Perspective of Care,

collaborative, team,
Special and family needs

PATIENTS STRESS IN ICU, &

THEIR RELATIVES AND NURSES
ROLE
 WHAT IS STRESS ?

Stress is simply called

Pressure
Strain
Tension

Prof. Dr. RS Mehta, BPKIHS 2

 DEFINITION

Stress is defined as any adjustive

demand that requires an adaptive
response . It is a condition in which
the human system responds to
changes in its normal balanced state.

Prof. Dr. RS Mehta, BPKIHS 3

 PATIENTS STRESS IN ICU

 A patient may experience a myriad of fears

and concerns when admitted to the
technologically sophisticated world of critical
care.
 Patient enters complex setting where staff
members converge with the variety of
procedures and supportive devices in an
attempt to monitor, strengthen , or stabilize the
physiological crisis .
Prof. Dr. RS Mehta, BPKIHS 4
 PSYCHOLOGICAL CRISIS IN ICU
PATIENTS
 Anxiety.
 Anger.
 Depression.
 Hopelessness.
 Fear.
 Denial.
 Powerlessness.
 Spritual distress.
Prof. Dr. RS Mehta, BPKIHS 5
 …
 This kind of feelings occurs as a reaction
to a threat to the person; the threat
encompasses potential physiological loss,
lifestyle changes, potential death,
invasive procedures, or concerns about
the unknown.

Prof. Dr. RS Mehta, BPKIHS 6

 Although patient may feel secure knowing
that skilled and knowledgeable health care
personnel are attending for fulfilling every
needs of critically ill patients.
 At times patient may develop different
physical and behavioral manifestations
aggravated by stressors as He /She is
immediately separated from significant others
and surrounded by strangers who move about
critical care environment with familiarity and
professional experiences.
Prof. Dr. RS Mehta, BPKIHS 7
 CAUSES OF STRESS IN ICU PATIENT

• A stressor is anything that causes stress.

• It is neither positive nor negative but
rather have positive or negative effects
as the person responds to change .
• In ICU setup illness acts as a stressor.

Prof. Dr. RS Mehta, BPKIHS 8

 CAUSES…

Stressors have physical, chemical and mental responses

inside of the body . Stressor can be either:
 Physical stressor.
 Biological stressor.
 Chemical stressor.
 Environmental stressor.
 Social stressor.
 Psychological stressor.

Prof. Dr. RS Mehta, BPKIHS 9

 CAUSES…

Intensive care units have been considered stress

generating areas. So some of the causes of stress in
ICU patients are :
 Physical aspects :
 Presence of tubes in nose and mouth.
 Impossibility to sleep.
 Immobilization. Loss of autocontrol , decrease a
muscle tone.
 Sensorial deprivation & sensory overload.

Prof. Dr. RS Mehta, BPKIHS 10

 CAUSES…

 Biological aspects :
 Nosocomial infection.

 Chemical aspects :Certain drugs used in ICU can

causes stress :
 Analgesics.
 Sedatives.
 Paralytics.
 Anxiolytic drug.
Prof. Dr. RS Mehta, BPKIHS 11
 …
 Environmental aspects :
 Presence of noise of various devices.
 Presence of excessive over lightening.
 Unfamiliar surrounding.
 Use of all kinds of machines and jargons.

Prof. Dr. RS Mehta, BPKIHS 12

 …

 Social aspects :
 Separation from relatives.
 Lack of social network.
 Security of the patient is questioned.
 Ineffective communication.

Prof. Dr. RS Mehta, BPKIHS 13

 …
 Psychological aspects :
 Lack of attention.
 Depersonalization.

Prof. Dr. RS Mehta, BPKIHS 14

 EFFECTS OF STRESS

 Behavioral :
 Short term : indulge in drugs , alcohol, impulsive
behavior , poor relationship with others, poor work
performance.

 Long term : Marginal family social isolation.

Prof. Dr. RS Mehta, BPKIHS 15

 EFFECTS…

 Physical :
 Short term : headaches, backache, backache ,
insomnia , indigestion , chest pain , nausea,
dizziness , excessive sweating and trembling.

 Long term :Heart disease , hypertension , ulcer, poor

general health.

Prof. Dr. RS Mehta, BPKIHS 16

 …

 Emotional :
 Short term : Tiredness , anxiety, boredom ,
irritability , depression , lack of concentration , low
self esteem.

 Long terms : Depression , neurosis, nervous

breakdown , suicide.

Prof. Dr. RS Mehta, BPKIHS 17

 Needs of critically ill patients
1. Oxygenation
2. Water and fluid
3. Food and nutrition
4. Mobilization
5. Elimination
6. Sleep and rest
7. Safety and security
8. Knowledge
9. Social needs
10.Self esteem needs
Prof. Dr. RS Mehta, BPKIHS 18
 Needs of critically ill patients
1. Oxygenation:
Assess
• Respiratory system: tachypnea, restlessness,
confusion, resp. rate, nail beds
• ABG analysis report
• Auscultate lungs every 8 hour
• Continuous monitoring oxygen saturation level and
inform if less than 90%.

