For patients, the ICU, which is often referred to as the ITU can be a very very strange place. The patient in the ICU/ITU is often attached to numerous pieces of equipment such as the ECG electrodes on their chest that monitor the Heart rhythm, and the rate, as well as the respiratory rate. the pulse oximeter device on their finger which measures the amount of oxygen in the patient's blood as well as the pulse rate, the blood pressure cuff on their arm which as the name states, measures the blood pressure, often oxygen which can be administered in several different ways such as the nasal cannulas, all the way up to the HIGHEST LEVEL OF SUPPORT. THE ECMO MACHine. Patients will almost ALWAYS have an IV cannula inserted into the back of their hand, or their arm as well as many other different places. There are numerous other pieces of equipment that may be attached to the patient. A LOT of this equipment has different noises. Such as the patient vital signs monitor which has both audio and visual alarms. These alarms can sound quite scary to some patients as well as their relatives and friends who come to visit them. The infusion pumps that deliver fluids and medications as well as nutrition, also make noises such as clicking noises and beeping noises. For the nurses and other healthcare team, this is something they are use to, but for somebody that has never had to be around this equipment, or never had to pay attemtion to it, this may seem like a space station. something that when face to face with for the first time, can be upsetting so the family, as well as the patient.
Often in Intensive care, the patient is given medications that sedate them as well as provide comfort from pain and when patients are receiving this medication, they often are very drowsy when awake, and when a patient receives these medications, they may have more difficulties understanding what is going on around them, and this can make the ICU noises from machines, people talking, and other ICU related noises very frightening. These medications, in a combination with the noises, and the patient's ilness not only effect the patient, but the family as well. When family members deal with a patient who can talk, and who is disorientated, they may be completely unable to copewith the feelings that they themselves are encountering.
Patients unable to talk because of ilness or because of the breathing tube, are now being forced to deal with the fact that they are in the Intensive Care unit, They have No Idea what is happening, and often, NO IDEA WHY THEY ARE THERE, and this in combination with the environment surrounding them, can be a LIVING NIGHTMARE. Eventhe bed that the patient is on can often play a roll in inducing horrible dreams and hallucinations.
For example, a patient in their state of sedation and awareness, may dream that they were out on sea in a boat with people who are performing horrible procedures on them, and the boat is running out of water. They may later reveal this to the ICU staff who were unaware that they while attempting to treat the patient's ilness, were seemingly to the patient hurting the patient. The patient when able to communicate with the healthcare team may say, "Why were you hurting me like that? I did nothing wrong to you."
It is important to let patients know that they are being propperly cared for and This includes talking to a patient who is sedated, and paralyzed in the ICU.
When performing procedures such as suctioning, the caregiver should tell the patient that they are going to suction them to assist with clearing their airways so that they will be able to breathe better.
An example of the dialog may be, "Mr. Stein? I am going to suction you through your breathing tube to help you breathe better. This will be a wee bit uncomfortable, but only for a few seconds. It might make you cough." Because in Mr. stein's sedative/analgaesic induced dreams, he may feel as if you are hurting him, or attempting to sufficate him. And two days later, when Mr. Stein had taken a drastic turn in his condition, becoming Septic with full blown ARDS, requiring heavy sedation, and paralysis, when the nurses went to initiate Continuous Lateral Rotation Therapy, CLRT on the critical care bed that had the air mattress that was capable of performing this very vital therapy, she carefully explained the action that she was going to be performing in such a language that he could understand.
"Hello Mr. Stein. I am going to be setting the bed that you are sleeping on to turn you every few minutes so that we can help clear out your lungs and help to keep you from getting soars on your body from being in the bed. Your bed will turn you every three minutes, and you will feel it moving you, but that is perfectly normal. You will not fall out of the bed." This will help in the future to avoid the conversation that Mr. Stein has to bring up when he was forced into a dream that he was on a ship that was sinking in the sea. But more importantly, it will help make his experience much more smooth.
Four beds over, a patient comes back from Cardiac Bypass and is on the ventilator still. The Dr. has ordered Percussion and Vibration Treatments which can be performed on his bed as well, because His bed contains the same type of air mattress that Mr. Stein's bed has available, and this air mattress can be used to perform not only Rotation therapy, BUT P&V, or Percussion And Vibration. The patient Mr. Porter has low ventilator settings, and will get off the ventilator the same day as his operation, or the next day. When the nurse comes to perform the P&V treatment that he had ordered, the nurse will calmly explain the task of which she is about to perform.
