Intensive Care Nursing PDF

 Intensive Care Nursing Intensive care is one of the most rapidly developing areas of Healthcare. This introductory textbook is written specifically for qualified nurses who are working in intensive care units and also for those undertaking post-registration courses in the speciali...

 Intensive Care Nursing Intensive care is one of the most rapidly developing areas of Healthcare. This introductory textbook is written specifically for qualified nurses who are working in intensive care units and also for those undertaking post-registration courses in the speciality. Intensive Care Nursing is structured in four parts. ‘Fundamental Aspects’ explores patient-focused issues of bedside nursing; ‘Monitoring’ describes the technical knowledge necessary to care safely for ICU patients; ‘Pathophysiology and Treatments’ illustrates the more common and specialised disease processes and treatments encountered; ‘Developing Practice’ looks at how nurses can use their knowledge and skills to develop their own and others’ practice. This accessible text is: Comprehensive: it covers all the key aspects of intensive care nursing. User-friendly: it includes fundamental knowledge sections, introductions, chapter summaries, a glossary of key terms, extensive and up-to-date references and a comprehensive index. Clearly written: by an experienced university lecturer with a strong clinical background of working in intensive care nursing. He has also published widely in the nursing press. Practically-based: end-of-chapter clinical scenarios provide stimulating discussion and revision topics. Intensive Care Nursing will be welcomed by ICU nurses throughout the world. Philip Woodrow, MA, RGN, Dip.N., Grad. Cert. Ed., is a Senior Lecturer at Middlesex University, where he is responsible for ENB 100 courses in intensive care nursing. Jane Roe is a Lecturer-Practitioner at St George’s Hospital Medical School and Kingston University, St George’s Hospital Intensive Therapy Unit.  What the reviewers said: ‘An informed, well written and clinically focused text that has ably drawn together the central themes of intensive care course curricula and will therefore be around for many years…. Revision activities and clinical scenarios should encourage students to learn as they engage in analysing and reflecting on their everyday practice experiences. More experienced nurses will also find it a valuable reference source as a means of refreshing their ideas or in developing practice.’ John Albarran, Faculty of Health and Social Care, University of the West of England ‘An excellent book which will be useful to nurses working in ICUs in many countries. The writers have managed to integrate theory with practice to produce an easy-to-read practical text which will be useful to both beginning and experienced ICU nurses.’ Kathy Daffurn, Associate Professor and Co-Director Division of Critical Care, Liverpool Health Service, Liverpool, Australia ‘Incredibly comprehensive…this text should meet Woodrow’s goal of contributing to the “further growth of intensive care nursing”. It should find a place on the shelves of intensive care units, as well as in Higher Education institutions providing critical care courses. It will also be a welcome source of reference for nurses caring for critically ill patients outside of the intensive care unit. Woodrow provides a balance between pathophysiology oriented aspects of nursing practice and the relationship between patient/family and nurses that is the very essence of intensive care nursing. The text is helpfully punctuated with activities for the reader, whilst the extensive references also enable the reader to pursue specific aspects in greater depth.’ Ruth Endacott, Adviser and Researcher in Critical Care ‘A book geared for practical use, it will be helpful to many intensive care nurses, especially those new to the discipline.’ Pat Ashworth, Editor, Intensive and Critical Care Nursing Intensive care nursing A framework for practice Philip Woodrow Clinical Scenarios by Jane Roe LONDON AND NEW YORK  To the States or any one of them, or any city of the States, Resist much, obey little, Once unquestioning obedience, once fully enslaved, Once fully enslaved, no nation, state, city, of this earth, ever afterwards resumes its liberty. Walt Whitman Fashion, even in medicine. Voltaire First published 2000 by Routledge 11 New Fetter Lane, London EC4P 4EE Simultaneously published in the USA and Canada by Routledge 29 West 35th Street, New York, NY 10001 Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2004. Main text © 2000 Philip Woodrow Clinical scenarios © 2000 Jane Roe Chapter 13 © 2000 Fidelma Murphy All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Woodrow, Philip, 1957– Intensive care nursing: a framework for practice/Philip Woodrow; clinical scenarios by Jane Roe. Includes bibliographical references and index. 1. Intensive care nursing. I. Roe, Jane. II. Title. [DNLM: 1. Critical Illness—Nursing. 2. Intensive Care—methods. WY 154 W893i 2000] RT120.15W66 2000 610.73′61–dc21 DNLM/DLC 99–33382 ISBN 0-203-44573-2 Master e-book ISBN ISBN 0-203-75397-6 (Adobe e-Reader Format) ISBN 0-415-18456-8 (Print Edition)  Contents List of illustrations ix Preface xiv Acknowledgements xvi List of abbreviations Xvii 1 Part I Fundamental aspects of ICU nursing 1 Nursing perspectives 2 2 Humanism 8 3 Sensory imbalance 14 4 Artificial ventilation 26 5 Airway management 37 6 Sedation 49 7 Pain management 61 8 Pyrexia and temperature control 72 9 Nutrition 79 10 Mouthcare 87 11 Eyecare 97 12 Skincare 103 13 Paediatric admissions to adult ICUs 112  14 Older adults in ICU 121 15 Infection control 127 16 Ethics 137 145 Part II Monitoring 17 Respiratory monitoring 146 18 Gas carriage 154 19 Acid-base balance and arterial blood gases 165 20 Haemodynamic monitoring 177 21 ECGs and dysrhythmias 192 22 Neurological monitoring and intracranial hypertension 216 232 Part III Pathophysiology and treatments 23 Cellular pathology 234 24 Acute myocardial infarction 243 25 Shock 254 26 Multiorgan dysfunction syndrome 263 27 Acute respiratory distress syndrome (ARDS) 267 28 Nitric oxide 275 29 Alternative ventilatory modes 282 30 Cardiac surgery 290 31 Disseminated intravascular coagulation (DIC) 305 32 Acute renal failure 312 33 Fluids 322 34 Inotropes 334 35 Haemofiltration 344 36 Gastrointestinal bleeds 355  37 Pancreatitis 363 38 Neurological pathologies 369 39 Hepatic failure 376 40 Immunity 384 41 Ecstasy overdoses 393 42 Obstetric emergencies in ICU 399 43 Transplants 407 44 Hepatic transplants 416 422 Part IV Developing practice 45 Professionalism 424 46 Stress management 431 47 Complementary therapies 439 48 Managing change 447 49 Managing the ICU 456 50 Cost of intensive care 463 Answers to Clinical Scenarios 468 Glossary 469 References 474 Index 519  Illustrations Figures 4.1 Continuous positive airway pressure (CPAP) valve 30 5.1 Main anatomy of the nasal cavity 38 5.2 Placement of an endotracheal tube (ETT) 39 5.3 High and low pressure cuffs on endotracheal tubes 41 7.1 Examples of referred pain 63 7.2 Bourbonnais (1981) pain assessment tool 66 10.1 The main anatomy or the oral (buccal) cavity showing salivary 89 glands 11.1 The external structure of the eye 100 17.1 Normal (self-ventilating) bream waveform 149 18.1 Oxygen dissociation curve 158 18.2 Carbon dioxide dissociation curve 161 19.1 Origin of acid-base imbalance 166 20.1 Intra-arterial pressure trace 180 20.2 Central venous cannulae 182 20.3 Pulmonary artery (flotation) catheter 184 20.4 Pressure traces seen as a pulmonary artery catheter passes 194 from the vena cava to the pulmonary artery 21.1 Normal sinus rhythm 195 21.2 Electrode placement: (a) Limb leads (b) Chest leads 196 21.3 Action potential of a single cardiac muscle fibre 198 21.4 Sinus arrhythmia 199 21.5 Supraventricular tachycardia 201 21.6 Atrial ectopics 202 21.7 Atrial fibrillation 203 21.8 Atrial flutter 204 21.9 Wolff-Parkinson-White syndrome 204 21.10 Nodal/junctional rhythm 205 21.11 First degree block 206 21.12 Second degree block (type 1) 207 21.13 Second degree block (type 2) 207 21.14 Third degree block 207 21.15 Bundle branch block 208 21.16 Multifocal ventricular ectopics 209 21.17 Bigeminy and trigeminy ectopics 210 21.18 Ventricular tachycardia 211 21.19 Torsades de pointes 212 21.20 Ventricular fibrillation 212 22.1 Intracranial pressure/volume curve 217 22.2 Intracranial hypertension and tissue injury: a vicious circle 218 22.3 Cross-section of the cranium showing the Foramen of Monro 223 22.4 Normal intracranial pressure waveform 224 23.1 Main components of a typical human cell 235 24.1 Coronary arteries, with inferior myocardial infarction 245 28.1 Production of nitric oxide by endothelium 277 30.1 The catheter of an intra-aortic balloon pump (IABP) (deflated 294 and inflated) 30.2 Arterial pressure trace showing augmented pressure from use 295 of an IABP 30.3 Ventricular assist device (VAD) 396 33.1 Perfusion gradients 326 36.1 A Sengstaken tube 357  Tables 3.1 Stages of sleep 20 6.1 The Ramsay sedation scale 53 6.2 The Cohen and Kelly sedation scale 54 6.3 The Newcastle sedation scale 54 6.4 The Addenbrookes sedation scale 55 6.5 The New-Sheffield sedation scale 56 6.6 The Bloomsbury sedation scale 56 7.1 Some misconceptions about pain in children 65 9.1 The Schofield Equation 80 9.2 A normal anthropometrie chart 84 10.1 The Jenkins oral assessment tool 91 12.1 UK consensus classification of pressure sore severity (‘Stirling 106 scale’) 13.1 Normal parameters for a child at rest 113 13.2 Body weight daily maintenance formula 116 18.1 Partial pressures of gases 156 18.2 Factors causing shifts in the oxygen dissociation curve 158 20.1 Normal intracardiac pressures 185 21.1 Reading the ECG 196 32.1 The functions of the kidney 312 33.1 Summary of intravenous infusion fluids 325 35.1 Commonly used terms for continuous renal replacement 344 therapies (CRRT) 43.1 Code of Practice for Brainstem Death diagnosis: preconditions 408 43.2 Brainstem death tests 409 43.3 Common reasons for next-of-kin refusing consent for organ 411 donation  Preface This book is for intensive care nurses. Intensive care nursing is a diverse speciality, and a text covering its every possible aspect would neither be affordable nor manageable to most clinical staff. This text, therefore, is necessarily selective, and will probably be most useful about 6 to 12 months into intensive care nursing careers. It assumes that readers are already qualified nurses, with experience of caring for ventilated patients, who wish to develop their knowledge and practice further. Discussion of clinical issues is therefore followed by implications for practice. Knowledge develops and changes; controversy can, and should, surround most issues. Some controversies are identified, others are not. But every aspect of knowledge and