Preventing Complications Sleep and Healing in Intensive Care Settings Jane C. Evans, PhD, RN, and Diana G. French, PhD, ‘Maximizing healing in the ICU environment requires active promo- tion of sleep as a nursing interven- tion. Changing practice requires a ‘two-pronged approach: developing ‘an expanded knowledge base rela ed 10 the physiological effects of sleep and especially healing, and rminimizing the impact of the tradi- tional ICU system on sleep depriva- tion. Applied Pathophysiology Sleep, a primary requisite of healing, is sometimes lost in the ICU environment of action. The difficulties of providing the eriti- cally ill patient with 4 to 6 hours of ‘uninterrupted sleep are well known. Jn fact, more than a quarter of a century has elapsed since sleep deprivation was identified as & serious problem for patients in intensive care units." Numerous articles have been written detailing the psychophysiologic alterations associated with lack of sleep, as RN, CS well as factors that contribute to sleep deprivation in the ICU (noise, pain, bright lights, and caregiving disruptions). Further, the relation- ship between sleep and healing, ‘both physical and mental, has been well deseribed.™” Sleep has been identified as a major focus for nursing research. ‘The American Association of Criti- cal Care Nurses (AACN) priorities for critical care nursing research specified the need for studies that explore effective methods to pro- rote sleep and to prevent sleep deprivation. A review of research related to these priorities reported few studies focused on prescribed interventions for sleep." Although clinical research studies have provided murses with useful information about sleep and the depriva critical’ care setings many nurses practice with multiple barriers to providing the patents with oppor nities for undisturbed sleep. Dra- ‘cup and Bryan-Brown suggest that tradition, tenure and tenecity in critical care nursing practice may act as barriers that work against the incorporation of research findings into clinical practice.” Therefore, even though clinicians may recog nize sleep 8s an important compo- nent of healing, traditional priosi- ties related to caregiving may inter- fore with sleep. Critical caro nurses often find that providing sleep periods is a continuous and vexing problem. This article pre- sents strategies for changes in the system that will assist the nurse in providing sleep opportunities for critical care patients, Physiological Properties of Sleep Understanding the physiologic properties of sleep enables murses to develop more effective strategies for ensuring critically ill patients receive complete sleep cycles to promote healing. There are two distinct types of sleep: rapid eye movement (REM) and non-rapid eye movement (NREM)._ Interest- ingly, there are different restorative VOL. 14, No. 4 July-August 1995 189Preventing Complications functions of the two types of sleep which are: ‘© REM (rapid eye movement) or "dream" sleep promotes emo- tonal healing, brain restoration, and growth, ‘© NREM, particularly Stages IIL and IV promote physical healing and growth, A complete adult sleep period is ‘composed of 4 to 6 successive sleep cycles over a 6 to 8 hour period of ‘uninterrupted sleep. Among indi- ‘viduals, the duration of sleep cycles varies within a range of 60 to 100 ‘minutes, ‘The hypnogram of a complete normal adult sleep period in Figure 1 illustrates the cessation of slow wave sleep (Stages IIT & IV) in NREM sleep (physical heal- ing) after completion of the first two sleep cycles, and the progres- sive lengthening in duration of REM (emotional healing) sleep periods over successive sleep oy- cles. ‘The duration of the average Adult sleep cycle is 90 minutes, ‘hile neonatal sleep cycles average 63 to 80 minutes for full-term infants and 72 minutes for pre-term infants. ‘Adult sleep cycles begin with Stage I sleep and progress through Stage IV NREM followed by & regression through the stages, which culminates in a short REM stage early in the night. The dura- tion of REM sleep gradually ength- ens from 10 minutes during the first sleep cycle to 25 or 30 minutes during the last sleep cycles, while ‘Stages IIT and IV completely disap- pear following the first two sleep ‘ycles. The length ofa sleep cycle is important to the critical care nurse in developing appropriate length rest periods during the day, 1s well as longer sleep periods at night. 