Nancy
Well-known member
Here are two articles on ICU psychosis. I think many can relate to what they say, and their families too.
I have certainly seen it, and anyone who has been "confined" for a time in this environment will recognize some of the items.
Good news is that it seems to be a limited thing and recovery is the norm.
http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=6727
Article below
One in every three patients who spends more than five days in a critical care unit will experience some sort of psychotic reaction.
Your patient, a 57-year-old man suffering from COPD, has been in the medical ICU for 19 days. His COPD is now complicated by acute respiratory failure and sepsis. Intubated and on a ventilator, he is lethargic, although at times he becomes agitated and thrashes around in bed. When this happens, you find yourself staring into his eyes trying desperately to understand what he is feeling. Is he anxious, depressed, terrified, disoriented, or psychotic? Does he think you are trying to hurt him?
Depending on the acuity of the illness, level of consciousness, physiological condition, history of previous psychiatric disorders, coexisting medical disorders, effects of the medications, and other factors, it is likely that he ? and the majority of patients who have extended stays in critical care units ? have experienced most, if not all, of these emotions at some point during their hospital stays.
Identifying the Demons
?A large percentage of patients in critical care units experience some level of agitation, disorientation, delirium, or psychosis,? says Brenda Hixon-Vermillion, RN, BSN, program manager of Medical ICU, division of critical care at Ohio State University Medical Center in Columbus, OH.
?Contributing factors include critical illness, which may have disrupted homeostatic mechanisms, alteration of circadian rhythms due to lack of natural light, continuous activity and noise during the day and night, and the constant presence of artificial light,? says Hixon-Vermillion. ?Patients on ventilators are unable to communicate verbally, which can increase their sense of isolation, fear, and hopelessness. Many of our patients are receiving medications ? including sedatives, anticholinergic agents, and analgesics ? which can alter perception and contribute to disorientation or agitation,? she adds.
Other factors that can contribute to agitation include dehydration, heart failure, and poorly controlled pain (especially when mixed with anxiety), according to Kim Brown, RN, MSN, CS-FNP, CEN, a faculty member at Oregon Health and Science University School of Nursing, Department of Acute Care.
Patients who have extended stays in ICUs, which Hixon-Vermillion defines as anything longer than two or three weeks, are more prone to the development of serious psychological and cognitive problems. Most critical care nurses are familiar with the term ICU psychosis. Brown cites studies which show that approximately one in every three patients who spend more than five days in a critical care unit will experience some sort of psychotic reaction.? She defines ICU psychosis as ?a disorder in which patients in an ICU or similar setting experience anxiety, have visual and/or auditory hallucinations, become paranoid, agitated, and potentially violent, and may become disoriented to time and place.?
Many healthcare professionals believe that ICU psychosis and other changes in mental status are caused by factors inherent in the critical care environment, such as the constant noise, frequent interruptions, windowless rooms, overwhelming and unfamiliar technology, and the lack of orientation clues.
However, multiple studies have found that the signs and symptoms displayed by these patients are diagnostic of delirium, which is intensified by environmental factors, but not caused by it.1 Differentiating anxiety and restlessness from the disorientation and disturbed states of arousal that accompany delirium is important for effective diagnosis and treatment.
According to Michele T. Laraia, RN, PhD, CS, associate professor, Division of Mental Health Nursing, Primary Care Department, School of Nursing, Oregon Health and Science University, in Portland, OR, delirium, which shares many similarities with ICU psychosis, can be caused by a biological change in one's internal environment due to ingestion of a toxic substance or inability to metabolize a substance (such as a prescribed medication, a street drug, or alcohol), or by a toxic reaction to one?s external environment. There can also be serious physiological reactions in patients taking certain medications, such as antidepressants or analgesics, if the drugs are abruptly stopped when they enter the hospital.
?Critical care patients are already very ill, coming from a traumatized situation, such as a motor vehicle accident, major surgical procedure, or exacerbation of a serious preexisting condition,? says Laraia. ?They may have lost consciousness or been comatose for an extended period of time. For some, it feels as if they have woken up on Mars, surrounded by aliens, with no idea of where they are and how they have gotten there. They perceive the critical care unit as overwhelming and full of unusual, frightening, or painful experiences, and this is made worse by sleep deprivation.?