practice should be actively questioned and constantly reassessed. If this book encourages further debate among practising nurses it will have achieved its main purpose. Since a novice (Benner 1984) has little knowledge or experience, ‘basic’ nursing texts tend to explain almost everything. This book is for competent and advanced practitioners, however, whose knowledge and experience will vary. To help readers, ‘fundamental knowledge’ is listed at the start of many chapters, so that readers can pursue anything they are unsure about. Much ‘fundamental knowledge’ is related anatomy and physiology, and it would be a disservice to readers to displace other material for superficial summaries when there are many excellent anatomy and physiology texts available. Any book is necessarily a pragmatic balance between the author’s priorities and interests; this book represents mine. Part I concentrates on values and some of the ‘basic’ aspects of care that can be lost in the dehumanised technological ICU environment. Part II reviews various means of monitoring, including application to relevant problems (e.g. intracranial hypertension). The more common pathologies seen in ICUs are included in Part III as nurses need an understanding of pathophysiologies and treatments. Many more topics could be covered (some were removed during writing), but this is not fundamentally a book about pathophysiology and the cost of comprehensiveness would be the book remaining largely unused and unread. Finally, Part IV explores aspects of career development. Any stage of professional development is a beginning rather than an end; to help readers develop further, each chapter concludes with ‘further reading’, which is generally restricted to recent and easily accessible books and articles. Full publication details are given in the References, pp. 539–67. A few classic key texts are also included in the further reading sections and, where the original year of publication provides a historical context for material, I have included this with the year of the edition consulted (for example, Nightingale 1980 ). The large numbers of specialist, general nursing and other medical journals means that new material is frequently appearing and readers should pursue current material through their libraries. The clinical scenarios by Jane Roe provide an opportunity for nurses to apply the knowledge acquired in each chapter to a clinical situation. I have tried to adopt Eliot’s ‘the word precise, but not pedantic’. The glossary explains technical terms that are likely to cause problems and the first occurrence of these have been highlighted in the text. Few laws of physics or medical formulae are included unless frequently used in clinical nursing practice. Many chapters identify issues surrounding families; this implicitly includes friends and all other significant visitors. A few chapters include references to statute and civil law; these are usually English and Welsh law, and so readers in Scotland, Northern Ireland and outside the United Kingdom should check applicability to local legal systems. I have tried to minimise errors, but some are almost inevitable in a text of this size; like any other source, this text should be read critically. Although intensive care nursing is younger than most healthcare specialities, it already possesses a wealth of nursing knowledge and experience. I hope this book contributes to further growth of intensive care nursing, and enables readers to develop their own specialist practice.  Acknowledgements I am grateful to everyone who has helped in the development of this text, especially Jane Roe (who has contributed so much as both author of the clinical scenarios and who has been a particularly conscientious reviewer of every chapter) and Fidelma Murphy (whose experience of both paediatric and general intensive care is combined in the chapter about nursing children in general ICUs). I would also like to thank all the reviewers who read and assisted with comments on the developing typescript: John Albarran, University of the West of England; Kate Brown and Maureen Fallon, Nightingale Institute, King’s College University; Kay Currie, Glasgow Caledonian University; Lynne Harrison and Mandy Odell, University of Central Lancashire. Thanks also to Jane Fellows, who illustrated the book. All reasonable efforts have been made to contact the copyright holders of material reproduced in this book. Any omissions brought to the attention of the publishers will be remedied in future editions. I am grateful to everyone at Middlesex University for the support given towards this book, and for the sabbatical leave which enabled me to complete it. I would especially like to thank Sheila Quinn (Senior Lecturer, Middlesex University), who has helped me at so many stages of my career, and who first suggested I should write a textbook. I am grateful to Sue MacDonald (RM) for her comments toward the obstetrics chapter. I would also like to thank everyone who has helped develop my ideas, especially past and present staff of the Whittington Hospital and all my past students and colleagues and clinical staff at Chase Farm and North Middlesex Hospital. And of course this book would not have been possible without the encouragement and support of Routledge, in particular Alison Poyner and Moira Taylor. Philip Woodrow, March 1999  Abbreviations ACE angiotensin converting enzyme ACT activated clotting time ACTH adrenocorticotrophic hormone ADH antidiuretic hormone AF atrial fibrillation AIDS acquired immune deficiency syndrome AMV assisted mandatory ventilation ANF atrial natriuretic factor (also called atrial natriuretic peptide =ANP) ANP atrial natriuretic peptide (also called atrial natriuretic factor =ANF) APRV airway pressure release ventilation APSAC anisolylated plasminogen streptokinase activator complex ARDS acute respiratory distress syndrome AST asparate transaminase ATP adenosine triphosphate BE base excess BiPAP biphasic/bilevel positive airway pressure BMI body mass index BMR basal metabolic rate BNF British National Formulary BSA body surface area BUN blood urea nitrogen c/cal calorie CABG coronary artery bypass graft cAMP cyclic adenosine monophosphate CAPD chronic ambulatory peritoneal dialysis  CAT computerised axial tomography (see also CT) CAVH continuous arteriovenous haemofiltration (=ultrafiltration); rarely now used in ICU CAVHD continuous arteriovenous haemodialysis CAVHDF continuous arteriovenous haemodiafiltration CCUs coronary care units (US: critical care units) CD4, CD8 CD=cluster designation, the numbers refer to different types CFAM Cerebral Function Analysing Monitor CFM Cerebral Function Monitors CK creatine kinase (formerly, creatine phosphokinase: CPK) CMV (1) cytomegalovirus; (2) controlled minute volume (depending on context) COP colloid osmotic pressure COPD chronic obstructive pulmonary disease COSHH Containment of Substances Hazardous to Health CPAP continuous positive airway pressure CPB cardiopulmonary bypass CPK creatine phosphokinase CPP cerebral perfusion pressure CRRT continuous renal replacement therapy CSF cerebrospinal fluid CT computerised tomography (see also CAT) CVA cerebrovascular accident (stroke) CVP central venous pressure CWH continuous venovenous haemofiltration CWHD continuous venovenous haemodialysis CWHDF continuous venovenous haemodiafiltration Da dalton (kilodalton: kDa) DHHNK diabetic hyperosmolar hyperglycaemic nonketotic coma DIC disseminated intravascular coagulation E coli Escherichia coli, a lactose-fermenting species of bacteria ECCO2R extracorporeal carbon dioxide removal ECMO extracorporeal membrane oxygenators EDRF endothelium derived relaxing factor EEC electroencephalogram EMD electromechanical dissociation EMRSA epidemic strains of MRSA (see below) EPIC European Prevalence of Infection in Intensive Care ERCP endoscopie retrograde cholangiopancreatography ESR erythrocyte sedimentation rate ESRF endstage renal failure ETT endotracheal tubes FDPs fibrin degradation products FEV forced expiratory volume (so FEV1=forced expiratory volume at one second) FFP fresh frozen plasma FiO2 fraction of inspired oxygen (see Glossary) FVC functional ventilatory capacity GABA gamma aminobutyric acid GBS Guillain Barré syndrome GCS Glasgow Coma Scale GI gastrointestinal GTN glyceryl trinitrate GvHD graft-versus-host disease HAI hospital acquired infection (nosocomial) HAS human albumin solution (ie albumin for infusion) HAV hepatitis A virus HbA adult haemoglobin HbF fetal haemoglobin HbS sickle cell haemoglobin HBV hepatitis B virus HCV hepatitis C virus HDU high dependency unit HDV hepatitis D virus HELLP haemolysis elevated liver enzymes and low platelets HES hydroxyethyl starch HEV hepatitis E virus HFJV high frequency jet ventilation HFOV high frequency oscillatory ventilation HFV high frequency ventilation HITTS heparin-induced thrombocytopaenia and thrombosis syndrome HIV human immunosuppressive virus HLA human leucocyte antigen HME heat moisture exchanger HUS haemolytic uraemic syndrome IABP intra-aortic balloon pumps ICP intracranial pressure Ig Immunoglobulin (eg IgA=immunoglobulin A) IL interleukin IMA internal mammary artery IMV intermittent mechanical volume iNO inhaled nitric oxide INR international normalised ratio (of prothrombin time) IPPB intermittent positive pressure breathing IPPV intermittent positive pressure ventilation IPR individual performance review IRDS infant respiratory distress syndrome (see also RDS) IRV inverse ratio ventilation IVOX intravenous oxygenators kPa kilopascal LDH lactate dehydrogenase LIMA left internal mammary artery LMAs laryngeal mask airways LVAD left ventricular assist device m/s metres per second MAP mean arterial pressure MCL modified chest lead MDMA 3–4 methylenedioxymethamphetamine (Ecstasy) MI myocardial infarction mmol millimole (unit for measuring chemicals) MMV mandatory minute ventilation MODS multiorgan dysfunction syndrome MOF multiorgan failure MRSA multiresistant (or methicillin resistant) Staphylococcus aureus MSSA methicillin sensitive Staphylococcus aureus mv millivolt NAPQI N-acetyl-p-bezoquinone imime NIRS near infrared spectroscopy NPPV noninvasive positive pressure ventilation NSAID nonsteroidal anti-inflammatory drug PAC pulmonary artery (Swan Ganz) catheters PACP pulmonary artery capillary pressure PAFC pulmonary artery flotation catheters PaO2 partial pressure of arterial oxygen PAWP pulmonary artery wedge pressure PBC primary biliary cirrhosis PCA patient controlled analgesia PCOP pulmonary capillary occlusion pressure PCP Pneumocystis carinii pneumonia PCWP pulmonary capillary wedge pressure PDIs phosphodiesterase inhibitors PEEP positive end expiratory pressure PEG percutaneous endoscopie gastrostomy PEG perfluorocarbon PGE2 prostaglandin E2 PGI2 prostaglandin I2, also known as prostacyclin pHi intramucosal pH ppm parts per