Describe about the Critical Care Nursing for Health Restoration.
Sleep is a necessary natural function to preserve physiological and psychological health. Sleep is more vital for the critically ill patients of the intensive care unit for their health restoration. Yet, patient’s sleep in the ICU has been reported by a huge number of patients and their family members to be of reduced quality. Sleep alteration can be described as the apparent or definite changes in night-time sleep (both quantity and quality) with successive day-time deficiency. Sleep disruptions may be transient or acute, but frequently it is a recurrent difficulty in patients of intensive care unit. Sleep in ICU patients is frequently disrupted by diverse environmental factors of ICU settings. Sleep architecture gets significantly altered when sleep periods are fragmented by frequent awakenings due to ICU environmental factors. Numerous evidence suggested that a considerable percentage of ICU patients experience deprived sleep quality and repeated awakenings which subsequently contribute to physical and mental suffering. It is the duty of the nurses to mitigate these environmental factors contributing in sleep alteration for the wellbeing of the patients. Therefore, appropriate nursing interventions and recommendations are vital for patient-centered care.
Even though sickness, pain, discomfort, and medication subsidise to alterations of sleep patterns in patients of intensive care, the prime aspect producing sleep interruption is the ICU environment (Pisani 2015). Environmental elements including patient care activities (monitoring, therapeutic interventions and diagnostic measures), uncomfortable positions, excessive light, noise from several sources like alarms, conversations, ventilation, beepers, television and phones (Luetz et al. 2016) are have been purported to interrupt sleep in critically ill patients (Pisani et al. 2015). Major complaints from ICU patients include falling asleep, early morning awakenings with incapability to continue sleeping, remaining asleep, too much daytime drowsiness and non-restorative sleep (Pisani 2015). Irrespective of the causes, sleep alterations disrupts the circadian rhythm that plays an important role in the biological function and has been found to be connected with harmful bodily consequences such as fatigue, alterations in metabolism, immune function, protein catabolism and nitrogen stability (Pisani et al. 2015). Sleep deficiency and disturbance are identified to interrupt the recovery process in patients, reduce the quality of life and cognitive abilities. Furthermore, sleep pattern alterations can upsurge pain intensity, anxiety, and depression (Matthews 2011).
According to the study of Carreira et al. (2015), even in critically ill patients without any sedation, sleep architecture, and quantity is severely disturbed. The severity of disease, comorbidities, and human interventions adversely upset sleep architecture and quantity. Sleep aberrations impact main ICU outcomes.
Noise intensities in ICU settings was recognized to be the prime environmental stressor for patient’s sleep alterations. Noise is a persistent factor in ICU due to the cacophony of medical activities and technological intensive care (Bihari et al. 2012). The World Health Organisation recommended that sound frequency within ICU must not surpass 30 decibel (A) at night in order to lessen sleep alteration. Noise intensities in ICU have progressively amplified over the last decades and healthcare professionals being the main source of the generated noises. Subjective investigations exploring the influences of sound on sleep specify that ICU patients ascertain the acquaintance to sound and incompetence to sleep as a key stressor (Luetz et al. 2016). In addition, objective surveys direct that the sound produced within the ICU environment is not favourable to the capability to sleep (Delaney et al. 2015).
Several of the drugs prescribed to the critically ill patients have strong effects of sleep pattern alterations. Opiates, antipsychotics, and benzodiazepines are associated with rapid eye movement sleep suppression. Standard sleep architecture can be affected by sedatives (Bihari et al. 2012). Sedation may have adverse impacts on sleep by affecting the normal characteristics of the sleep electroencephalogram (Matthews 2011 and Bihari et al. 2012).
Figure 1: Impacts of drugs used in the Intensive Care Unit on sleep (Weinhouse and Schwab 2006).