190 © 1995 Dimensions of Critical Care Nu ours (REM = 1,8) eres Mle Enetonal Pare (enoee Figure 1. Adult Sleep Hypnogram. Stages III and IV of Non-Rapid Eye ‘Movement Sleep (NREM) are present only in the first two sleep cycles. Rapid Eye Movement (REM) sleep periods become progressively longer with ‘each successive sleep cycle. Adapted and reprinted by permission of The Putnam Publishing Group from the BRAIN: A User's Manual by the Diagram Group. Copyrighi(o) 1982 by the Diagram Group. Healing Properties of NREM Sleep Growth and physical healing ‘cour during Stages II and IV of (NREM) sleep. ‘The fact that Stages II and IV NREM occur only during the first two sleep cycles has important ramifications for critical care mursing. The secretion of growth hormone and other hormones, which stimulate ‘protein anabolism for cell repair, ‘growth, and replication, peak dur- ing night sleep, while cortisol secretion is normally reduced. Actually, 70% of the total 24-hour secretion of growth hormone occurs during Stages III and IV sleep.*Preventing Complications 5 HREM Btoes 1M) 4 Secrtea Git Homers easels eos Tron Bets ‘anmoa eid #Riboconel AaMy—¢ROA Sytbesis— ¥Brakdown Pras Acetate gaan ‘rake Emo ede {en Bynbass ntnter cots pexectcats syamats Essent tele Sustances Pyare, 2etuar Sent Gesine Posse)” Prone Prete Dapoetlon resenalon Pn Sts Matnance ctu Pincons Lis Protas Teste Rese Figure 2. Sleep/Healing Flow Chart. Growth hormone influences the metabolism of fats, proteins, and carbohydrates to increase protein synthesis, maintain cellular function, and promote cellular growth and healing. Growth hormone influences: the Once awakened, an adult begins sleep cycle prior to being awak- ‘metabolism of proteins, fats, and again at the boginning of the sleep ened. carbohydrates promotes increased cycle. This.means a return to the Since Stage IV sleep usually liver production of somatomedins to initial sleep cycle where Stage I is begins following the first 40 min- promote bone and cartilage growth, followed by Stages II and III, and utes of the first sleep cycle, pe and stimulates RNA (Ribonucleic then 20-minute Stage IV begins tients who achieve at least one 90- Acid), amino acid uptake, and approximately 40 minutes after the minute sleep period over a 24-hour protein synthesis to increase both patient falls asleep. The initial period will have at least one period the number and the size of cells" sleep cycle has only 10-minute of increased release of growth (see Figure 2). REM stage. hormone. ‘Protein synthesis and cel division Takahashi et al. found that sub- ‘The physical importance of for the repair of tissues such as jects who were awakened for2 to3 Stages II and IV NREM sleep is brain, bone, gastric mucosa, skin, hours and then allowed to return to emphasized by the fact that these and bone marrow occurs primarily sleep experienced a second plasma two stages, also known as slow during Stage IV sleep.‘ The 24- peak of growth hormone."* ‘Thus, wave sleep (SWS), take priority hhour plasma growth hormone peak it is possible that repeated awak- over all other sleep stages during occurs during the first 90 minutes enings in the ICU may not be all the rebound sleep of individuals of sleep and lasts from 1.5 to 3.5 bad, provided that the patient is who are recovering from sleep hours." able to complete a full 90-minute deprivation, VOL. 14, No, 4 July-August 1995 191Preventing Complications ute sleep cycle and/or the normal sequence of sleep stages. Sleep fragmentation may be associated with symptoms of sleep deprivation, even though the patent actually achieves normal total sleep time (IST) of 8 or more hours, ‘The same amount of total ‘Table 1. Clinical Manifestations of NREM Sloop Stages fone ocr sleep achieved in fragments rather RR even HR 4 by 5 to than continuously is less restorative er 10% than non-fragmented sleep." Slower eg RR Several studies have doseribod BP 4 by 20% the length of sleep and extent of sleep deprivation for ICU patients 200 Occasional Paris! Muscles 4 Muscle Tone : Movement whole body elation rleced (Gee Table 2), Other studies have fork emteing postural shown: muscles ‘+ A.30-60% deprivation of NREM sleep for patients in a Respiratory Snoting © Maximum available sleep times over 24 hours in intensive care Only 2/3 of lost REM sleep is retarded children have very litle units range from a low of S min- recovered, while almost all of REM sleep." ‘utes toa high of 30 minutes.