Stress of any type—whether positive or negative, biological, psychological, or social—elicits the same physical responses.1 Extensive literature exists describing the relationship between mind-body interactions and the immune response to stress. All personal resources can be depleted by exposure to severe or prolonged stress. Several studies have shown the effects of life events such as an acute illness that is perceived to be a threat to personal integrity.^2–4 The effects of an illness that requires hospitalization can be further compounded if admission to an intensive care unit (ICU) becomes necessary.

The ICU environment can be frightening. Technological equipment can control one’s breathing and prevent speaking. Invasive procedures, abrupt or continual noises, loss of privacy, sleep interruptions, pain, medications, isolation, and minimal contact with significant support people all create feelings of powerlessness and loss of control. Disorientation, which is common for patients in the ICU, is influenced by several factors, including the severity of the physical problem, chemical imbalances, sensory overload or deprivation, and previous experiences with the health care system. In addition to these factors are personal variables such as biological factors, social roles, and the individual’s emotional responses of anxiety, confusion, or depression.^1–3 However, for some people, the ICU is perceived as a safe environment where life-saving procedures are immediately at hand and administered by highly competent caregivers.

Precipitating stressors may arise from the individual’s internal or external environment; adaptation may depend on the number of stressors and the timing of their occurrence, as well as the degree of change that is represented. See Box 4-1 for a listing of stressors in the critical care unit. The accumulation of daily hassles can often influence a person’s response to a major stressor. Personal characteristics that facilitate constructive adaptation to stress include hardiness, resilience, hope, a positive self-concept and internal locus of control, a sense of belonging, and the presence of social support.^5–7 Use of maladaptive or destructive measures may temporarily minimize anxiety but do not resolve the personal conflicts. There are four stages of nursing activities: (1) stabilizing the patient in a time of crisis, (2) providing symptomatic relief and assessment of the patient’s coping responses, (3) reinforcing adaptive behaviors and improved patient functioning, and (4) implementing strategies for health promotion and optimal quality of life.

Anxiety is a normal subjective human response to a perceived or actual threat to self-integrity, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. Anxiety is the most common of all mental illnesses.8 Symptoms of anxiety closely parallel the biological stress responses described earlier. The initial emotional responses of excitement and heightened awareness diminish as anxiety levels increase, the individual’s perceptual field narrows, and problem-solving and coping skills are lost. Prolonged stress can exhaust available resources.

A cyclic relationship exists between levels of anxiety and perceptions and tolerance of pain. This relationship varies according to whether pain is produced by disease processes or invasive procedures, is acute or chronic, or is anticipatory. Pain affects the whole person. It has been defined as “an unpleasant sensory and emotional experience associated with actual and potential damage, or described in terms of such damage.”9 Pain is also multidimensional in nature, necessitating comprehensive assessment and management. In conditions of high acuity, pain can be caused by a variety of factors, such as injured tissues, imposed immobility, intubation, lighting, noise, and interrupted sleep.

When an illness or pain is severe enough, the person experiencing it is forced to conserve all energies and focus inward to gain control of anxiety feelings. He or she may startle easily, become irritable, display anger and rage, be vigilant and wary of caregivers, or be demanding. There is a tendency to blame others, to be confused, and to be indecisive. The patient may withdraw from interpersonal contact and may indicate that the situation is overwhelming.^8,10 It is crucial for the nurse to identify the cause of the patient’s pain, validate observations with the patient, and identify a plan for pain management. (For detailed information on pain management, see Chapter 8.)

Once pain management has been addressed, the nurse evaluates for ongoing anxiety. Again, the nurse needs to identify the cause of a patient’s anxiety and to validate observations with the patient. Medications frequently administered in the ICU can contribute to feelings of anxiety; they include theophylline, anticholinergics, dopamine, levodopa, salicylates, and steroids.^8,9,11 Whether the causes of anxiety are biochemically induced, related to genetic factors, or secondary to a threat imposed in an emergency or a crisis situation, the nurse must take all factors into consideration for interventions to be effective. Panic attacks (outcomes of severe anxiety), which are frequent occurrences in the ICU, can also produce physiological symptoms such as tachycardia, hyperventilation, and dyspnea.¹⁰

Powerlessness, as a nursing diagnosis, is defined as the perception of the individual that his or her own actions will not significantly affect an outcome.12 Unrelieved powerlessness may result in hopelessness, which is discussed in the next section.