Other stresses of a long-term critical care stay that may lead to ICU psychosis, delirium, or anxiety and agitation can include sensory ? tactile, visual, auditory, and kinesthetic ? overload, the use of physical restraints, inadequate pain control, separation from family, or impaired ability to communicate, says Brown.
Banishing the Demons
When patients are being weaned off the ventilator, says Hixon-Vermillion, they need to be well rested because weaning takes an enormous amount of energy. Because agitation can tire the patient and hinder weaning, it is important that any undue anxiety or agitation be assessed and treated promptly.
Brown remembers the case of Mr. G, a 60-year-old man in generally good health, who presented at the ED with severe abdominal pain. He was rushed to the OR where he underwent a 10-hour surgery for an aortic artery dissection. During the procedure, he lost a lot of blood, became hypotensive, and needed large amounts of fluid. As soon as he awoke from the surgery, he appeared agitated and calmed down only after being medicated with lorazepam and morphine for pain. For the next few days, he was given an opiate analgesic every four hours, benzodiazepines for anxiety, and a neuromuscular blocking agent to decrease motor activity. Mr. G became increasingly disoriented and, by the fifth postop day, he was unable to recognize his wife or his adult children. His course over the next few weeks was stormy, with frequent episodes of agitation in spite of sedation. He developed renal failure, required dialysis, and was unable to be weaned from the ventilator.
Trying a new approach, he was started on around-the-clock doses of haloperidol, and within two hours he was more alert and oriented and was able to identify his wife and daughter. Thirty-six hours later, a less-agitated Mr. G was able to be weaned off the ventilator. He proceeded to make marked improvements.
Creating a Demon-Free ICU
Laraia, Brown, and Hixon-Vermillion emphasize that nurses play an important role in minimizing the likelihood of ICU psychosis. Here are a few of their suggestions ?
Regularly and frequently reorient your patient. Introduce yourself every time you return to the patient and address the patient by name. Place family pictures where the patient can see them.
Because the patient may not process information very well, speak clearly and simply. Provide a communication board for the patient who cannot verbalize.
Plan and group patient care in blocks of time so the patient?s rest is not constantly interrupted.
Lower lights at night and encourage the night staff to work quietly. Promote as normal a sleep cycle and environment as possible.
Use a nonverbal or analog pain scale to assess your patient?s level of discomfort and keep him or her well medicated without oversedating.
Administer anxiolytics, sedatives, and antipsychotic medication as needed.
Provide psychological support for the family and patient. *
Terms You Should Know
Delirium has four essential elements: disordered attention or arousal; cognitive dysfunction; acute development of signs and symptoms (from hours to several days); and a medical, not psychiatric, cause. These can lead to perceptual disturbances (illusions, hallucinations, delusions), unstable mood, disorientation, lack of awareness of one?s surroundings, distractibility, memory impairment, difficulty following commands, and disturbances in the sleep-wake cycle. Experts estimate that about 38% of patients in critical care settings experience some type of delirium, with elderly patients (especially those suffering from dementia) being most at risk.1
Hypoactive delirium is characterized by withdrawal, lethargy, apathy, and a total lack of responsiveness at times and can be related to infection, hypoxia, hypothermia, hyperglycemia, hepatic and renal insufficiencies, and thyroid dysfunction. Hyperactive delirium, caused by the adverse effects of drug intoxication, chemical withdrawal, and anticholinergic drugs, manifests itself in agitation, emotional lability, disorganized thinking, fear, paranoia, and disruptive behaviors. During the course of a prolonged illness and hospitalization, patients may experience both types of delirium with frequent fluctuations between the two.1
Anxiety is a sustained state of apprehension in response to a real or perceived threat. It is associated with motor tension and increased sympathetic activity. It?s frequently present in patients in critical care units.
Agitation, an excessive, nonpurposeful motor activity associated with internal tension, may be accompanied by anxiety, panic, depression, delusions, hallucinations, flights of thought ,and delirium. Agitation is associated with increases in heart rate, respiratory rate, blood pressure, cardiac contractility, and myocardial oxygen consumption.2
http://www.medicinenet.com/icu_psychosis/article.htm
I have certainly seen it, and anyone who has been "confined" for a time in this environment will recognize some of the items.