million PS pressure support PSV pressure support ventilation PTCA percutaneous coronary angioplasty PTT prothrombin time PUFAs polyunsaturated fatty acids PVR pulmonary vascular resistance QALYs Quality Adjusted Life Years RAP right atrial pressure RDS respiratory distress syndrome REM rapid eye movement RNA ribonucleic acid RQ respiratory quotient RR respiratory rate RVEDP right ventricular end diastolic pressure  SA sinoatrial (node) SBC standardised bicarbonate SEE standardised base excess SCUF slow continuous ultrafiltration removal of ultrafiltrate, usually using a small-pore filter, so minimising solute removal; used only for removing/reducing fluid overload SD plasma solvent detergent plasma SDD selective digestive decontamination SCOT serum glutamic oxaloacetic transaminase SIADH syndrome of inappropriate antidiuretic hormone SIMV synchronised intermittent minute volume SIRS systemic inflammatory response syndrome; (formerly called septic inflammatory response syndrome) SNP sodium nitroprusside SV stroke volume SVR systemic vascular resistance SWOT strengths, weaknesses, opportunities, threats TCNS transcutaneous nerve stimulation (see TENS) TENS transcutaneous electrical nerve stimulation (see TCNS) TIPS transjugular intrahepatic portosystemic shunt TMP transmembrane pressure TMR total metabolic rate TNF tumour necrosis factor t-PA, TPA tissue plasminogen activator TPN total parenteral nutrition TTP thrombotic thrombocytopenia purpura TV tidal volume (also written at Vt) UKTSSA United Kingdom Transplant Support Service Authority VAD ventricular assist devices VAP ventilator associated pneumonia V/Q ventilation to perfusion ratio VRE vancomycin resistant enterococci vWF von Willebrand’s Factor  Part I Fundamental aspects of ICU nursing Part I explores issues that are fundamental to ICU nursing and can be read sequentially or used as a resource for later chapters. It develops issues that may have been introduced during pre-registration courses, but which can too easily be lost in the technical demands of intensive care. The first chapter therefore explores the values underlying intensive care nursing; the second chapter develops these through outlining two influential moments in psychology. The third chapter examines issues about the environment in which intensive care patients are nursed. Intensive care units (ICUs) developed primarily from respiratory units, and so Chapters 4 and 5 discuss respiratory management while Chapter 6 reviews sedation. The human needs and problems of nursing rituals are explored in the chapters on pain management, pyrexia, nutrition, mouthcare, eyecare and skincare. The next two chapters then explore the extremes of age: paediatrics and older adults. Most ICU patients are immuno-compromised, and infection control is discussed in Chapter 15. The final chapter of this section applies ethical principles and theories to ICU nursing practice.. Chapter 1 Nursing perspectives Introduction This book explores issues for intensive care nursing practice, and this first section establishes its core fundamental aspects. Nurses’ salaries have always formed a major part of healthcare budgets: Endacott (1996) estimates that nursing accounts for three- quarters of ICU costs. Thus it is important for ICU nurses to clarify their roles in, and value to, healthcare in order to be able to ‘articulate the importance of their role in caring for patients and their relatives’ (Wilkinson 1992:196). To help readers to do this, this first chapter explores what nursing means in the context of intensive care and the following chapter outlines two schools of psychology (behaviourism and humanism) that have influenced healthcare and society. The Department of Health publication A Strategy for Nursing (DoH 1989) identified four possible roles for nurses: 1 as surrogate parent 2 as technician 3 as contracted clinician 4 as advocate Previously, Ashworth (1985) had identified similar role conflicts within ICUs: 1 the technician 2 the doctors’ assistant 3 the carer for patients while others deal with technical treatment and maintenance 4 the ‘prickly’ professional Both these documents raise issues of values and beliefs. Acknowledging and continuously re-evaluating our individual values and beliefs is part of human growth, so that examining nursing’s values and beliefs within the context of our own area of practice is part of our professional growth. This is something that each nurse can usefully explore and there are a number of published exercises available in this respect (e.g. Manley 1994), but essentially it means working out a nursing philosophy for oneself. What is meant by this is not some esoteric message hung neatly on a wall and seldom read or practised—such as ‘man is a bio-psycho-social being’—but, rather, simple values which may be more meaningful—such as ‘remember our patients are human’. This question of values is well illustrated by the semantic dilemma of whether to call the speciality ‘Intensive Therapy’ (ITU) or ‘Intensive Care’ (ICU)—in practice, the terms are often interchangeable, and many ICU staff value cure rather than care (Steel &  Nursing perspectives 3 Hawkey 1994). Care can (and should) be therapeutic, but therapy (cure) without care is almost a contradiction in terms. Thus, in order to emphasise the caring human role of critical care nurses (and other staff), this book refers to ‘intensive care (ICUs)’. Technology Intensive care is a young speciality. Respiratory units for mechanical ventilation developed from the polio epidemic of 1952–3 (Edwards 1994), and the first purpose-built intensive care units (ICUs) in the UK opened in 1964 (Ashworth, personal communication). These units offered potentially life-saving intervention during acute physiological crises, with the emphasis on medical need and availability of technology. As the technology and medical skills of the speciality developed, so technicians were needed to maintain and operate machines. Although many ICUs employ technicians, technology-related tasks are still delegated to nurses—such as managing bedside machines, recording observations from them and changing regimes as prescriptions change. However, the fact that technology provides a valuable means of monitoring and treatment should not allow it to become a substitute for care. For nursing to retain a patient-centred focus, it is the patients themselves and not the machines that must remain central to the nurse’s role. Therefore, technology should not justify the role or presence of nurses. Healthcare assistants (and, potentially, robots) can be trained to perform technological tasks—and are cheaper to employ. While acknowledging the need for technical roles, then, ICU nurses need to be more than just technicians. Doctor-nurse relationships Ford and Walsh (1994) observed that nurses working in high dependency areas often have good relationships with medical staff. Most ICU nurses would agree with, and value, this. But Ford and Walsh suggest this good relationship is on the terms of the medical staff. Some Canadian studies (Grundstein-Amado 1995; Cook et al. 1995) suggest that values differ between doctors and nurses (influenced by profession rather than gender), and this can lead to potential communication breakdown. For example, nursing’s focus on the emotional costs to intensive care patients may limit the wider recognition of nursing as a profession (Phillips 1996). Nurses should collaborate with doctors (and other members of the healthcare team) (UKCC 1992a), but how that collaboration is achieved will vary between units and individuals. However, while recognising and respecting the valuable and unique role of doctors, this collaboration by nurses should not mean subservience (i.e. ‘doctor’s handmaiden’). The roles of technician and doctors’ or contracted assistant should be only part of ICU nursing. ICU nurses need to define their unique role and contribution actively and positively within the specialty, and this can be achieved through exploring nursing values.  Intensive care nursing 4 Psychology The increasing emphasis by the nursing profession on psychology and the psychological needs of patients, whether conscious or unconscious, makes psychological care an essential part of holistic care—a focus noticeably absent in the medical and technological perspectives above. Cochran and Ganong (1989) suggest that ICU nurses are more concerned with the psychosocial stressors, while patients are more concerned with their physical care. Patients’ needs and nursing care vary between units and individuals, but, if Cochran and Ganong are right, there is cognitive dissonance between ICU nurses and their patients. Since patients are admitted to ICU with acute physiological crises, intervention must necessarily focus care on their physical needs—for instance, considerations about needle phobias are obviously inappropriate during a cardiac arrest. However, psychology and physiology are not two separate and distinct pigeon-holes that some nursing (and other) course timetables might suggest, and the subject of homeostatic imbalances from psychological distress is explored in Chapter 3. Rather than ritualistically following lists of pre-ordained cues (e.g. assessment forms), nurses should actively evaluate the holistic needs of their patients; by acknowledging these individual psychological needs, ICU nurses can complement the valuable physiological care offered by the other professions. In recognising both the physical and psychological needs of patients, nurses can add a humane, holistic perspective into their care, preparing their patients for recovery and discharge. The importance of assessing and planning nursing care is a recurring theme in many of the later chapters of this book. Care or torture? Following Ashworth’s seminal study of 1980, psychological stresses specific to, or accentuated by, intensive care have been widely discussed in nursing literature. Dyer (1995) arguably makes the most poignant exploration, comparing ICU practices to torture. ICU patients, often deprived of the ability to speak, make decisions or alter their own environment, are confronted not only with a barrage of unusual sensory inputs, but also suffer a deficit of normal inputs when some of the most basic human physiological functions—such as breathing and movement—are replaced. Admittedly, ICU environments present the ingredients for successful psychological (and physical) torture, but whereas the normal purpose of torture is to enforce the victim to serve the torturer (such as through confession), the aim of ICU treatment is to overcome the patient’s physiological disease and restore health. To this end, it is often necessary, unfortunately, to add knowingly to the patient’s suffering, but this is one of the costs of critical illness (Carnevale 1991). However, much suffering can be prevented or minimised through good nursing care. Since suffering is inevitable in ICUs, the admission of any patient unlikely to survive becomes inappropriate (cruelty), since that patient will in effect be tortured to death. The rationing of ICU care is often financially determined, but there can also be valid humanitarian reasons for refusing inappropriate admissions.  