The causes of powerlessness include factors in the health care environment, interpersonal interactions, cultural and religious beliefs, illness-related regimen, and a lifestyle of helplessness. The range in levels of powerlessness varies and depends on the person’s perceived sense of control, the amount of loss experienced, and the availability of social support. Powerlessness can be manifested by delayed decision making or refusal to make decisions or by expressions of self-doubt in role performance. Frustration, anger, and resentment over being dependent on others often occur and are exhibited as verbal expressions regarding dissatisfaction with care.¹³

Individuals vary in the amount of control they prefer.¹⁴ The routines of the critical care unit may oppose or preclude any control by the patient. The person for whom control is important should be helped to continue to control as many areas of his or her life as possible. On the other hand, a patient must be given the opportunity to choose not to control.

Critically ill patients generally have experienced a rapid onset of illness without having had time to acquire the illness role. If control is defined as the ability to determine the use of time, space, and resources, admission to a critical care unit strips away this power. On admission, persons lose their independent status. They become patients. Choice of clothing and use of other personal belongings are usually restricted in a critical care unit. Patients cannot decide who enters the room, who provides personal care, or who intrudes with painful treatments. Hospital rules are usually not open to modification. Patients may feel anxious because they are separated from a familiar environment and have restrictions on who may visit them.

Poor interactions with health care providers can make the situation worse. Patients may react aggressively, may try bargaining, or may refuse to comply with diagnostic and treatment regimens. They may resent the close scrutiny of the nurses and physicians and the invasion of their privacy. By virtue of their experiences with critical illness and care, people may lose sight of areas of influence they still do retain over themselves because so much control has been taken from them. Nurses can emphasize the patient’s influence or control and thereby help to preserve it.^13,15

Hopelessness is a subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on his or her own behalf.12 To help clarify hopelessness, the following definition of hope is included: a feeling that provides comfort while enduring life threats and personal challenges; a feeling that what is wanted will happen; a desire that is accompanied by anticipation or expectation. Most people agree that an element of hope must be maintained, no matter how hopeless things appear. Hope is a force that helps one survive.^16,17 An interdisciplinary concept analysis of hope and hopelessness in the literature from theology, medicine, nursing, and psychology revealed that absolute hopelessness is viewed as incompatible with life. Hope often arises in the presence of crisis and instills vigorous resistance to giving up. The help of others in the situation supports the patient’s belief.^5,15 Hope wards off despair, mental anguish, disorganization, and helplessness.¹⁷ When people expect something to happen, they usually act in ways that increase the likelihood that the expectation will be met.¹⁸ The expectation, whether positive or negative, becomes stronger the more times the “reinforcing circle” occurs. This process is defined as a self-fulfilling prophecy.

The critically ill patient is a multiproblem patient. Nurses and physicians are tempted to focus on the crisis and the use of technical equipment and to overlook the patient in his or her totality. The health care team may stereotype patients and underestimate their individual strengths.^19,20 The very nature of the critical care unit is frightening and increases a patient’s sense of vulnerability and fear of death. Therefore, it is important to foster a realistic sense of hope in the patient.^12,21 The critical care nurse can project an attitude of hope; identify some aspect of the situation in which hope is warranted, no matter how grave the situation; and attempt to channel feelings toward some positive outcome.

When the situation moves from hopeful to hopeless in the critical care unit, the decision to write a do-not-resuscitate order must be carefully considered.^22,23 It must be recognized that members of the health care team and the family may reach this decision at varying times.^24,25 However, it is important to not avoid difficult conversations and to keep patients and families informed. Careful medical and nursing assessments, use of family and team conferences to foster communication, and enlisting the assistance of a spiritual counselor can make these situations less frustrating for all concerned.

Families also need hope. Nursing strategies for supporting the family include clarifying any distorted thinking, providing opportunities for the family to be with the patient, presenting realistic patient outcome expectations, and expanding the coping repertoire of the family.^22–24,26 See Box 4-2 for additional strategies.