Good news is that it seems to be a limited thing and recovery is the norm.
http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=6727
Article below
One in every three patients who spends more than five days in a critical care unit will experience some sort of psychotic reaction.
Your patient, a 57-year-old man suffering from COPD, has been in the medical ICU for 19 days. His COPD is now complicated by acute respiratory failure and sepsis. Intubated and on a ventilator, he is lethargic, although at times he becomes agitated and thrashes around in bed. When this happens, you find yourself staring into his eyes trying desperately to understand what he is feeling. Is he anxious, depressed, terrified, disoriented, or psychotic? Does he think you are trying to hurt him?
Depending on the acuity of the illness, level of consciousness, physiological condition, history of previous psychiatric disorders, coexisting medical disorders, effects of the medications, and other factors, it is likely that he ? and the majority of patients who have extended stays in critical care units ? have experienced most, if not all, of these emotions at some point during their hospital stays.
Identifying the Demons
?A large percentage of patients in critical care units experience some level of agitation, disorientation, delirium, or psychosis,? says Brenda Hixon-Vermillion, RN, BSN, program manager of Medical ICU, division of critical care at Ohio State University Medical Center in Columbus, OH.
?Contributing factors include critical illness, which may have disrupted homeostatic mechanisms, alteration of circadian rhythms due to lack of natural light, continuous activity and noise during the day and night, and the constant presence of artificial light,? says Hixon-Vermillion. ?Patients on ventilators are unable to communicate verbally, which can increase their sense of isolation, fear, and hopelessness. Many of our patients are receiving medications ? including sedatives, anticholinergic agents, and analgesics ? which can alter perception and contribute to disorientation or agitation,? she adds.
Other factors that can contribute to agitation include dehydration, heart failure, and poorly controlled pain (especially when mixed with anxiety), according to Kim Brown, RN, MSN, CS-FNP, CEN, a faculty member at Oregon Health and Science University School of Nursing, Department of Acute Care.
Patients who have extended stays in ICUs, which Hixon-Vermillion defines as anything longer than two or three weeks, are more prone to the development of serious psychological and cognitive problems. Most critical care nurses are familiar with the term ICU psychosis. Brown cites studies which show that approximately one in every three patients who spend more than five days in a critical care unit will experience some sort of psychotic reaction.? She defines ICU psychosis as ?a disorder in which patients in an ICU or similar setting experience anxiety, have visual and/or auditory hallucinations, become paranoid, agitated, and potentially violent, and may become disoriented to time and place.?
Many healthcare professionals believe that ICU psychosis and other changes in mental status are caused by factors inherent in the critical care environment, such as the constant noise, frequent interruptions, windowless rooms, overwhelming and unfamiliar technology, and the lack of orientation clues.
However, multiple studies have found that the signs and symptoms displayed by these patients are diagnostic of delirium, which is intensified by environmental factors, but not caused by it.1 Differentiating anxiety and restlessness from the disorientation and disturbed states of arousal that accompany delirium is important for effective diagnosis and treatment.
According to Michele T. Laraia, RN, PhD, CS, associate professor, Division of Mental Health Nursing, Primary Care Department, School of Nursing, Oregon Health and Science University, in Portland, OR, delirium, which shares many similarities with ICU psychosis, can be caused by a biological change in one's internal environment due to ingestion of a toxic substance or inability to metabolize a substance (such as a prescribed medication, a street drug, or alcohol), or by a toxic reaction to one?s external environment. There can also be serious physiological reactions in patients taking certain medications, such as antidepressants or analgesics, if the drugs are abruptly stopped when they enter the hospital.
?Critical care patients are already very ill, coming from a traumatized situation, such as a motor vehicle accident, major surgical procedure, or exacerbation of a serious preexisting condition,? says Laraia. ?They may have lost consciousness or been comatose for an extended period of time. For some, it feels as if they have woken up on Mars, surrounded by aliens, with no idea of where they are and how they have gotten there. They perceive the critical care unit as overwhelming and full of unusual, frightening, or painful experiences, and this is made worse by sleep deprivation.?
