Psychosocial Aspects of Critical Care

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CHAPTER 10

Psychosocial Aspects of Critical Care

SYSTEMWIDE ELEMENTS

Psychosocial Considerations

1. Scope of critical care nursing practice

a. “The scope of practice for acute and critical care nursing is defined by the dynamic interaction of the acutely and critically ill patient, the acute or critical care nurse and the health care environment” (American Association of Critical-Care Nurses [AACN], 2000, p. 2) (Figure 10-1)

b. Critical illness is a crisis for both the patient and family members. This crisis situation can present numerous, oftentimes complex psychosocial issues and problems that require the expertise of the critical care nurse working collaboratively with the multidisciplinary team. The crisis of a critical illness may be superimposed on other chronic stressors (e.g., addiction).

c. Needs or characteristics of the patient and family influence and drive the characteristics or competencies of the critical care nurse (AACN, 2003)

d. Challenges of meeting psychosocial needs

i. Other conflicting priorities such as addressing the physiologic instability of the patient may preclude or inhibit nurses from meeting the psychosocial needs of the patient and family

ii. Psychosocial needs often involve family members (an aspect unique to psychosocial needs in contrast to physiologic needs); for example, issues such as grief and loss, and powerlessness may pertain more to the family than to the patient in some situations (e.g., brain-dead patient)

iii. Value systems in critical care units often emphasize performing nursing tasks over attending to the psychosocial needs of the patient and family

iv. Meeting psychosocial needs demands a coordinated, multidisciplinary approach to care

v. Critical care environment is often a barrier to effectively meeting psychosocial needs

vi. Growing evidence supports an interrelationship between psychosocial and physiologic problems (e.g., stress and immunity)

e. Patient

f. Family

g. Critical care nurse

h. Critical care team

i. Critical care environment (interaction among elements—hence complexity)

2. Common elements

a. Life cycle

b. Needs of the patient

c. Family issues

i. Family system theories

ii. Family systems

iii. Caregiver issues

d. Critical care environment

i. Can directly affect the ability to meet a patient’s needs, including the need for rest and sleep (e.g., lack of doors on patient rooms, fluorescent overbed lighting, etc.).

ii. Staff awareness and behaviors also can have a profound effect on modifying environmental influences that affect the patient.

iii. Unusual patterns of light and noise, together with the constant activity of a critical care unit, alter the patient’s biologic rhythms and may negatively affect patient outcomes (Jastremski and Harvey, 1998)

iv. Environmental factors may lead to sensory overstimulation or sensory deprivation

v. Strategies for creating a healing environment: See Box 10-1

e. Stress

i. Definition: Condition that exists in an organism when it encounters stimuli (Selye, 1974)

ii. Critical illness is a stressful situation. Directed interventions by the nurse can lessen stress and/or the impact of stress on the patient and family. Nursing presence and the anticipation of patient needs have been reported to be associated with less stressful critical care experiences (Holland, Cason, and Prater, 1997; Pettigrew, 1990).

iii. Selye (1974) identified two types of stress

iv. Common psychologic stressors for critically ill patients and their families

v. Response to stress

Patient and Family Psychosocial Assessment

1. Nursing history

a. Patient history

b. Family history: Family assessment data obtained on admission or as soon as possible

2. Nursing examination of patient

3. Appraisal of patient characteristics: Almost all patients with a critical illness experience some psychosocial issues during the course of their illness. However, each patient and family is unique and brings a unique set of characteristics to the care situation (Hardin and Kaplow, 2005). Examples of characteristics of patients and family that the nurses need to assess include the following:

a. Resiliency

i. Level 1—Minimally resilient: A 52-year-old divorced woman who has attempted suicide via drug overdose on three previous occasions is admitted with a nonlethal self-inflicted gunshot wound to the head

ii. Level 3—Moderately resilient: A 23-year-old man with a 9-year history of “problem drinking,” stabilized after chest trauma suffered in an alcohol-related automobile accident, is being prepared for transfer to a military hospital where he will receive extended treatment for alcohol abuse

iii. Level 5—Highly resilient: A healthy 21-year-old female college student with a 3.9 grade point average comes to the emergency department exhibiting multiple abrasions and unruly, belligerent, and delirious behavior after attending her first “spring breakout celebration,” which included drinking, some drug experimenting, and falling off the roof of a moving car

b. Vulnerability

i. Level 1—Highly vulnerable: A malnourished 9-year-old child who has been a victim of child abuse since birth is recovering from his most recent “fall down the stairs” and is scheduled for discharge home the next day

ii. Level 3—Moderately vulnerable: An extremely overweight 37-year-old woman admits to feeling “even more depressed” following her unsuccessful suicide attempt. Numerous diets, pills, and plans have not worked, and her primary physician relates that she does not meet the criteria for surgical treatment of morbid obesity.