> 24 Stages TI and TV NREM sleep are Patients are_very difficult to # A mean rest period of 50 minutes reclaimed during rebound sleep arouse during REM sleep, which (potential for sleep) reported for following sleep deprivation. ‘may influence the nursing inter- adult ICU patients? pretation/evaluation of neurological» BEG tracings revealed one sam- Healing Properties of REM Sleep signs in patients with intracranial _ple of adult ICU patients received pathology.” Responsiveness to only 8 minutes of continuous ‘The hormonal secretions during voice arousal or painful stimuli is _sleep during an 8-hour night. REM sleep continue to facilitate diminished during REM sleep. A mean total sleep time (TST) of protein anabolism, but during this Significant increases in intracranial 285.5 minutes with an average of same period, cerebral blood flow, pressure (ICP) have been reported 50 awakenings. intracranial pressure, heart rate, to ovcur during REM sleep in pa- © Mean time spent in Stage TM and cardiac output, systolic blood pres- tients with intracranial pathology.” IV sleep for adult ICU patients sure, and oxygen consumption are ‘was 12 minutes or 3% of their all increased. Seo Table 1 for Sleep Deprivation/Sleep {otal sleep time (TST) versus the clinical manifestations of REM and Fragmentation norm of 90 minutes (20%). NREM sleep. Indeed, Hemenway « Early studies of ICU and CCU stated that blood flow to cerebral Sleep deprivation and sleep frag- patients revealed percentages of ray matter nearly doubles during mentation interfere with healing Stages IM and IV ranging from REM sleep." The theory that during patient stays in intensive none to 14.7%, suggesting that REM sleep facilitates the growth care environments. Sleep depriva- patients were deprived of 40 to ‘and repair of brain tissue and emo- tion in ICU settings includes de- 100% of the sleep time associated tional healing *"” is supported by creases in the consistency, quality, with secretion of growth hor- the fact that REM sleep predomi- or amount of sleep a patient gets in _-mone.>*#” nates during neonatal and infant each 24 hour period. Sleep frag- sleep when the brain is undergoing mentation occurs when frequent The last trimester of pregnancy its most rapid period of growth and interruptions prevent the patient and the first two years of life are development, and that mentally from completing an entire 90-min- critical growth periods during 192 ©1995 yensions of Critical Care NursingPreventing Complications (Cureton Lane (1982) Neonatal (NICU) Evans (1981) Duxury (1 8) Table 2. Mean Reported Duration of ICU Sleep Periods Intensive Care ‘Mean Duration Setting Sources Adult 1c Flicherdcon (1986) Pediatic (PICU) Effects of REM Sleep Deprivation Deprivation of REM sleep for ‘more than 24 to 48 hours is associ ‘ated with psychological disturbanc- es such as: apathy, depression, irvitabilty, illogical thinking, con- fusion, disorientation, combative ‘ness, delusions, hallucinations, and parmoia.2" Table 3 compares the clinical manifestations of REM and NREM sleep deprivations, The ‘Teble 3. Comparison of NREM ond REM Sleep Deprivation, Increased immunosuppression Delayed healing Nous, diarrhea Constipation Heedacho Vertigo Discoordination Nock muscle weekness Manifestations of Menitestations of NREM Deprivation Fatigue Restlossnose 1 pain toloronce Intaity Confusion ines jod secretions of cortisol Combative constellation of symptoms resulting from REM deprivation has been identified as "ICU psychosis," or “ICU syndrome." The psychoses and hallucinations rarely oceur prior to 48 hours of sleep depriva- tion. Physiological decreases in steroid secretions are also associat- cd with deprivation of REM sleep. Since steroids are precursors for the synthesis of certain hormones, decreases in steroid production may influence both endocrine balance and fonction. fess of NREM Deprivation Deprivation of NREM sleep leads to immunosuppression, decreased tissue repair, decreased pain toler ance, and profound fatigue of the central sympathetic nerve centers % (600 Table 3). Loss of Stage IV which infants spend 60 to 80% of minutes in duration, and only two sleep for more than 24 hours is each 24 hours in sleep. Brains _of tem infants received a grow to 80% of their adult size by rest period greater than 90 min- or le associated with nausea, constipation jiarchea, headache, muscle two years of age and infants double utes during an entire 24-hour discoordination, neck muscle weak- their body weight in 6 months, period in a Neonatal Intensive ness and vertigo." In addition, ‘Therefore, there may be growth Care Unit (NICU). and development implications for infants in intensive care settings deprivation of Stage 1V (slow wave sleep) leads to bodily malaise and ‘The mean NICU period of undis- fatigue, and decreased muscle who fail to experience adequate turbed rest was 30.2 minutes strength, all of which are signs of a sleep. Research on neonates also over a 3-hour observation peri- decrease in the energy available for shows changes in rest related to od.” ICU stays: tissue repair and healing.