"Mr. Porter? Your operation went very very well. I am going to set your bed to sort of pound on your back to help get that fluid out of your lungs so that we can remove that breathing tube soon. The bed will shake some, but this is perfectly normal, so just relax and allow the bed to do its therapy. It will be over in 15 minutes." Had the nurse have just gone into the patient's room and initiated P&V, Mr. Porter upon being extubated, and being able to speak, might have asked the nurses why there was an earthquake, or why his bed was shaking. Thanks to this wonderful nurse, the two patients are well aware that they are being taken care of. It is such a good feeling to patients knowing that they are in very good hands. Patients do not choose to be sick, and being sick, and often CRITICALLY ILL in the Intensive Care Unit, is often a nightmare. Patients like Mr. Stein and Mr. porter can be given the best circumstances even in the worst of the worst circumstances when they are assisted in understanding the care that they are receiving.
For family members, seeing their loved ones who are so critically ill inside of the Intensive Care Unit, is a nerve racking nightmare that often gets worse before it gets any better. Its the Job of the Intensive Care staff to help ease the nerves of these familiesby carefully explaining to the family members, and the friends of the loved one what is happening. Just bringing a Family member into the room of a patient who is on a ventilator, and unable to talk, can be a horrible mistake. NOBODY wants to deal with a shreaking and screaming family member who may not have even known that their loves one required ventilatory support and now they, after not being told of this, come to see their loved one who is on the ventilator, unable to breathe on their own, see that the ventilator is attached to the patient express grief and often anger, because they could have been warned that the patient was on a ventilator, and he would be unable to talk with the endotracheal tube between their vocal cords. They need to be reassured that the patient is well taken care of.
Mr. Stein's mother who is visiting him from out of the Country, has seen TV shows such as ER, Grey's Anatomy, and House M.D., but this is the ONLY place she's ever seen a ventilator. She was told by Mr. Stein's Brother that he was very sick, but, His brother was neglectful in telling her that Mr. Stein was on a ventilator, and unable to speak because of the breathing tube. A nurse in charge of bring her to see Mr. Stein is now responsible for tellingher that he is hooked up to several tubes, and wires to help him get better. Dialog from the nurse may include, "Hello Mrs. Stein. before we go and see your son, I do want to let you know that when you go into the room to see your son, he will be attached to a lot of machines, and on a breathing machineto breathe for him while he is recovering from his condition. This may seem scary, but this is to help him, and we are closely monitoring these pieces of equipment and they will alarm if something goes wrong. The ventilator is inserted into his trachea so it is between his vocal cords, so he will not be able to speak, but you can still talk to him. In fact, even though he is sedated, you need to talk to him and let him know that you are there. Do you have any questions?" Allowing Mrs. Stein to ask any questions that she may or may not have, and allowing her to explain how she feels, is PROFOUNDLY IMPORTANT.Allowing Mr. Stein's mother to express herself and express the fact that she was not notified that he was attached to the mechanical ventilator, can help in easing her concerns and can be what makes her experience as smooth as possible. The nurse also explains the bed's movement and the air mattress can help when she goes into the room and hears the noise from the quiet blower. Mr. Stein's Mother is comforted when she sees her son even though he is attached to so many pieces of equipment and even though he iscritically ill. she's comforted because she was given warning that he was attached to a lot of equipment, andwhen she went in there, she did not see the ventilator totally unaware of its presence. Later in the course of Mr. Stein's hospital stay, when Mr. Stein leaves the Intensive Care Unit, the nurse gets praise because she was up front with his mother and did not just bring her into the room without notification of then ventilator. she thanks the nurse for easing her mind and for the wonderful support that she received. When Mr. stein leaves the ICU, he Thanks the nurse for explaining the procedures that she was performing. Over in Mr. Porter's room when His son enters the unit to visit him so the nurse is right there with him as well. She carefully explained to him that his Father would be on the ventilator. He understood this because he was on a ventilator once a few years ago do to a profound Asthma flare up that required intubation for a few days. His son, now out of highschool is aware of the reason ventilators are used, and when he enters the room, he is comforted by the nurse who prior to his entering the room explained the ventilator to him. He visits with his Father for a few hours, and two hours into his visit, he saw the nurse enter the room, and she explained to him that she was going to perform some Percussion and vibration with the assistance of the bed, and that theis was to assist in lung clearance. He was very greatful to this nurse who was patient in explaining all the machines, and the procedures that were being performed.
