieved.

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