Other stresses of a long-term critical care stay that may lead to ICU psychosis, delirium, or anxiety and agitation can include sensory ? tactile, visual, auditory, and kinesthetic ? overload, the use of physical restraints, inadequate pain control, separation from family, or impaired ability to communicate, says Brown.
Banishing the Demons
When patients are being weaned off the ventilator, says Hixon-Vermillion, they need to be well rested because weaning takes an enormous amount of energy. Because agitation can tire the patient and hinder weaning, it is important that any undue anxiety or agitation be assessed and treated promptly.
Brown remembers the case of Mr. G, a 60-year-old man in generally good health, who presented at the ED with severe abdominal pain. He was rushed to the OR where he underwent a 10-hour surgery for an aortic artery dissection. During the procedure, he lost a lot of blood, became hypotensive, and needed large amounts of fluid. As soon as he awoke from the surgery, he appeared agitated and calmed down only after being medicated with lorazepam and morphine for pain. For the next few days, he was given an opiate analgesic every four hours, benzodiazepines for anxiety, and a neuromuscular blocking agent to decrease motor activity. Mr. G became increasingly disoriented and, by the fifth postop day, he was unable to recognize his wife or his adult children. His course over the next few weeks was stormy, with frequent episodes of agitation in spite of sedation. He developed renal failure, required dialysis, and was unable to be weaned from the ventilator.
Trying a new approach, he was started on around-the-clock doses of haloperidol, and within two hours he was more alert and oriented and was able to identify his wife and daughter. Thirty-six hours later, a less-agitated Mr. G was able to be weaned off the ventilator. He proceeded to make marked improvements.
Creating a Demon-Free ICU
Laraia, Brown, and Hixon-Vermillion emphasize that nurses play an important role in minimizing the likelihood of ICU psychosis. Here are a few of their suggestions ?
Regularly and frequently reorient your patient. Introduce yourself every time you return to the patient and address the patient by name. Place family pictures where the patient can see them.
Because the patient may not process information very well, speak clearly and simply. Provide a communication board for the patient who cannot verbalize.
Plan and group patient care in blocks of time so the patient?s rest is not constantly interrupted.
Lower lights at night and encourage the night staff to work quietly. Promote as normal a sleep cycle and environment as possible.
Use a nonverbal or analog pain scale to assess your patient?s level of discomfort and keep him or her well medicated without oversedating.
Administer anxiolytics, sedatives, and antipsychotic medication as needed.
Provide psychological support for the family and patient. *
Terms You Should Know
Delirium has four essential elements: disordered attention or arousal; cognitive dysfunction; acute development of signs and symptoms (from hours to several days); and a medical, not psychiatric, cause. These can lead to perceptual disturbances (illusions, hallucinations, delusions), unstable mood, disorientation, lack of awareness of one?s surroundings, distractibility, memory impairment, difficulty following commands, and disturbances in the sleep-wake cycle. Experts estimate that about 38% of patients in critical care settings experience some type of delirium, with elderly patients (especially those suffering from dementia) being most at risk.1
Hypoactive delirium is characterized by withdrawal, lethargy, apathy, and a total lack of responsiveness at times and can be related to infection, hypoxia, hypothermia, hyperglycemia, hepatic and renal insufficiencies, and thyroid dysfunction. Hyperactive delirium, caused by the adverse effects of drug intoxication, chemical withdrawal, and anticholinergic drugs, manifests itself in agitation, emotional lability, disorganized thinking, fear, paranoia, and disruptive behaviors. During the course of a prolonged illness and hospitalization, patients may experience both types of delirium with frequent fluctuations between the two.1
Anxiety is a sustained state of apprehension in response to a real or perceived threat. It is associated with motor tension and increased sympathetic activity. It?s frequently present in patients in critical care units.
Agitation, an excessive, nonpurposeful motor activity associated with internal tension, may be accompanied by anxiety, panic, depression, delusions, hallucinations, flights of thought ,and delirium. Agitation is associated with increases in heart rate, respiratory rate, blood pressure, cardiac contractility, and myocardial oxygen consumption.2
http://www.medicinenet.com/icu_psychosis/article.htm