™ Tmmunosuppression during ‘© The only reference suggesting NREM deprivation occurs through + Forty-seven percent of infant rest mean duration of rest in Pediatric several mechanisms. Increased periods (opportunities for uninter- Intensive Care was approximately secretion of cortisol within minutes rupted sleep) were less than 10 28 minutes.” of the onset of physical or neuro- VOL. 14, No. 4 July-August 1995 193‘genic stress causes rapid mobiliza- tion of amino acids and fats from cells which enable damaged tissues to utilize newly available amino acids to from new proteins essential pr the life of the damaged cells.”* Cortisol causes the stabilization of lysosomal membranes in dam- aged cells and reduces inflamma- tion. However, prolonged secre tion of cortisol reduces lymphocyte and granulocyte functions that interfere with the body's ability to heal and prevent infection. Prolonged stress can also abolish the circadian periodicity of cortisol secretions, further diminishing immunosuppression.** Cortisol secretions are normally diminished during sleep, but lack of sleep combined with the stress that accompanies trauma, surgery, and the ICU environment keep these secretions elevated, Prolonged cortisol secretion depresses T cell function and leads to increased susceptibility to infection, Differences in Morning and Afiernoon Daytime *Naps" Since patients in intensive care settings require frequent caregiving interruptions, long uninterrupted periods of healing sleep are rare. Instead of having sleep concen ed in an 8 hour block during the night, sleep occurs for short peri ods over the entire 24 hours. Nurses may be able to enhance either physical or emotional healing cor both by providing 90-minute blocks of healing slep throughout the 24-hour period. Although itis extremely difficult to provide ert cally ill patients with up to 4 hours of sleep during the night, it is possible to provide naps between Scheduled periods of caregiving Preventing Complications activities. Afternoon naps contain more NREM sleep, while morning naps contain more REM sleep. Daytime naps are significantly different in the duration of sleep stages within sleep cycles than night sleep. Naps between 7 a.m. and 2 p.m. contain significantly more REM sleep, whereas Stage IV sleep predominates in late afternoon, and evening naps.“ Healing for patients with brain injuries may be enhanced by pro- viding uninterrupted sleep periods during morning hours, whereas pa- tients with severe physical trauma may benefit more from afternoon periods of uninterrupted sleep. Impact of the ICU on Sleep ‘An understanding of the patho- physiology illustrates that critically ill patients have limited energy reserves with stressful life threat- ening health problems that require physical and mental energy for tissue repair. Yet, the literature is replete with articles outlining prac- tices that interfere with sleep, and exhorting nurses to provide more sleep for their patients. What are the most common barriers to pro- viding adequate sleep to ICU pa- tients? ‘A number of research studies have documented a variety of envi- ronmental factors, such as the constancy of noise and bright lights? in the ICU, that consis tently interfere with sleep. Artifi- cial lighting which denies the pa- tient a day-night orientation contrib- lutes to sleep pattern disturbance, Noise generated within the environ- ment and by the staff were shown. to disturb ICU patients sleep, on average, every 20 minutes.” Research in critical care units frequently found sound levels be- 194 © 1995 Dimensions of Critical Care Nursing tween 60 and 80 decibels.” These ‘are sound levels to which the staff may be quite accustomed, but from ‘which the patient has no escape, Steep Promotion Strategies ‘Theories borrowed from anthro- pology help identify other factors in the critical care unit that are bacti- cers to sleep-promoting behaviors among nurses, Although the criti ‘eal care nurse may recognize the patient’s physiological and psycho- logical need for sleep, the action- oriented subculture of the ICU may have an indirect but powerful influence on nursing behaviors and actions. Four common themes of ICU nursing emerge that influence sleep disturbances: forms and documen- ion records; peer pressure; con- flicting priorities; and external influences. By developing strat- egies that address these ICU themes, the nurse can promote sleep as a priority intervention and provide sleep opportunities for ICU patients, Revise Documentation Records Written shift reports, care plans, medications, IV records, and the ICU flow sheet all influence nurs- ing actions regarding sleep. Be- cause ofthe degre of physiological insult to the critically ill patient, care plans, flow sheets, and other documentation generally focus on data gathering, which reflects po- tential life-threatening alterations, treatment procedures, IVs, and invasive monitoring. While the plan of care for the critically ill