Nursing perspectives 5 Holistic care The intrinsic needs of patients derive from their own physiological deficits, including many ‘activities of living’ (e.g. communication, comfort, freedom from pain); meeting these needs is fundamental to nursing, and this provides the focus of the first part of this book. People are influenced by, and interact with, their environment; their extrinsic needs, which define each person as a unique individual, rather than just a biologically functioning organism, include: dignity privacy psychological support spiritual support It is within the nurse’s scope to promote, proactively and creatively, a therapeutic environment, and accounts of patients’ own experiences in ICUs, such as those provided by Watt (1996) and Sawyer (1997), make salutary reading. Waldmann and Gaine (1996) describe one patient, unable to drink, feeling tortured by hearing a can opened—opening cans of enterai feed away from a patient’s hearing may reduce such unintentional, but unnecessary, suffering. Again, probably few ICU nurses would wish to sleep naked (with only a single sheet) in a mixed ward, yet many ICU nurses subject their patients to this potentially degrading experience. Thus, nurses need to question every nursing action proactively, no matter how small and apparently insignificant it may seem to be. Patients are dehumanised by admission to ICUs (Calne 1994); nurses can restore that humanity (Ball 1990; Mann 1992). Psychological approaches to nursing should be individually planned and implemented according to each patient’s needs. These needs can be assessed through the patients themselves and augmented by information from families and friends. Different nurses will feel comfortable with different approaches, but all should recognise the individual human being within each patient. Unlike the other medical and paramedical professions, nurses do not treat a problem or a set of problems. Unique among healthcare workers, ICU nurses remain with patients throughout their hospital stay. A fundamental role of a nurse, therefore, is to be with and for the patient; this is compatible with the advocacy role promoted by A Strategy for Nursing (DoH 1989). This role is facilitated by making patients the focus in the organisation of care (such as through primary/named nursing). As the one member of the multidisciplinary team continuously present in the patient’s environment, an ICU nurse is ideally placed to put the patient (as a person) first. The recommended one-to-one nurse-patient ratio (DOH 1996a) in the UK reflects the higher dependence of ICU patients here than elsewhere (Silvester 1994); it also highlights the unique role of ICU nurses in the UK. Although an ideal (at times most ICU nurses care for more than one ventilated patient at the same time), the overall nurse-patient ratio in the UK is 0.85 (Ryan 1997a). Depasse et al. (1998), profiling six European countries, found that the UK had the highest number of nurses per bed (4.2), and on average the sickest patients. This constant presence of a specific nurse at the patient’s bedside should allow more holistic, patient-centred care.  Intensive care nursing 6 Relatives Relatives, together with friends and significant others, form an important part of each person’s life, and they too are similarly distressed by the patient’s illness. The psychological crises experienced by relatives necessitate skilful psychological care, such as the provision of information to allay anxiety and make decisions, and facilities to meet their physical needs (Curry 1995). Relatives should be offered the opportunity to be actively involved in the patient’s care (Hammond 1995) without being made to feel guilty or becoming physically exhausted, rather than left sitting silently at the bedside, afraid to touch their loved ones in case they interfere with some machine. Whether units should permit ‘open’ visiting, and how open ‘open’ this should be, is a matter for debate; ICUs might become more humane if visiting were individualised to meet, first, the individual needs of each patient and, second, the needs of families and friends (Simpson 1991). Despite some recent interest in the care of relatives (e.g. Jones and Griffiths 1995; Plowright 1995), ICU nursing still has much to learn from other specialities (in particular, paediatrics). Implications for practice a nurse needs technical knowledge and skills, but nursing is more than being a technician ICU nurses have a unique role in the holistic, patient-centred perspectives that humanise a technology-orientated environment nursing values underpin each nurse’s actions; the clarification of values and beliefs helps each nurse and each team to increase their self-awareness since patients’ experiences are central to ICU nursing, nurses need to consider what their patients are experiencing Summary Intensive care is labour intensive; nursing costs consume considerable portions of hospital budgets. Therefore, ICU nursing needs to assert its value by: recognising nursing knowledge valuing nursing skills offering holistic patient/person-centred care Person-centred care involves nurses being there for each patient, rather than the institution. Having recognised the primacy of the patient, nurses can then develop their valuable technological skills, together with other resources, in order to fulfil their unique role in the multidisciplinary team for the benefit of patients. ICU nurses should value ICU nursing on its own terms—namely, to humanise the environment for their patients. The beliefs, attitudes and philosophical values of nurses will ultimately determine nursing’s economic value. Much of this book necessarily focuses on the technological and pathological aspects of the knowledge needed for ICU nursing. This chapter is placed  Nursing perspectives 7 first in order to establish fundamental nursing values, prior to considering individual pathologies and treatments; nursing values can (and should) then be applied to all aspects of holistic patient care. Further reading Much has been written on what nursing is or should be. Henderson, famous for her earlier definition of the unique role of the nurse, wrote a classic article about nursing in a technological age (Henderson 1980). More recent perspectives from ICU nurses include Ball (1990), Calne (1994), Carnevale (1991), Mann (1992) and Wilkinson (1992). Manley (1994) offers a useful framework for clarifying values and beliefs. Over the years, many accounts of patients’ experiences have been written; Watt (1996) and Sawyer (1997) are recent, easily accessible and vivid articles, while Dyer (1995) offers further challenging perspectives. Clinical scenario Q.1 Identify environmental, cultural, behavioural and physiological factors that may (potentially) contribute to the suffering and dehumanisation of patients in ICUs. Q.2 Outline specific nursing strategies which can minimise the range of factors identified in Q.1. Examine the potential conflicts between these strategies and the more technical, physiologically necessary interventions. Q.3 Reflect on the role of specialist nurses within ICU. What is their role (or range of roles) and how did this develop? What do they contribute to actual patient care, and how is their effectiveness evaluated?  Chapter 2 Humanism Introduction Philosophical beliefs affect our values, and so influence our approaches to care. Chapter 1 identified the need to explore values and beliefs about ICU nursing. This chapter describes and contrasts two influential philosophies to supply a context for developing individual beliefs and values. As this is not a book about philosophy, descriptions of these movements are brief and simplified, and readers are encouraged to pursue their ideas through further reading. The label ‘humanism’ has been variously used throughout human history, probably because its connotations of human welfare and dignity sound attractive. The Renaissance ‘humanistic’ movement included such influential philosophers as Erasmus and Sir Thomas More. In this text, however, ‘humanism’ is a specifically twentieth-century movement in philosophy led primarily by Abraham Maslow and Carl Rogers. The humanist movement, sometimes called the ‘third force’ (the first being psychoanalysis, the second behaviourism), was a reaction to behaviourism. Our beliefs, even if we are unaware of their source, influence our practice. Playle (1995) suggests that the art-versus-science debate within nursing is an extension of the humanistic-versus- mechanistic (i.e. behaviourism) debate of philosophy. The art of ICU nursing—the process of bringing humanity into intensive care—can be optimized by being there sharing supporting involving interpreting. advocating (Andrew 1998) This chapter begins therefore by describing behaviourism. Behaviourism The behaviourist theory was largely developed by John Broadus Watson (1878–1958) who, drawing on Pavlov’s famous animal experiments, stated that if each stimulus eliciting a specific response could be replaced by another (associated) stimulus, the desired response (behaviour) could still be achieved (‘conditioning’) (1998 ). The behaviourist theory enabled social control and so became influential when society valued a single socially desirable behaviour. Thus behaviourism focuses on outward,  Humanism 9 observable behaviours and for behaviourists, learning is a change in behaviour (Reilly 1980). Holloway and Penson (1987) have suggested that nurse education contains a ‘hidden curriculum’ controlling the behaviour of students and their socialisation into nursing culture. Through Gagne’s (1975, 1985) influence, many nurses have accepted and been acclimatised into a behaviouristic culture without always being made aware of its philosophical framework. Hendricks-Thomas and Patterson (1995) suggest that this behaviouristic philosophy has often been covert, masked under the guise of humanism. Thus using aspects from humanism, such as Maslow’s hierarchy of needs in Roper et al.’s model of nursing (1996), does not necessarily reflect the adoption of a humanistic philosophy. For instance, the debate surrounding nursing uniforms and their replacement in ICU with theatre-style ‘pyjama suits’ can reflect values about outward appearance. Whether from cause (‘types’ of nurses attracted to work in ICU) or effect (values learned from others), similar covert socialisation among ICU nurses encourages adoption of such defensive mechanisms as limiting communication to under one minute (even with conscious patients), and providing nurse-led information, questions and commands (Leathart 1994). Behaviourist theory draws largely on animal experiments; but humans do not always function like animals, especially where cognitive skills are concerned. Focus on outward behaviour does not necessarily change inner values. People can adopt various behaviours in response to external motivators (e.g. senior nursing/medical staff), but once stimuli are removed, behaviour may revert; when no external motivator exists, people are usually guided by internal motivators, such as their own values. Thus if internal values remain unaltered, desired behaviour exists only as long as external motivators remain (see Chapter 48). Behaviourism in practice Time out 1 A patient in ICU attempts to remove his endotracheal tube. There have been no plans to extubate as yet. Options: explanation (cognitive) accepting extubation analgesia and sedation (control) restraint (e.g. chemical sedation) Comment: Here, ‘pure’ behaviourism has already been tempered with humanitarianism: to try and comfort. Nevertheless, description remains deliberately behaviouristic, seeing the problem as behaviour (extubation). While extubation causes justifiable concern, behaviour is a symptom of more complex psychology. The patient attempts extubation because the tube causes distress. Until underlying problems are resolved, they remain problems; restraint only delays resolution.  