Prof. Dr. RS Mehta, BPKIHS 19

Intervention:
• Suction every 2 hour
• Keep patient in semi-fowler or fowler position
• Measure peak pressure & inform if necessary
• Sedate the patient as needed to control ventilator
fighting
• Decrease Fio2 <50% as quickly as possible to
prevent oxygen toxicity.
• Promote effective secretion mobilization by using
deep breathing & coughing exercise, chest
percussion& postural drainage

Prof. Dr. RS Mehta, BPKIHS 20

• Administer bronchodilators as order to promote
effective airway
• Observe patient closely for increase respiratory
obstruction edema in to the alveoli
• Recognize painful respiration, dyspnea and nasal
congestion
• Administration of mucolytics to liquefy the
secretions

Prof. Dr. RS Mehta, BPKIHS 21

2. Water and fluid
Assess
• Monitor vital signs
• Continous monitor urine output and report if
<30 ml/hrs
• Observe for sign of overload/ wt. gain, increase
output, edema, dehydration, cold &clammy skin.
Intervention
• Wt. daily
• Maintain I/O chart hourly
• Planning of fluid administration as per order
• Administer frusemide as per indicated
Prof. Dr. RS Mehta, BPKIHS 22
3. Food and nutrition
• Obtain nutritional consultation for all ventilator
dependent patients
• Monitor serum albumin level to determine
malnutrition.
• Weight daily
• Start total parental nutrition if patient is unable
to tolerate enteral feeding
• Perform calories counts to ensure adequate
nutrition
• Suggest family bring food from home if patient
does not like hospital food

Prof. Dr. RS Mehta, BPKIHS 23

• Avoid too much carbohydrate feeds as it
may increase co2 production and may cause
hypercapnia
• Keep head of bed elevated if patient is in
naso-gastric feeding to decrease potential
aspiration
• Auscultate for the presence of bowel sound
and medicate to prevent constipation

Prof. Dr. RS Mehta, BPKIHS 24

 4. Mobilization
• Assess for GI problems:
• Preventive measures include antacids or H2
receptor antagonist therapy, adequate sleep cycles
• Observe skin integrity for pressure ulcers
• Turn patient at least every 2 hour
• Back care
• Use pressure relief mattress if indicated
• Maintain muscle strength with active/ active
assistive/ passive ROM exercises and prevent
contractures with use of splints.
Prof. Dr. RS Mehta, BPKIHS 25
 5. Adequate knowledge
• Explain purpose, mode and all treatments
• Explain alarms
• Explain about disease, progress
• Encourage patient to relax and breathe with
the ventilator
• Provide alternate method of communication ;
keep call bell within reach

Prof. Dr. RS Mehta, BPKIHS 26

6. Safety and security needs
• Freedom from harm
• Person must feel safe & secure physically, mentally
& emotionally
• Use proper hand washing technique
• Prevent from infection by using sterile technique
• Explain before the procedure
• Maintain warm adequate body temperature
• Put side rails
• Open visiting or release visiting hours for critically
patients

Prof. Dr. RS Mehta, BPKIHS 27

7. Elimination and waste products
• Catheter care
• Proper cleaning, use of bed pan if possible

Prof. Dr. RS Mehta, BPKIHS 28

8. . Sleep and rest:
• Assess the patient sleep pattern
• Decrease noise level if possible
• Decrease conversation level at bed side
• Turn monitor alarm down if possible
• Provide soft music if possible
• Use dim light if possible
• Cover patient eyes with clean guaze

Prof. Dr. RS Mehta, BPKIHS 29

 9. Social needs:
• Love and affection begin with bonding at birth must
be continous through out the life
• Encourage visitor card and phone call
• Provide verbal clues before touching patient
• Use of signals, signs, nodding, palm writing, lip
reading
• Provide paper & pencil, magic slate
• Allow patient to respond and repeat explanations
• Respect their dignity

Prof. Dr. RS Mehta, BPKIHS 30

10. Self esteem needs
• Positive self esteem, senses of personal worth
• Nurse always assist patient regarding positive self
esteem by encouraging independent, rewarding for
progress

Prof. Dr. RS Mehta, BPKIHS 31

STRESS OF FAMILY AND RELATIVES IN
ICU
 When an individual undergoes a physiologic
crisis and is admitted to an intensive care unit
(ICU); the other family members undergo a
psychological crisis, shock , and disbelief may
be the first emotional experienced by the
family.

Prof. Dr. RS Mehta, BPKIHS 32

CAUSES OF STRESS IN RELATIVES IN ICU

 Prolonged hospitalization.
 Inadequate knowledge.
 Financial burden.
 Impaired communication.
 Fear of losing.
 Limited visiting hours .
 Lack trust with health care workers.

Prof. Dr. RS Mehta, BPKIHS 33

 FAMILY NEEDS

The major needs of families are :

 Relief of anxiety.
 Assurance that care is competent.
 Access to the patient.
 Information about the patient.
 Emotional support.