Spiritual distress has been defined as a disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biological and psychosocial nature.12 Adherence to a particular philosophical, psychological, sociological, or political belief may provide a sense of one’s value and of life’s meaning. Threats imposed by any physiological or psychological illness or prolonged pain and suffering can challenge a person’s spirituality.²⁷ Life-threatening illness causes a person to face his or her own mortality. The provision of holistic nursing care is not limited to meeting a patient’s religious needs; it also encompasses all that provides meaning to life.

An individual who is in spiritual distress may question the meaning of suffering and death in relation to his or her personal belief system. Anger toward God or a supreme being, feelings of self-blame, or regret over inability to practice belief rituals may be expressed. Individuals may even question the necessity for the therapeutic regimen. Spiritual care has been described as health-promoting interventions to relieve responses to stress that affect the spiritual perspectives of individuals or groups.¹² Creating an environment of compassion in which patients feel that their emotional and spiritual needs are met is at the heart of holistic care.²⁸ Listening to the patient’s concerns, offering support, and enlisting the support of a spiritual counselor can promote the healing process.

A major depressive episode is a mood disorder of at least two weeks’ duration that is characterized by depressed mood, diminished interest or pleasure in usual activities, insomnia, poor appetite, psychomotor retardation or agitation, and loss of energy. Patients with this disorder also may report feelings of hopelessness, worthlessness, and guilt. Recurrent thoughts of death, loss of interest in life, and recurrent suicidal ideation may be present.29 Major depression may complicate a patient’s underlying physical illnesses; for example, asthma, headaches, ulcers, arthritis, or coronary heart disease may be exacerbated to the point of a life-threatening situation.^10,29 Depression deepens and suicide ideation frequently resurfaces after surgery if a life-threatening diagnosis is confirmed.

The nurse can listen empathetically and convey to the patient that recovery from the depression is expected, while understanding that the patient’s depression cannot be overcome by cheerfulness or reassurance. If the patient is on suicide precautions, the nurse safeguards the patient according to department policy and procedure and alerts all members of the health care team and the family. The nurse also informs the patient that precaution measures are being taken as a safeguard until his or her mood improves. Requesting a comprehensive mental health assessment by a mental health professional would provide the means for giving proper attention to the patient’s mind-body experience.

Depression is a causal factor in 30% to 70% of suicide attempts among the high-risk groups of youth (ages 15 to 24 years), the elderly population (>65 years), and individuals with psychiatric disorders. Suicide has been described as a self-destructive response to a stimulus resulting from an undesirable, unacceptable, or overwhelming event; as a response to overcome high anxiety feelings about abandonment by God or significant others; as a hostility toward self; and as the only solution for ending a helpless or hopeless situation. Nurses in high acuity and emergency settings will be challenged by patients who have attempted suicide or are at risk for doing so. Persons with cognitive impairment resulting from delirium effects of medications, fluid and electrolyte imbalances, anoxia, surgery, or trauma are at greatest risk for attempting suicide. Hallucinations may compel their self-destructive behavior.30 A primary focus for care of the person with self-destructive behavior is protection from harm.^10,30,31 Nurses also must consider their own responses to patients’ self-destructive behaviors, which can enhance or inhibit their interactions with patients. Interventions may include removal of harmful objects; consistent supervision; active listening; contracting with the individual to cease harmful activities; promoting the person’s self-esteem and self-control in regulating emotions and behaviors, which frequently includes administering anxiolytic medications and mobilizing social support systems; and providing mental health education.

Patients who require critical care must cope with a variety of stressors (Box 4-1). Each patient’s response to these stressors is unique and depends on a variety of environmental factors and individual differences. The nurse’s knowledge of assessment, diagnosis, and effective coping strategies also affects how well the patient copes. The uncomfortable effects of a situation (e.g., anxiety, grief, loss of control) can lessen the effectiveness of coping mechanisms when people are faced with serious problems that they cannot overcome using familiar behaviors.

Coping is a dynamic process involving cognitive and behavioral efforts to manage specific internal or external demands that are perceived to exceed the person’s resources.^32,33 Aguilera³⁴ states that coping activities encompass all the diverse behaviors that people use to meet actual or potential demands. The available coping mechanisms are those behaviors that a person draws on that have been found to be effective in the past. The key to effective coping is using the best strategy or mix of strategies in a given situation.