Intensive care nursing 10 No philosophy is ideal for all circumstances, and few are without some merit. In this scenario, behaviourism may justifiably ‘buy time’ until underlying pathophysiology is resolved or reduced, when extubation will no longer be a problem, and may be medically desirable. Behaviourial approaches can be useful, but they can also be harmful by dehumanising others to a list of task-orientated responses. Smith (1991) found that preregistration courses still emphasised task-orientated, rather than holistic, nursing. Nurses should analyse their values and beliefs, understanding the implications they have for practice, and selecting appropriate approaches to each context; this is, after all, an extension of individualising care. Humanism The humanist movement was concerned that behaviourism overemphasised animal instincts (and relied too heavily on animal experiments) in an attempt to control outward behaviour. Hence humanism emphasises inner values that distinguish people from animals and is a ‘person-centred’ philosophy; rather than emphasising society’s needs, humanism emphasises the needs of the individual self. Maslow’s Motivation and Personality (1987 ) popularised the concept of ‘holism’ (the whole person). Humanists believe that people have a psychological need to (attempt to) achieve and to realise their maximum potential. Maslow (1987) described a hierarchy of needs, self-actualization being the highest of these; Roper et al.’s (1996) adoption of this in their model of nursing illustrates the influence of humanistic philosophy in nursing. However, adopting primacy of the individual, inherent in humanism, conflicts with the objective decontextualisation of traditional scientific methodologies (Playle 1995), raising difficulties when undertaking humanist research, as exemplified by debate surrounding qualitative and quantitive nursing research. Emphasis on inner values led humanist educationalists to concentrate on developing and/or attempting to change inner values: values that are internalised will continue to influence actions after external motivators are removed. Thus, changes in nursing practice made in order to conform with the desires of another may not continue after that person has left, or even when absent (e.g. days off), but changes made because staff concur with them will continue as long as that consensus remains. Concern for inner values and holistic approaches to care makes humanism compatible with many aspects of healthcare and nursing, although over-familiarity with terms can reduce them to clichés. Humanism has much to offer nurses in the process of analysing their philosophies of care and practice, but ideas should not be accepted uncritically. Lifelong learning Where the aim of behaviourist education was to achieve conformity, humanist education sought to promote individuality, and these differences are reflected in the training-versus- education debate. Training seeks to equip learners with a repertoire of responses to specific stimuli, and is, by implication, time-limited. In animals, stimulus-response reactions are often simple (as with Pavlov’s dogs); in humans, more complex responses  Humanism 11 may be learned. Such subconscious (conditioned) responses can be valuable: a cardiac arrest requires rapid action and follows protocols shared by other team members. However, for many nursing interventions, ‘training’ fails to provide the higher skills to work constructively through actual and potential problems. Training equips the learner to be reactive to problems (stimuli) rather than proactive (to prevent potential problems occurring). For humanist education, facts and ideas are quickly outdated (Rogers 1983) and so are less valued by humanists than the development of skills to enable personal growth (Maslow 1971) and learning (Rogers 1983). Humanism seeks to develop higher cognitive and affective skills in order to analyse issues according to individual needs—most valuable human interactions occur above the stimulus-response levels. For healthcare, humanism promotes a person-centred philosophy that enables learning to continue beyond designated courses; each clinical area becomes a place for learning, and nurses should be extending and developing their skills through practice. The current trend away from the teaching of factual information to the emphasis on individualised learning (e.g. learning contracts), reflection and lifelong learning will be familiar to nurses. This pragmatic hybrid not only values factual knowledge (e.g. research), but also recognises the individuality of the learning process, which is determined less by behaviourist outcomes than by what is meaningful for each individual. The UKCC’s PREP requirements (UKCC 1997) emphasise that attendance at a study day does not ensure learning has taken place. The more radical aspects of humanistic education (e.g. Neill 1992), which in recent years have been largely discredited, have not been applied to nursing. Many nursing actions can have (literally) vital effects and professional safety has to be ensured (Rogers 1951); humanistic elements, as with any other valuable philosophy, have been adapted to meet professional needs, and most countries have professional bodies, such as the UKCC, to regulate nursing education and registration. Problems Humanism has a weak research base, and so acceptance or rejection of its philosophy remains largely subjective. Arguably, research-based approaches conflict with humanism’s fundamental beliefs in individualism; Rogers’ early work did attempt to adapt traditional scientific research processes to humanism, but his later work adopts more discursive, subjective approaches. A great deal of learning occurs through making mistakes, and individualistic learning necessarily means making mistakes. Accepting the possibility of errors involves taking risks, and human fallibility does need to be recognised; the expection that mistakes will not occur, thus treating them as unacceptable, is unrealistic. However, errors with critically ill patients can cause significant and potentially fatal harm. Staff in ICU, particularly at managerial level, need to achieve the difficult balance between facilitating a positive learning environment and the maintenance of safety for patients and others.  Intensive care nursing 12 Implications for practice philosophy (our beliefs and values) influence our practice; in order to understand our practice, we need to understand our underlying beliefs and values changing inner values, rather than just outward behaviour, ensures continuity when external stimuli are removed healthcare, nursing and ICU retain behaviouristic legacies that can undermine individualistic, patient-centred care humanism emphasises inner values and individualism, and humanistic nursing helps to humanise ICU for patients Summary Philosophy is not an abstract theoretical discipline, but something underlying and influencing all aspects of practice. Hence it is relevant to each chapter in this book. This chapter has outlined two influential and opposing philosophies: behaviourism and humanism; applying these beliefs to nursing values (see Chapter 1) helps to clarify our own and others’ motivation. Further reading Much has been written on behaviourism, including within the context of nursing. Skinner (1971) gives interesting late perspectives on behaviourism, while Gagne (1975, 1985) significantly influenced nurse education. Maslow (1987 ) is a classic text on humanistic philosophy. Rogers is equally valuable, and possible more approachable; his 1967 text synthesises his ideas, while his 1983 book gives a useful discussion of educational theory. Many texts identified in Chapter 1 (for example, Ball 1990) reflect (often unacknowledged) humanistic philosophy. Andrew (1998) offers valuable applications of humanistic principles to intensive care nursing.  Humanism 13 Clinical scenario Mr Oliver is orally intubated, awake and being weaned from positive pressure ventilation. He moves his hand towards the endotracheal tube (ETT). This movement causes the nurse to respond. Q.1 Describe a behaviourist response by the nurse to Mr Oliver reaching for his ETT. Q.2 Explain how a humanistic response would differ from a behaviourist response in this interaction. Consider the values that underpin each response, e.g. safety, duty of care, motivation of Mr Oliver, needs of Mr Oliver. Q.3 Reflect on your own practice, evaluate typical responses to the above patient gesture, your own and others motivating values.  