patient, of necessity, includes data collection on physi- logical parameters, the plan often does not indicate specified times for uninterrupted sleep for the patientDocumentation records that focus fon the nurse's recording of essen- tial physiologic data usually lack a specified space to record amount of patient "sleep time." Such an omission may indirectly influence the prioritization of caregiving activities through the communi- cation of behavioral expectations. ‘The provision of uninterrupted sleep as a nursing intervention may have low priority within the ICU because there is no particular re- quirement to document the occur- rence or non-occurrence of sleep. ‘To counteract this omission, bed- side documentation forms could be adapted to add sleep, while sleep periods of a specified length might be included in standardized care plans. Using a case management proach, length of sleep periods could be included in critical path- ‘ways. For example, the respiratory care patient on the first day of intensive care might be expected to sleep 90 consecutive minutes twice in 24-hour period; while at3 days post-admission to ICU, sleep might bbe expected for 2-hour periods occurring 3 to 4 times in 24 hours. ‘As reflected in the forms and documentation records, the mes- sages imbedded in the ICU subcul- ture demonstrates that frequent date ‘gathering and treatments are highly valued, while providing sleep for the patient is accorded a low value. ‘As more critical paths are imple ‘mented as a method of managing care and controlling costs, perhaps sleep periods will appear as mea- surable outcomes. For example, critical paths for each day of he talization might reflect a given umber of hours of uninterrupted sleep the patient experienced. Positive patient outcomes may be more easily correlated with ade- quate sleep. Preventing Complications Determine Impact of Peer Pressure Informal discussions with a num- ber of critical care nurses reveal that in some ICUs there is signifi ‘cant peer pressure to conform to a particular norm of expected nursing behaviors. Implied within this normative system isthe dictum that to be a “good” ICU nurse, one must always be doing something to, or for, the patient, and to depart from the normative expectations of the peer group invites rebuke and criticism, The unwritten code of action may have a strong effect on nursing action, especially among novice and advanced beginner practitioners. Critical care murses, educators, managers, CNSs, and researchers ‘need to work together to create and foster a practice environment where positive reinforcement and encour- ‘agement is given to murses who individualize caregiving activites in ‘a manner that provides undisturbed sleep whenever possible: add a criteria to performance evaluations on “organizes care so that patient hhas periods of uninterrupted sleep;" comment to nurses that planning sleep is an important treatment strategy; and request that during shift reports information on sleep be added as this helps the team on different shifts focus on sleep as a caregiving strategy. Reevaluate Priorities Patient care regimens for the critically ill call for frequent po: tion changes, frequent hemodynam- ic data collection, and pulmonary care routines. The nurse is faced with a conflict between performing these activities or allowing the patient to sleep, ‘The reality of critical care murs- ing practice is that patients are in intensive care units because they are extremely ill and require close observation and specialized nursing care, While acknowledging this reality, there are also many instanc- ces where caregiving activities may bbe performed as a matter of routine or tradition. In the "stable" pa tient, the murse makes a decision between allowing the patient to sleep or performing a routine as- sessment. The choices represent a constant in critical care mursing practice; conflicting priorities ‘The nurse's judgment regarding prioritization of patient care needs is vitally important. Nurses who recognize the value of sleep will decide in favor of allowing the patient to sleep rather than obtain- ing routine vital signs. For exam- ple, since wel-calibrated hemody- namic monitoring devices accurate- ly reflect blood pressure, pulse, and temperature, these readings can be obtained without disturbing the patient, ‘Nursing care protocols should be developed and revised to allow for individual nursing judgment, ‘Tim- ing of treatment provedures and ‘medications positioning is all within the scope of nursing care planning; therefore, scheduling of caregiving activities will better facilitate sleep periods. ‘When documenting in the patie- at's record, it is helpful to indicate the nursing rationale for prioritizing