iii. Level 5—Minimally vulnerable: A 44-year-old single father, admitted for monitoring overnight subsequent to an automobile crash in which he was cited for aggressive driving, relates that since his recent divorce, he occasionally has had episodes when his anger quickly escalates to violent behaviors. He fears “taking it out” on his two sons.

c. Stability

d. Complexity

i. Level 1—Highly complex: An 89-year-old man is experiencing liver failure secondary to the ingestion of 200 acetaminophen tablets following the death of his wife. Patient has multiple medical problems, including lung cancer. He stated in his suicide note that he “is tired” and wants to be with his wife. Family is adamant that everything be done to save his life.

ii. Level 3—Moderately complex: A 60-year-old patient with amyotrophic lateral sclerosis develops acute respiratory failure while in the ICU. Patient has already stated he does not desire mechanical ventilation to prolong life. Family is supportive of the patient’s wishes.

iii. Level 5—Minimally complex: A 50-year-old woman in the ICU for the management of gastrointestinal bleeding secondary to nonsteroidal antiinflammatory use develops delirium after receiving sedatives

e. Resource availability

i. Level 1—Few resources: A 40-year-old homeless man is admitted to the ICU after attempted suicide by gunshot to the head. No patient identification is available.

ii. Level 3—Moderate resources: An 83-year-old woman is admitted from a local nursing home to the ICU with possible urosepsis. Patient’s family has been paying out of pocket for the nursing home but says “the money is almost gone.”

iii. Level 5—Many resources: A 60-year-old computer executive develops delirium tremens 4 days after undergoing elective hip surgery. Family is very supportive and confident the patient would be concerned if he realized how his drinking (three to four glasses of wine per day) had affected him. Patient has excellent insurance coverage for both inpatient care and outpatient substance abuse treatment.

f. Participation in care

g. Participation in decision making

h. Predictability

4. Diagnostic studies

Psychosocial Care Issues

1. Interdependence—Many of the psychosocial issues and concerns of the critically ill patient are interdependent. For example, inadequately managed pain may lead to feelings of powerlessness, anxiety, and depression that, in turn, heighten the patient’s perception of pain (Figure 10-2).

2. Powerlessness

a. Description of problem

b. Goals of care

c. Collaborating professionals on health care team

d. Interventions

i. Promote patient-nurse communication

ii. Involve the patient and family in the care planning process and decision making

iii. Encourage the patient and family members to meet with spiritual support persons if they would find this helpful

iv. Prepare the patient for procedures: Explain what will be happening, when it will happen, and how the patient will be affected

e. Evaluation of patient care: Patient and family are active participants in care planning and delivery (to the extent possible)

3. Sleep deprivation

a. Description of problem: Sleep deprivation in the critically ill patient involves a decrease in the amount, consistency, and/or quality of sleep that occurs in a 24-hour period. Sleep fragmentation occurs when the patient fails to complete a 90-minute average sleep cycle that includes both rapid eye movement and non–rapid eye movement sleep (Gawlinski and Hamwi, 1999).

b. Goals of care

c. Collaborating professionals on health care team

d. Interventions

i. Attempt to provide at least two 90-minute periods of uninterrupted sleep in a 24-hour period

ii. Cluster activities so that the patient is allowed periods of rest

iii. Prioritize activities to allow a stable patient to have periods without unnecessary, frequent assessments

iv. Decrease the noise level to promote sleep

v. Decrease overhead lighting to promote sleep

vi. Provide adequate pain relief

vii. Teach the patient and family relaxation techniques to promote rest and sleep

viii. Administer pharmacologic agents as needed to promote sleep (e.g., benzodiazepines, diphenhydramine). Note: Long-term use of benzodiazepines can abolish stage IV sleep.

ix. Consult with a pharmacist regarding the best drug choices for promoting sleep, particularly for high-risk populations such as the elderly

e. Evaluation of patient care

4. Grief and loss

a. Description of problem: The grief reaction is the emotional response to a loss in which something valued is changed or altered so that it no longer has its previously valued traits (Gawlinski and Hamwi, 1999)

b. Goals of care

c. Collaborating professionals on health care team

d. Interventions

e. Evaluation of patient care: Patient and family express grief in a culturally appropriate way

5. Sensory overload or deprivation: See Box 10-1

SPECIFIC PATIENT HEALTH PROBLEMS

Anxiety

1. Definition: Anxiety is the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension. Focus of anticipated danger may be internal or external (American Psychiatric Association [APA], 2000).

2. Etiology and risk factors: Results from multiple sources in the ICU, including the following:

3. Signs and symptoms: See Box 10-2