Chapter 3 Sensory imbalance Fundamental knowledge Sensory receptors and nervous system Motor nervous system Autonomic nervous system Introduction Sensory balance and psychological health are threatened by exogenous (e.g. environmental) and endogenous (e.g. body rhythms) factors. Sensory imbalance includes overload and deprivation, although literature may use other names (ICU syndrome, ICU psychosis/delirium, sleep disturbance/deprivation). Confusion may have many causes: sensory imbalance acute cerebral hypoxia/ischaemia/damage chronic cerebral damage Physiological as well as psychological causes of confusion should therefore be assessed. Sensory imbalance, like so many aspects of intensive care, initiates a stress response, which causes many physiological and psychological problems. The stress response is described in this chapter, but is referred to in many later chapters. Sedatives can provide comfort and anxiolysis (see Chapter 6), but are also a means of (chemical) restraint, and so should not become substitutes for nursing care. Despite sedation, most patients remember being in intensive care (Green 1996), even if memories are incomplete and compressed. ICU environments are abnormal, exposing patients both to excessive and deficient sensory stimulation, and causing psychological and physiological problems. Intubation severely limits interactive communication with ICU patients; even if conscious, most ICU patients experience difficulty writing, due to psychomotor weakness, impaired vision, or both, and asking closed questions limits quality of information. Patients’ gestures, facial expression and physiological signs (e.g. tachycardia) can indicate comfort, pain or anxiety. Isolation can be physical (e.g. side rooms) or social; social isolation may be overt (e.g. gowns and masks, emphasising subhuman ‘untouchable’ status, restricting visiting) or covert (e.g. deprivation of quality touch and meaningful conversation). Solitary confinement is an established and effective measure for torture (Dyer 1995), often unwittingly imitated on many ICUs. The five senses (sight, hearing, touch, taste, smell) supply raw materials for interpreting environments. Misinterpretation or imbalance of sensory inputs may cause  Sensory imbalance 15 confusion/delirium (‘rubbish in—rubbish out’). To approach this topic experientially, first work through these exercises: Time out 1 Take 2–3 minutes to list your own impressions of your environment at this moment; complete this before reading any further. Review your list, noting down beside each item whether impressions were perceived through sight, hearing, touch, taste or smell. Some items may be perceived by more than one sense. How often was each sense used? Most items are probably listed under sight, followed by a significant number under hearing. Touch is probably a poor third, with few (if any) under taste or smell. This reflects usual human use of senses: most input is usually through sight and hearing, with very limited inputs perceived from other senses. Time out 2 Imagine yourself as a patient in your own ICU. Jot down under each of the five senses any inputs you are likely to receive. When finished, review your lists analysing how many of these inputs are ‘normal’ for you. Remember that people usually rely most on visual and auditory inputs. Sensory input Even if their eyes are/can open, ICU patients often have distorted vision from drugs causing blurred vision absence of glasses (if normally worn). Absence of vision may be caused by periorbital oedema (preventing eye opening) coverings to prevent corneal drying (see Chapter 11: Eyecare) Those able to see may be nursed supine: ceilings are usually visually unstimulating; overhead equipment may be frightening. Attempts to rationalise such sensory inputs, especially if unprepared for this environment before admission, are likely to cause bizarre interpretation. Watching overhead monitors detracts from eye contact (non-verbal communication), and becomes dehumanising. Nurses should actively develop non-verbal skills (e.g. open body language, quality touch). Windows (with beds placed to give patients a view) help maintain orientation to normality. Patient recall of ICU suggests that hearing remains unaltered by critical illness, so staff and visitors should assume patients can hear normally, although hearing may be impaired by absence of hearing aids  Intensive care nursing 16 ototoxic drugs (e.g. gentamicin, frusemide); many accentuate high pitches (e.g. alarms), blurring lower pitches (e.g. voices), so causing pain and further isolation Normal conversation or other human interaction relies heavily on response (‘cueing’) (Eastabrooks & Morse 1992), which few ICU patients can give. Auditory input is too often confined to either instructions or others’ conversation (e.g. medical/nursing/team discussions, sometimes spoken across patients). Both are detrimental; instructions, although valid in themselves, should be supplemented by quality conversation. Patients learning about their own condition and progress (or misinterpreting conversation as being about them) may become understandably anxious; half-heard discussions and misunderstood terms are likely to compound anxieties. Touch is a major means of non-verbal communication, especially with disordered vision; touch deprivation is the most remembered deprivation in ICU (MacKellaig 1990), while overload of abnormal tactile sensations may be caused by: heavily starched (and sometimes patched) sheets (few nurses living in nurses’ accommodation tolerate them, yet expect patients to be comfortable) pulling from tubes/drains/leads oral endotracheal tubes endotracheal suction pressure area care Most touch in ICU remains task-orientated (Verity 1996a). Task-orientated touch is necessary, but reduces individuals to commodities, reinforcing their dehumanisation. Patients appreciate having their pillows turned and their head stroked in a comforting manner (affective touch). Affective touch is individual, and may become threatening (e.g. invading personal space; overload); as with any aspect of care it should be assessed. Factors such as culture and gender affect how touch is interpreted (Eastabrooks & Morse 1992); touching some body parts can suggest inappropriate intimacy (Lane 1989) or power (Davidhizer et al. 1995). Touching hands, forearms and shoulders is usually acceptable (Schoenhofer 1989). Massage offers valuable opportunities for developing qualitative touch (see Chapter 47), but spontaneous affective touch can rehumanise care. Few ICU patients receive oral diets, thus taste is limited to drugs (e.g. intravenous cephalosporins cause a metallic taste) and anything remaining in the mouth: blood vomit mucus mouth wash (reminiscent of dentists) toothpaste (difficult to rinse out with supine patients) thrush Air turbulence over four nasal conchae (or tubinates) exposes smells to olfactory chemoreceptors. Intubation largely bypasses this mechanism, but it remains intact and presumably functional, and so total absence should not be presumed. ICU smells are often abnormal: ‘hospital’ smells (disinfectant, diarrhoea, body fluids)  Sensory imbalance 17 human smells (perfume, body odours, cigarette smoke) putrefying wounds nasogastric feeds Reaching across patients (e.g. for thermometers or suction equipment) places the axilla near the patient’s nose. ‘Normal’ smells (e.g. food/drinks, entering through windows, ventilation systems or from bedsides) may reinforce perceptions of deprivation, while vitamin deficiencies can alter taste. Patient experiences Abnormal sensory inputs (both overload and deprivation) results in abnormal interpretation of environments; hallucinations, ‘ICU psychosis’, frequently occur (Mackellaig 1990). Psychological imbalance is twice as likely on ICUs as on general wards (Green 1996), and may remain undetected (Hopkinson & Freeman 1988). Hallucinations and psychosis are a form of psychological pain (stress), a response to a stimulus, and in humanistic nursing should receive similar attention to physiological pain. Responses depend on both reception (sensory stimuli) and perception (sensory transmission to, and interpretation by, higher centres). Hallucinations vary, often being vivid, and usually terrifying. Since Ashworth (1980), many authors have described patients’ experiences. Jones et al. (1994) record a range of hallucinations, many bizarre and horrific, from being in hell, trapped in fireplaces and buried alive, to being on a cross-channel ferry. Healthy adults suffering eight hours sensory deprivation can experience acute psychotic reactions, delusions and severe depression for several days, and anxiety for several weeks (Hudak et al. 1998)—the duration of one ‘traditional’ nursing shift. Understanding patients’ perceptions and interpretations is not always possible, but it can make sense of hallucinations and bizarre actions—for instance, lying on alternating mattresses may resemble cross channel ferries. Reported experiences often suggest profound fear; nurses (and other healthcare professionals) can appear as devils/tormentors, so that nurses attempting to explore fears or reassure patients may meet resistance. Stress response Stress, however initiated, causes physiological responses to enable ‘fight or flight’. Catecholamine release and sympathetic stimulation make circulation hyperdynamic: tachycardia vasoconstriction hypertension and so increase oxygen consumption. Neuroendocrine release includes catecholamines (primarily adrenaline; also nor adrenaline): as above  Intensive care nursing 18 cortisol (immunosuppression, impaired tissue healing) antidiuretic hormone: fluid retention, oedema (including pulmonary) growth hormone: anabolism (tissue repair) glucagon: hyperglycaemia (also peripheral insulin resistance from catecholamines) insulin. Sodium and water retention, with plasma extravasation, cause oedema formation (including pulmonary). Stress also activates intrinsic clotting pathways. Barrie-Shevlin (1987) describes classic studies in which healthy volunteers, exposed to sensory deprivation, experienced hallucinations, impaired intelligence and psychomotor skills, and body water and electrolyte imbalance. For critically ill (hypoxic) patients, these demands may exceed homeostatic reserves, provoking myocardial infarction or other crises; even moderate hyperglycaemia aggravates immunocompromise (Torpy & Chrousos 1997). Reticular activating system This dense cluster of neurons between the medulla and posterior part of the midbrain selects which stimuli reach the cerebral cortex, preventing overload and so maintaining internal balance (biorhythm). Repetitive, familiar or weak signals are filtered out, and so loud, but unimportant, sounds may remain unnoticed (e.g. constant heavy traffic). Quieter, meaningful noises may be noticed (parents sleeping through heavy traffic may waken with small noises from their children). As the reticular activating system filters out progressively more, or receives progressively fewer/abnormal sensory stimuli, the cortex attempts to rationalise remaining stimuli, resulting in hallucinations and progressively disorganised behaviour. Reticular activating system function can be altered by: reduced sensory input relevance deprivation repetitive stimulation unconsciousness (O’Shea 1997) All may occur in ICU. The reasons behind nursing actions may appear mysterious to many patients (relevance deprivation), and explanations can reduce anxiety and psychological (and so physical) pain (Hayward 1975). (Meaningless stimuli and the enforcement of meaningless petty rules are often used in torture procedures (Dyer 1995).) Reality orientation can be useful, but may provoke aggression (most people react negatively