sleep above routine. The nurse, as manager and coordinator of the patient's care, is the professional best suited to make judgments about the relative value of a given assessment or procedure versus an ‘uninterrupted sleep period, Jenny and Logan maintain that expert murses make clinical judg- ments and provide rationale for ‘nursing actions based on "knowing the patient." VOL. 14, No. 4 July-August 1995 195Preventing Complications cal/Surglal intensive Care Units for ton years. Work Ing the night shift for most of these years, she has long fecognized. her patients’ ns, fo) cu ‘ctiviies around respiratory 9800 or ‘teatmonts In coordination 4b, because most patients "oe ‘othore Tows..talkto thepationts to caregiv calm” and reassure them ‘0% ‘that you willbe monitoring because two hours of uninterrupted teeks." sleep. {alk songe helps ‘need for sloop and the im- baby down tol Ccare,.we request reepire: idea for plecing @ sign on Family visite are. delayed tory therepy to a ‘ment tim ile ‘around the lab'e stan sonnel riving d9rdblood draw times, e.g., ask permission af the nurse Twithreepleatory therapy and oslo roports thet using en Another tactic Marty finds the bedside and hold tho ry probleme infant's are To comploto noi on tho radio or uoo a torte, and 0 981V88 68 baby. individua lights may background sounds which be dimmed over ech eolet te, "The RN ie the one ther for the neor them, and allow st least {9% pationt rather then uses’ Stage on Fromotag Sep ‘Medical/Surgical. Intensive Care Unit. Sloop is encour- ‘completing taske then el aged by dimming lights for lowing thepationttoeleop.” the whole ICU at 10 p.m, ‘This problom was adéres- telovsions are turned off, id mn hor unit by took curtaine ere closed, and that come up with an noiee ls kept tow minimum. pt teat. the patient's door, "Quiet! - Someone Sleeping ~ Do Not Distr.” All medical por- physicians, 8 1100." before entering the room. th patente who are frld to sloop fe to ait by ‘over Indicates tho helpful Is to play’ whito patients hand while cho her charting. signal to tape recorder to play Pache- to not dleturb tho bol’s Canon to. provide who of @ focus on the ‘System supports should be devel- ‘oped that provide the nurse with the necessary latitude to take the kinds of actions necessary to insure sleep for their patient. Improve Multidisciplinary Collaboration The high-tech nature of critical care requires an interdisciplinary approach to patient management, For this reason, the critical care period when the laboratory techni feam includes providers from a cian arrives to take blood. variety of medical specialties and For patients withthe most fatigue institutional departments. Each of and need for sleep, coordinate these interdependent team members nursing care with expected times hhave their own set of priorities and for RT and lab, and even physician tend to create time demands within Discuss sleep needs while the ICU that may not be consistent on rounds with MDs, and let others with allowing the patient time for know you are scheduling sleep sleep. For example, the nurse may times, In neonatal ICUs, all pro- hhave just finished the patient’s bath fessionals are expected to respect and encouraged a 90-minute sleep the rest periods nurses schedule for 196 © 1995 Dimensions of Critical Care Nursingill infants. Sighs can be made and placed on the isolette as a way of communicating with other team members. ‘Edwards and Shuring have re- cently developed protocols aimed at providing the ICU patient a 4-hour lock of uninterrupted sleep be- tween the hours of 1 and 5 am.* Coordination among nursing, resp ratory therapy, and the medical staff is a key element in ensuring the success ofthe protocols. Schedule 90 Minute Blocks of Sleep Ninety-minute scheduled rest periods can bo used in adult ICU as they are in some NICUs. For ex- ample, premature infants in the ICU are provided significant rest periods of 1 to 1 1/2 hours every 6 hours. During this time « blanket is placed over the isolette, lights are dimmed, and noises are decreased, For adult ICUs, the lights can also be dimmed, the door ‘or curtain pulled, and a sign placed on the door to notify other team members of the sleep period. ‘The patient may also be offered ear plugs or headphones with soothing ‘music during the rest period. Patient Reassurance Since unfamiliacty with surroun- dings and fear compound sleep patter disturbances, patient teach ing by the nurse about the impor- tance of sleep may allay anxiety. ‘As part ofa plan for sleep promot- ing strategies, communication by the nurse of "permission" to sleep conveys a total care approach to the patient. Assure the patient that sleep is part ofthe healing process. Provide reassurance thatthe