The chemo-sensitivity of the respiratory center of the brain is declined among sleep-deprived patients. Researches have showed many hostile impacts of sleep deficiency on respiratory muscle functioning (Kamdar et al. 2012). A substantial decrease in forced expiratory volume 1 (mean decline of six percent) and forced vital capacity (mean decline of five percent) in sleep-altered patients with the chronic obstructive pulmonary disorder compared to non-sleep-altered chronic obstructive pulmonary disease patients have been observed. Findings suggest that sleep-deficient conditions may cause patient hypoventilation, harmfully causing pulmonary reserves and generally ability and readiness to accelerate preventing from mechanical ventilation (Delaney et al. 2015).
The appearance of cardiovascular disorders due to sleep alteration originates from the stimulus of the sympathetic nervous structure and the discharge of the catecholamine adrenaline and noradrenaline. As a consequence, heart rate and blood pressure level get increased because of modifications in baroreflex sensitivity (Delaney et al. 2015).
The adaptive immune system and the effective function of the T-cells was found to be susceptible to sleep alterations, as researchers have discovered that sleep performs a vital part in T-cells extravasation. Moreover, the functioning of natural killer cells was revealed to be harmfully affected by altered sleep conditions (Delaney et al. 2015). Disruption of circadian rhythm and sleep alteration in critical conditions cause dysfunction of innate immune response (Dengler et al. 2015).
Irregular cortisol levels in intensive care patients cause disorders with circadian rhythms, as cortisol discharge is generally amplified earlier to awakening to facilitate the patient into a status prepared to be active. An escalation in cortisol amounts and reduction of melatonin creates a tendency for patients to be in the insomniac condition which can promote the worsening of catabolic activity and surges oxygen intake (Delaney et al. 2015).
Sleep alterations negatively impact carbohydrate metabolism causing insulin resistance and clearance of glucose. The rise in sympathetic nervous system functioning and the subsequent pressure reaction overwhelms the discharge of insulin from β-cells of pancreas. This event within the ICU patients can intensify underlying comorbidities, putting those patients at risks for other secondary complications. For instance, increased patient mortality has been linked with instability in blood glucose levels (Delaney et al. 2015).
Sleep alteration in ICU environment can lead to delirium. It is well-recognised that sleep alteration is a usual event in critically diseased patients and delirium arises often in patients at greater threats (Barr et al. 2013). A rising frame of evidence proposing that the advancement of delirium due to sleep alteration caused by the disturbing ICU environment is an independent prognosticator of the greater span of stay, amplified morbidity and mortality, disposition to an institutional setting from the hospital, and impairment of cognitive abilities during discharge from hospital (Pulak and Jensen 2016).
Numerous investigation data have established that sleep alteration has deleterious impacts on the patient’s quality of life in ICU both in the course of their hospitalization and for a different span of time afterward their discharge. It has been proposed that the sleep fragmentation, endured by ICU patients may be linked to persistent neurocognitive dysfunction (Barr et al. 2013). Contemporary studies of sleep alteration and chronic sleep deficiency have confirmed neuro-cognitive scarcities that mount up with time, regardless of any adaptation to the subjective sense of sleepiness (Kamdar et al. 2012). Clinical investigation of patients with obstructive sleep apnea, who also suffered from sleep alteration occasionally related with hemodynamic variability and hypoxia. These studies have exhibited the deformities in a wide range of neuro-cognitive and social activities some of which can even persist for months even after beginning of treatment with the constant affirmative approach (Barr et al. 2013).
Nurses deliver the holistic care to the patients. It is a prime duty of a nurse to evaluate and minimize alteration in sleep patterns of patients due to ICU environment.
Evaluation of sleep alterations
According to Matthews (2011), depending on the patient’s condition, a nurse should evaluate how the ICU environment, treatment procedures, and medications subsidise to sleep alterations. Sleep evaluation can be characterized as objective, behavioral, and subjective. The most effective method of measuring sleep is polysomnography (Elliott et al. 2013). Bispectral index is another method practiced in ICU to measure sleep (Matthews 2011).
Most efficient behavioral measure is actigraph. It a leg or wrist accelerometer that registers gross motor activities and rests over a prolonged period (Solverson and Doig 2014). Uninterrupted actigraph observation is used in seriously ill patients to direct usage of medications, sedative and improve recognition of agitation (Matthews 2011).