to being contradicted). Repetitive stimulation can make actions appear meaningless and irritating. Patients often quickly forget so that nurses should not assume patients will remember rationales given previously. Environmental stimuli can also become annoyingly repetitive (e.g. flickering lights). Ashworth (1980) describes one patient interpreting a monitor as fluorescent light displays in Piccadilly Circus. Alarms are deliberately irritating (to nurses) to ensure prompt response; patients’ responses vary (from fearing something is wrong to using alarms to control attention), but the purposes of alarms should be  Sensory imbalance 19 explained to patients and families, and the parameters selected should balance safety against stress. Reticular activating system dysfunction may cause failure to filter out stimuli, bombarding the cortex with excessive, often meaningless, inputs. Sensory filters can be removed by drugs (e.g. lysergic acid (LSD), Ecstasy; see Chapter 41), causing sensory overload (‘psychedelic’ effects); sensory overload in ICU may result from dysfunction through critical illness. Sleep The purpose of sleep remains unclear; Canavan (1984) observes that some people sleep little without consequent impairment, alluding obscurely to one (unidentified) author’s suggestion that sleep is merely an instinct. Most literature suggests sleep is restorative (physically and psychologically), although precise benefits from each stage remain disputed, and (cerebral) hypoperfusion may limit applicability of information from sleep research on healthy volunteers to ICU patients (Turnock 1990). Sleep patterns vary widely, most people sleeping 6–9 hours each night (Atkinson et al. 1996), although the amount of sleep required usually decreases with age (Canavan 1984). Each patient’s normal sleep pattern should therefore be individually assessed. Sleep cycles are controlled by the suprachiasmatic nucleus (‘biological clock’) in the hypothalamus, which regu-lates the preoptic nucleus (sleep-inducing centre). Precise mechanisms of sleep remain debated; theories of passive control by the reticular activating system have been largely discounted in favour of active inhibitory hormone control (Guyton & Hall 1997), especially by serotonin. Other hormonal changes with sleep include: melatonin increases twentyfold overnight (production is suppressed by light) most growth hormone is produced during stages 3 and 4, or orthodox sleep (Lee & Stotts 1990); this stimulates protein anabolism, contributing to tissue repair most ACTH is produced overnight ADH increases overnight (until 4 a.m.), concentrating urine (hence the value of early morning urine samples Hormone changes regulate circadian rhythm (below, p.27). Full sleep usually consists of 4–5 cycles, each lasting about 90 minutes (Hodgson 1991). Each cycle consists of a number of stages. Terminology varies, but most authors identify two main parts: orthodox or non-REM sleep paradoxical or REM sleep Orthodox (non-REM) sleep Names, length and function of sleep stages vary; McGonigal’s (1986) influential description is followed here. Timings of stages vary between individuals and over  Intensive care nursing 20 subsequent sleep cycles. McGonigal (1986) describes orthodox (non-rapid eye movement, slow-wave) sleep as having four stages (see Table 3.1). Orthodox sleep reduces metabolism, respiration, heart rate (Atkinson et al. 1996), and so oxygen demand. Whether orthodox sleep achieves emotional healing (Evans & French 1995), protein synthesis, physical restoration and leucocyte production (Krachman et al. 1995) is disputed, but deprivation causes a stress response (Krachman et al. 1995), reduced pain tolerance and central nervous system exhaustion (Lee & Stotts 1990). Dreams during Table 3.1 Stages of sleep Stage Duration Description 1 few minutes aware of surroundings; muscle jerking 2 15–20 sleep becoming deeper; oblivious of surroundings, but remains easily minutes aroused 3 15–20 progressively deeper minutes 4 10–20 deep sleep minutes Source: After McGonigal 1986 orthodox sleep are usually realistic, resembling thought processes (Turnock 1990), and often forgotten on waking (Guyton & Hall 1997). The duration of stage 4 reduces steadily from birth, and often disappears altogether by about 60 years of age, contributing to poor sleep and muscle atrophy in older people. Paradoxical (REM) sleep As cerebral metabolism (and oxygen consumption) increases, EEG patterns reflect consciousness (McGonigal 1986), hence ‘paradoxical’. Paradoxical sleep has two stages: initial rapid eye movement (REM) and muscle twitching gives way to profound muscle relaxation (McGonigal 1986). Dreams during REM sleep are often dramatic, emotional and illogical (Turnock 1990; Atkinson et al. 1996), being remembered only if interrupted (Atkinson et al. 1996). Arousal level varies (Krachman et al. 1995), but disturbing someone after one hour’s sleep probably interrupts REM dreams, causing mental frustration; frequent recall of illogical dreams may contribute to emotional instability and personality disorders (Marieb 1995). If woken during paradoxical sleep, the person returns to stages 1 and 2 orthodox sleep, thus being deprived of the later stages. Sleep deprivation may impair tissue repair (Krachman et al. 1995), although Landis and Witney’s (1997) animal study found skin healing unimpaired after 72 hours sleep deprivation. Paradoxical sleep occupies about one-half of an infant’s sleep cycles, but by adulthood forms only about one-fifth of total sleep (Atkinson et al. 1996). Overnight paradoxical  Sensory imbalance 21 sleep progressively replaces stage 4 orthodox sleep (Guyton & Hall 1997), providing mental restoration. Topf and Davies (1993) found significant deprivation of REM sleep occurred in patients in intensive care. Sleep disturbance Orthodox stages 3 and 4, and REM sleep are seriously disturbed or absent following major surgery (Aurrell & Elmqvist 1985) and presumably any critical illness. Exogenous factors can also disturb sleep, including pain (ibid.) and noise. Whenever possible, clustering nursing actions to minimise physical disturbance can help to ensure undisturbed stretches of 2 hours (one sleep cycle). Barrie-Shevlin (1987) cites classic studies showing that two-fifths of ICU nurses failed to distinguish non-essential from essential tasks between 10 p.m. and 6 a.m., and that some critically ill patients slept for only 2.6 hours in a day. Awareness of the need for sleep has increased, and lights are now usually dimmed overnight to maintain circadian rhythm, but commencing nursing activities early each morning (e.g. 6 a.m.) may deprive patients of their final sleep cycle (Davis et al. 1997; Cureton-Lane & Fontaine 1997). One of the most valuable nursing interventions at night is usually to allow patients to sleep. Family and close friends may also suffer sleep deprivation from prolonged overnight vigils (Hodgson 1991); nurses should encourage visitors to get adequate sleep. Daytime sleep Sleep patterns alter during the day, although generally the quality of daytime sleep is poorer than night sleep (Wood 1993). Morning sleep contains more orthodox stage 4 and REM than afternoon sleep (Turnock 1990), making morning sleep more useful for patients with head injuries, while increased stages 3 and 4 during afternoon/evening sleep assists wound healing (e.g. after surgery or myocardial infarction (MI)). Since the length of stage 2 sleep increases during daytime, less daytime sleep provides less tissue recovery than night-time sleep (Turnock 1990). Although not usually identified in literature, nightwork may alter hormone and sleep patterns; individual assessment of patients’ normal patterns will help nurses to plan appropriate individualised care (e.g. maintaining daytime sleep patterns for permanent night workers). Circadian rhythm Circadian rhythm (change in body function over a day) is individual to each person, with slight variations normal between each day; however critical illness and abnormal environments (ICU) can severely disrupt the circadian rhythm. Times and figures given here are ‘averages’, and should be treated as guides rather than absolutes. The circadian cycle usually peaks at about 6 p.m. and ebbs between 3 a.m. and 6 a.m. (Clancy & McVicar 1995). Since most nurses working night duties experience the ebb  Intensive care nursing 22 stage, high-risk actions (such as extubation) should be avoided during this period when they and their colleagues are likely to be least efficient. The release of catecholamine peaks around 6 a.m. (Todd 1997) causing sympathetic stimulation (including increased heart rate and vasoconstriction) in preparation for increased physical activity. The risk of myocardial infarctions and strokes is therefore increased between 6 a.m. and 10 a.m. (Todd 1997). Early morning stimulation (e.g. washes, physiotherapy) are best avoided with vulnerable patients. Reduced peripheral circulation may cause ischaemia (‘night cramps’); assessment should identify whether patients normally suffer from night cramps, and what they do for relief. Circadian rhythm adapts to environments; dimming lights can mimic day/night cycles, but ‘dimmed’ lighting often exceeds levels most nurses would choose for their own bedrooms at night. Night-time environments should generally be as dark as is safely possible. Daylight, rather than artificial light, helps psychological wellbeing, so fluorescent lighting is a poor substitute for lack of windows. Drug benefits may be increased by coinciding with circadian rhythm (chronotherapy); leucocyte count peaks and bacterial reproduction ebb make once daily antibiotics most effective in the early morning. Other ‘natural’ body rhythms may also exist. For example, seasonal affective disorder (SAD) (Ford 1992) affects emotions, causing more depression and suicides during winter. Noise Noise (undesired sound) is subjective: what is useful or enjoyable for one person can annoy others (e.g. overloud ‘personal’ cassettes). Noise impairs both quality and quantity of sleep (Topf et al. 1996). ICUs are noisy; much noise is unavoidable, inevitably continuing overnight. However, ‘unnecessary noise is the most cruel absence of care which can be inflicted on either sick or well’ (Nightingale 1980:5); nurses should actively seek to reduce unnecessary noise. Physical pain results at levels from 130 decibels (dB); while equipment and interventions in ICU rarely reach this level, they constantly exceed the International Noise Council’s recommended upper limit of 45 dB for ICU during daytime and 20 dB overnight (Granberg et al. 1996), and often exceed the UK upper legal limit of 85 dB for noise at work. Reading et al. (1977) measured 71 dB from cardiac alarms ten feet away, 70 dB from endotracheal suction and 68 dB from physicians talking fifteen feet away (further than distances between most ICU beds). Studies consistently show staff conversation (potentially reaching 90 dB) as a major cause of ICU noise (Kam et al. 1994). Even whispers usually cause 30 dB, enough to disturb sleep (Wood 1993), and exceeding the International Noise Council’s night-time limit of 20 dB. Conversation cannot be avoided, and appropriate conversation can benefit patients, but volume, tone and pitch of speech vary between individuals, and nurses coordinating care should ensure that both content and timing of conversation is appropriate.  