Family members usually don't know that hospital beds can perform these special therapies, and so the sudden noise of the blower delivering oscillations of air into the air bladders in the mattress, when unexpected, can be shocking and/or scary to family members not aware of their source and reason. So now that the nurse has explained the sound Mr. Porter's son will not be concerned when he hears this thump thump thump thump. The nurse has once again successfully helped in a family member's visit to the ICU. While this may not be the most pleasant experience, seeing a patient, ESPECIALLY A FAMILY MEMBER in the Intensive Care Unit, the healthcare team can play such a profound roll in making a visit AS EASY AS POSSIBLE, AND This while not making things all better, can help make as BEST AS POSSIBLE.
A few days later, Mr. Stein has been continuing to improve however the Dr. decided that Mr. Stein might be better supported with the use of the High Frequency Oscillating ventilator. Mr. Stein while still sedated and paralyzed was informed about the oscillator, because the nurse as caring as she is, knows that even patients heavily sedated, may still hear some things. She explained to him and his family about the machine, and allowed his family to see what the machine looked like out in the hallway as well as very very carefully explained to them the operation of the ventilator in terms that they will understand. She was very careful in informing them that the machine would make Mr. Stein's chest vibrate, and that this was normal. The oscillator is somewhat loud, and so the nurse warned them of this. The family chose to wait inside of the waiting room until they had transitioned Mr. Stein onto the oscillator. Upon Initiation of High Frequency Ventilation, Mr. Stein's Oxygen levels came up over the course of a few hours and with some careful adjustments of the skilled Respiratory Therapist, the blood gases which while improved, were not the best, were now looking more like what you would want to see. They still were not text book normal, but for Mr. Stein's condition, these blood gases would do. When the family came back to the Intensive Care Unit, they were once again, warned about the noise and the vibrations induced via the oscillator, and so they understood. The nurse and the Respiratory Therapist did such a wonderful Job of explaining this procedure. A week later, when the oscillator was downgraded to the conventional ventilator and the family as well as Mr. Stein were guided through this procedure. Once again, the room was somewhat quieter, and now Mr. Stein was actually off the paralyzing agent, and was beginning to initiate breaths from the ventilator. A family member saw the extra breaths from the ventilator, and when she asked what was wrong with the ventilator, it was carefully explained to her that this meant that Mr. Stein was attempting to breathe with the ventilator, and this was acceptable now.
Back in Mr. Porter's room, He had been extubated the following day of his operation, and it was explained to him that his throat would be soar. His first words were, "Your nurse was such a great nurse when she explained every single thing that she was doing. I cannot thank her enough." So, the nurse's efforts to reassure the patient, were not forgotten even through Mr. Porter's sedated Haze. That nurse was not on the ICU on the following day of his operation, but Mr. Porter made certainty that she was told of how much Mr. Stein appreciated her reassurance, and care.
Back in Mr. Stein's room, over the next couple of weeks, his condition improved enough to where he was able to get a tracheostomy, and was able to get off of the ventilator graduating to Oxygen via mask after 48 hours on a T-Piece simulator with the ventilator which was set to what is known as the TPS settings. TPS equals T-Piece Simulator Settings. Now Mr. Stein is undergoing Physical therapy and him and his family are being walked through the rest of the ICU stay. Finally, He was able to get transported down to the conventional ward, and now the patient must receive care just as good as he received in the Intensive Care Unit. JUST BECAUSE A PATIENT IS ON THE CONVENTIONAL WARD DOES NOT MEAN HE GETS LOWER CARE. He should have just as good communication and just as good coaching as well as his family members, until he leaves the hospital. AND EVEN THEN, the healing process does not stop. Its thanks to the Care he received, he does not have to deal with profoundly horrible nightmares of people who are attempting to murder him, and of people who are out on sea with him in a hospital boat performing mean procedures. He and Mr. Porter both made a full recovery, both going back to the ICU to thank the staff and give them sweets and other gifts.
The family members also give credit to the staff at the hospital, because they not only took care of the physical aspect of his care, but also the psychological and emotional aspect of their care. For patients, the ICU can be a profoundly scary place. For family members and friends, it can be a profoundly scary place, BUT, AS THE MEDICAL TEAm, They bear the responsibility of making sure that every bit of effort is not only put into medical care, but also psychological amd emotional care. reassuring a patient that you are about to initiate P&V may ver well be the one thing that prevents him from suffering months of hallucinations, flash backs, and nightmares of being shot at, or being trapped in an earthquake.
GOD BLESS YOu ALL!!
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