Subjective assessment approaches such as nursing observations and self-reports of patients can offer additional useful means of assessing sleep features and effectiveness of sleep interventions. Sedation assessment tool that uses descriptive statistical measures is actually more accurate than results of sleep and non-sleep conditions (Matthews 2011).
As described by Matthews (2011), using own appraisal of the patients about their sleep is necessary since they are capable of comparing normal quantity and quality sleep with the quantity and quality of sleep during their serious disease conditions. Everyday sleep records, visual analog scale and quality of life feedbacks are essential and have been practiced in a diverse critical care observations.
For the patients with stable conditions, verbal communication of trouble in falling asleep, sleep fragmentation and restlessness required to be promoted on a regular basis with the procedure of formal evaluations. Patients and their family members can also contribute insights to etiological aspects and evaluation of their insight of sleep complications and potential respite methods can facilitate suitable treatment (Aitken et al. 2016). Even though objective accounts of the quantity of sleep periods and disruptions may vary from the perception of the patients, monitoring of sleep and wakeful behaviours over twenty-four hours, and representations of physical and mental sleep fragmentation (e.g., pain, sound, anxiety) may be beneficial in evolving a comprehensive care strategy (Matthews 2011).
If evaluations suggest sleep alterations a multidisciplinary methodology should commence immediately. Incorporation of assessment result of patient’s sleep arrays and habitual sleep rituals into the care plan is significant. Normal sleep patterns are specific for each patient and data collected via holistic and comprehensive assessments are necessary to be determined the etiology of sleep alterations. Anxiety in the ICU environment interferes with sleep. Nursing interventions such as relaxation therapy can help patients reduce anxiety (Matthews 2011). A nurse should also evaluate the potential sources of noise and act to minimize those noises. Simple measures like providing quiet time to allow the patient’s mind to slow down, comfortable temperature, ventilation and dim light can increase the quality of sleep (Maidl et al. 2014). Research has shown that mild back massage before bedtime can effectively promote sleep (Matthews 2011). Providing pain relief shortly before bedtime and positioning patients comfortably can promote sleep. Excessive noise can cause sleep alterations that can result in ICU psychosis. Keeping the ICU ambient quite by lowering the volume on television and radio, avoiding the use of intercoms, setting beepers on non-audio mode, talking quietly on the unit and anticipating alarms on IV pumps are obligatory (Luetz et al. 2016). Using sound generators with soothing sounds like rainfall, ocean, and waterfall can induce sleep (Su et al. 2013). Observation of patient’s medication and diet is vital because difficulty in sleeping can be a side of drugs such as bronchodilators. In situations like this, nurses need to change medications immediately after the evaluation findings. Benzodiazepines are frequently recommended in the treatment of sleep alterations (Matthews 2011).
Conclusion
Sleep alterations and related health complications are crucial difficulties for patients in intensive care units. Different environmental factors of ICU such as patient care activities, uncomfortable positions, excessive light, and noises, all contribute to a incompetence of the patients to sleep. A collective methodology that integrates evaluations of sleep alterations and disturbances, behavioral interventions, control of environmental factors, appropriate pharmacological management and educational are essential to diminish the influence of sleep alterations and disturbances in patients of ICU. Following the comprehensive assessments of environmental aspects of ICU, an effective care plan must be developed to deliver times of uninterrupted sleep and reduce disturbance, identification of medication regimens that can promote sleep and recommendation non-pharmacological interventions constructed on individual requirements and desires or the patients. Nurses possess the suitable position to detect problems in their own units that can hamper quality and quantity patient’s sleep. Support from not only the nurses but also from all associates of the healthcare crew is necessary for implementing environmental modifications and make advancement in addressing sleep and energy requirements for the patients.
References
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Carreira, S., Lavault, S., Pallanca, O., Mayaux, J., Delemazure, J., Arnulf, I., Similowski, T. and Demoule, A., 2015. Risk Factors and Prognostic Impact of Sleep Alterations in ICU Patients: A Prospective Observational Polysomnographic Study. In D16. PREDICTING RISK AND OUTCOMES FOR CRITICAL ILLNESS (pp. A5397-A5397). American Thoracic Society.
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