Sensory imbalance 23 Suction catheters (with vacuum running) under pillows places noise near patients’ ears; suction units are also usually near patients’ heads. Suction should therefore normally be switched off when not in use. Environmental noise combines all these (and other) activities. Citing 1977 material, Krachman et al. (1995) suggest that total ICU noise levels range from 53 dB (day average) to 42.5 dB (night average). Recent measurements are higher: 61.3–100.9 dB (McLaughlin et al. 1996), 84.8 dB (day) and 79.9 dB (night) (Meyer et al. 1994), and 55 dB on a paediatric ICU (Lane and Fontaine 1992). An average quiet bedroom at home might measure 20–30 dB overnight (Krachman et al. 1995). Sound and interruption levels on ICU are severely disruptive, preventing patients from maintaining normal circadian and sleep cycles (Meyer et al. 1994). Children have fewer coping mechanisms than adults (Bood 1996) and so may be more susceptible to disturbed sleep. Scothern et al. (1992) found that nearly one-quarter of mothers reported anxiety and phobias among children for three months after discharge from (general) ICUs. Childrens’ normal circadian rhythm and psychological health may be helped by play, an essential need during prolonged admissions (Palmer 1996), but adult nurses are often less able than paediatric nurses to meet children’s play and other needs, and may have less access to play therapists. Music Sensory inputs can be pathways for pleasure. Music therapy can be positively developed in ICU, reducing heart rate and pain (O’Sullivan 1991; Zimmerman et al. 1996), although haemodynamic effects may be minimal (Coughlan 1994). Music should: reflect the patients’ choices (rather than staff’s) use comfortable volume levels (this varies between individuals, choosing the right level for someone unable to speak can be problematic) include prompt side changes (especially if single pieces last more than one side of the tape) be varied rather than repeated allow rest periods (especially if using headphones, which can quickly become uncomfortable) Memories of ICU Dyer (1995) compares many ICU nursing actions with Amnesty International’s categories of torture (see Chapter 1). ICU is only one episode in a patient’s healthcare needs, but can cause significant residual complications; follow-up clinics and studies can identify/resolve problems for individual patients, while gathering valuable information to develop practice. (For instance, abdominal girth measurements may be misinterpreted as coffin measurements (Waldmann & Gaine 1996)). Transfer from ICU can increase psychological stress, and so introducing liaison nurses can facilitate discharge planning  Intensive care nursing 24 (Hall-Smith et al. 1997), although significant numbers of ‘mild to moderate’ problems may remain unresolved, some necessitating referral to mental health teams (Daffurn et al. 1994). Post-discharge support may include: follow-up clinics discharge liaison nurses inviting patients to return or telephone the unit While potentially easing psychological trauma, nurses should be confident that they have the knowledge and skills needed to provide adequate support, including providing psychologically ‘safe’ environments (confidentiality, privacy) and meeting local ethical requirements; unit managers should be able to guide staff on such issues. Implications for practice sensory imbalance is a symptom of psychological pain, provoking a stress response; alleviating pain provides both humanitarian and physiological benefits, so should be fundamental to nursing assessment and care monitors should be sited unobtrusively facilitating sleep is usually the nurse’s most important role overnight sleep is individual, so each patient’s normal sleep pattern should be assessed whenever possible, planned care should include 4 sleep cycles, each lasting at least 90 minutes (patients remaining undisturbed during this time) circadian rhythm can be facilitated through daylight, interesting views and, overnight, by dimming lights as much as is safely possible relatives should be encouraged to participate in care, and encouraged to share news and use touch. They should not be made to feel guilty or exhausted. Open visiting, facilities and information can give relatives much-needed support patients should be offered psychological support following ICU discharge information gained from post-discharge surveys can valuably develop practice continuing education raises staff awareness of sensory imbalance Summary Sensory imbalance includes both sensory overload and sensory deprivation. Maintaining sensory balance helps to maintain psychological health and reduces complications from stress responses. Many factors contribute to sensory imbalance, including sleep deprivation (quality or quantity) and noise. Nurses should assess each individual patient’s needs; while safety and physiological needs of critically ill patients necessarily compromise psychological care, nurses can humanise even the most technological environments.  Sensory imbalance 25 Further Reading Much has been written on sensory imbalance: West (1996) and Granberg et al. (1996) offer reliable and recent overviews; Barrie-Shevlin’s (1987) classic paper remains useful. Detrimental physiological effects of stress are described by Torpy and Chrousos (1997). Dyer (1995) is valuably provocative. Jones et al. (1994), Waldmann and Gaine (1996) and Green (1996) offer insights from post-discharge interviews/clinics. Clinical scenario Edward Creighton is a 20-year-old university student admitted with bacterial meningitis. He has a fever of 39.2°C, a variable level of consciousness with deteriorating respiratory function, which has necessitated intubation and ventilation. He is sedated, paralysed and given intravenous antibiotics (Cefotaxime 2 g, 8 hourly). This is Edward’s first ever hospital admission. Q.1 Examine the structure of current sensory/psychological assessment used in your clinical practice area. Does this structure allow for documentation or give a scale rating of patient’s psychological risk factors; previous history, time on ICU, prescribed drugs that may adversely effect cognition, memory, sleep, etc. Q.2 Identify Edward’s risk factors and potential for developing ICU psychosis. How can these risks be minimised? Edward recovers, but may be left with some long-term neurological complications (e.g. deafness, visual and behavioural disorders) from bacterial meningitis and psychological imbalances from his ICU experience. Q.3 Evaluate strategies which ICU nurses can implement to help Edward understand and transcend his residual sensory imbalances (e.g. referral to specialists, follow up ICU visits and use of discharge clinics, etc.).  Chapter 4 Artificial ventilation Fundamental knowledge Respiratory physiology Normal (negative pressure) breathing Dead space Normal lung volumes Experience of nursing ventilated patients Introduction Intensive care units developed from respiratory units: the provision of mechanical ventilation, and thus the care of ventilated patients, is fundamental to intensive care nursing. In this chapter a brief revision of nursing care is given. Nurses should have a safe working knowledge of whichever ventilators they use— manufacturers’ literature and company representatives are usually the best source for this. This chapter discusses the main components of ventilation (tidal volume, I:E ratio) and the more commonly used modes. Additional ventilatory options are discussed in Chapter 29. Since negative pressure ventilation is rarely used in ICUs, it is not discussed in this book. The chapter ends by identifying the complication of positive pressure ventilation on other body systems. The UK terminology of ‘ventilator’ is used throughout the chapter, although outside the UK other terms, such as ‘respirator’, may be used; ‘respiration’ is used wherever possible for self-ventilating breaths and ‘ventilation’ for mechanically initiated breaths. Artificial ventilation should meet physiological deficits (metabolic oxygen demand and carbon dioxide elimination). Early positive pressure ventilators were simple and basic—driven by gas or electrical bellows, delivering gas at a set rate (time), volume or pressure—and so ventilators were classified as: time cycled volume cycled pressure cycled Although these terms are still used, modern ICU ventilators (e.g. Servo® 300, Puritan- Bennett® 7200ae) are arguably too sophisticated for such crude categories: when controlled minute volume (CMV; volume-cycling) modes are used, upper pressure limits are normally set (pressure-cycling). These terms are therefore not used here, but readers should be aware of their existence and meanings. Oxygenation relies on functional alveolar surface area, so is determined by  Artificial ventilation 27 mean airway pressure inspiration time PEEP FiO 2 pulmonary blood flow. Carbon dioxide removal requires active tidal ventilation and so is affected by inspiratory pressure tidal volumes expiratory time. Manipulating these factors can optimise ventilation while minimising complications. Normal adult alveolar ventilation is about four litres each minute; normal cardiac output is about five litres each minute. This creates a ventilation:perfusion (V/Q) ratio of 4:5, or 0.8 (Pierce 1995). Perfusion without ventilation is called a shunt. Shunting can also occur at tissue level (reduced oxygen extraction ratio, see Chapter 20). Care of ventilated patient The care of ventilated patients should be holistic—the sum of many chapters in this book, especially in Part I. This chapter identifies only those aspects specifically related to ventilation. Artificial ventilation causes potential problems with: safety replacing normal functions system complications Ventilated patients have respiratory failure, so ventilator failure or disconnection may be fatal. Modern ventilators include alarms and default settings, but each nurse should check, and where appropriate reset, alarm limits for each patient; Pierce (1995) recommends a ‘rule of thumb’ margin of 10 per cent for alarm settings. Alarms do not replace the need for nursing observation. Alarms may fail and so nurses should observe ventilated patients both aurally and visually. This necessitates appropriate layout of bed areas to minimise the need for nurses t