patient will be closely watched while slep- {ng and that no vital observations ll go unnoticed, Preventing Complications Summary Maximizing healing in the ICU taxes the ingenuity and skill of the nurse, Healing is a complex inter- ral process that can only be accom- plished by the patient, but it can be facilitated and maximized with the help of the nurse who most directly manages the patient environment. a systemic synergistic process involving the reorganization and redirection of energy that is manifested by healing and growth. Facilitating this process in the ICU is a challenge and requires refram- ing our ideas. Attention to system issues and ‘bedside monitoring of patient sleep cycles accompanied by active inter- ventions that promote patient sleep will improve the patients’ percep- tions of the quality of their inten- sive care experience. Decreased morbidity, recidivism, hospital costs, and length of stay ray well be side effects of imple- ‘menting active sleep interventions to promote healing. Clinical Research Questions: * Does provision of 6 periods of 90-minute sleep cycles improve recovery outcomes? * Does providing at least two 90- ‘minute sleep cycles in the morn- ing hours reduce the incidence of complications and improve heal- ing? + Do patients who receive a total of 8 to 10-hours TST in the inten- sive care setting have a shorter length of stay and/or fewer com- plications than patients who fail to achieve a total of 8 to 10 hours TST? * What is the effect of sleep cycle disruption in the ICU environ- ‘ment on the neurological outcome of pationts with intracranial pa- thology? * Does the inclusion of sleep moni- toring boxes on the flow chart increase attention to promotion of sleep? Is there a difference in the sleep ppatiems and heart rhythms of patients recovering from acute illness in the TCU or CCU and after they go home? Key Words ‘Sleep, sleep deprivation, healing, nursing care, nursing documenta- tion, sleep promotion. Acknowledgements ‘The authors would like to thank Patricia J. Metting, Ph.D., Asso- ciate Professor of Physiology and Molecular Medicine at the Medical College of Ohio for her assistance with the sleepfheating flow chart developed for this manuscript. Thanks are also extended to Rose- sary Kahle, RN, MSN and Robert Ulrich for their assistance with the ‘graphics in this manuscript, References 1. McFadden EH, Giblin EC, ‘Sleep deprivation in patients having. ‘open-heart. surgery. Nursing. Re- search, 1971;20:249 - 254. 2. Walker BB. The post-surgery heart patient: Amount of uninter- rupted time for sleep and rest during the first, second, and third postoperative days in teaching hospital Nursing Research, 1972; 21:164-169. 3. Oswald I. 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Nursing Times. 1991 87(19): 30-31, 47. Hilton BA. Noise in acute patient care areas. Research in Nursing and Health, 1985;8: 283- 291) 48. Benner P. From Novice to Expert, Mento Park, CA:Addison- Wesley.1984. 49. Jenny J, Logan J. Knowing the patient: One aspect of clinical knowledge. Image: Journal of Nursing Scholarship, 1992;24(4): 254-258, 50. Edwards GB, Shuring LM. Pilot study: Validating staff nurs- es" observations of sleep and wake states among critically ill patients using polysomnography. American Journal of Critical Care, 199332 (@):125-131. 51. Quinn JF. On healing, wholeness, and the haelan effect, Nursing and Health Care 1989; 10(10):553-556. About the Authors Jane C. Evans, PhD, RN is an Associate Professor, and Director of the Center for Nursing Research and Evaluation in the School of ‘Nursing at the Medical College of Ohio, Dr. Evans is an experienced NICU nurse, who has multiple funded research projects and refer~ ‘eed publications. Your may reach her at (419) 381-5842 (work) Diana G. French, PhD, RN, CS is aan Associate Professor in the School of Nursing at the Medical College of Ohio. Dr. French, who is an experienced adult intensive care nurse and an ANA Certified Clinical Nurse Specialist, is also a Lieutenant Colonel in the Army ‘Nurse Corps and Chief Nurse ofthe 145th MASH Ohio Army Nationat Guard, DCCN, Priced So You Can Have Your Own Copy! You no longer have to borrow someone else's copy of DCCN, we now have a special price for a personal subscription, Price (check your selectio 1178 Regula, Insttion Pec (Por depariment or tibrary. S45 Individuals Price (Use by one person, not dept. o brary.) ($39 Discounted Personal Prise Your full name, home address, and personal check mus scompany order fo persona price.) (Foreign: Check must bein USS drawn on ‘US bank. Canada add $10 and overseas sd $18 mailing Tes, Payment Method Cl Payment ensued. Send in your order today! 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