Prof. Dr. RS Mehta, BPKIHS 34

Family needs of critically ill patient
• Need to be with critically ill patient
• Need to help to the critically ill person
• Need for assurance of comfort of critically ill patient
• Need to be informed of impending death
• Need to ventilate emotions/ feeling
• Need for comfort & support of the family members
• Need for acceptance, support comfort health

Prof. Dr. RS Mehta, BPKIHS 35

 Parents, children, sibling needs
• To feel there is hope
• To feel that hospital personnel doing well
• To know the prognosis of patient’s condition
• To receive the information about the patient once a
day
• To see the patient frequently
• To have explanation about his/her condition

Prof. Dr. RS Mehta, BPKIHS 36

Nursing intervention to meet family needs

1. Cognitive needs:
• To know specific factors about patient progress
• Avoid using generalization. E.g. he is much better
• Use simple term to discuss prognosis of patient
• Relate the prognosis to illness as you have
described initially
• All nurses must use the same terminology

Prof. Dr. RS Mehta, BPKIHS 37

2. To know the probable outcomes
• Be realistic as possible but be aware families coping
mechanism
• If patient prognosis is poor allow to adequate time to
spend with the family
• To inform what is being done for the patient, how the
patient is being treated medically & why things are
being done for the patient
• Briefly describe each line, & or monitoring device
including urinary catheter, NG tube, oxygen devices

Prof. Dr. RS Mehta, BPKIHS 38

• Encourage them to question.
• Remember that explanation may not be enough
• Anxiety is barrier in learning
• Use simple terminology such as breathing tube,
cardiogram & ET tube
• Promote continuity of care through the nursing
care plan

Prof. Dr. RS Mehta, BPKIHS 39

3. To have questions answers honestly
• Be specific, discuss are issues as they relate to
the patient as a unique individual
• Maintain good communication with physician so
that we will be aware of what they have told to
family
4. Emotional needs
• To ensure that best possible care is being given
to the patient
• To be called at home about changes in the
patient’s condition to release information once a
day

Prof. Dr. RS Mehta, BPKIHS 40

5. Physical needs
• Involve them in small procedure
• Allow them to visit any times and have
waiting room near the ICU

Prof. Dr. RS Mehta, BPKIHS 41

ICU Team Collaboration

T - TOGETHER
E - EVERYONE
A - ACHIEVE
M - MORE

Prof. Dr. RS Mehta, BPKIHS 42

 ICU Team Collaboration

• The ICU team is a self-organizing, complex entity that

expands and contracts depending on the needs of the
moment.

• The core team may consist of the bedside nurse,

respiratory therapist, and physician and may expand to
include other disciplines such as social workers,
dietitians, and physical therapists.

• The degree of collaboration and conflicts within the team

fluctuate.

Prof. Dr. RS Mehta, BPKIHS 43

• As a member of collaborative care team, each individual
has a responsibility to:

 interact with team members

 maintain a patient-centered focus of care
 understand and respect the roles and skills of
providers within the team
 listen to and value the input of team members in
the care of a patient
 communicate effectively with all members of the
team
Prof. Dr. RS Mehta, BPKIHS 44
 Contd…

 enhance intra-professional collaboration and

inter-professional collaboration with other
providers
 encourage and foster personal growth of team
members
 champion ethical practice and work with the other
health professions to develop a common code of
ethics to be used by collaborative care teams.
 

Prof. Dr. RS Mehta, BPKIHS 45

Importance of Team collaboration

• Clinical care become more specialized

• Reduces the number of medical errors
• Increases patient safety
• Increase healthcare members satisfaction
• Enhance communication
• Enhance the skills of each members
• Improves the ability to solve the problem
• Improves organizational productivity

Prof. Dr. RS Mehta, BPKIHS 46

Barriers to Team Collaboration

Barriers to effective collaboration includes:

 
• Lack of communication
• Conflict between team members
• Failure to anticipate potential problems
• Legal barriers to participation
• Lack of Resources / Competence
• Lack of knowledge and expertise
• Lack of trust
• Differences in status
• Lack of training
• Poor recording and reporting

Prof. Dr. RS Mehta, BPKIHS 47

Solutions to overcome barriers
 

• Set goals for the future

• Share plans
• Solve problems quickly and successfully
• Make decisions appropriately 
• Assume responsibility when needed
• Provide formal team training
• Make logical and sound judgments
• Work together efficiently
• Communicate effectively

Prof. Dr. RS Mehta, BPKIHS 48

 Contd…

• Coordinate on joint activities

• Learn to listen others
• Recognize and appreciate the differences among team
members
• Learn from mistakes
• Learn more about each individual
• Be open to other’s thoughts and opinions
• Trust and support other team members

Prof. Dr. RS Mehta, BPKIHS 49

Interaction with the ICU team members

• The ICU is a very complex unit, and appears to be an

environment apart from the hospital.

• It may give the impression that it is an independent

unit within the hospital, although it is extremely
interconnected to and dependent on it.

• The ICU care environment needs to offer a warm

reception, be integrative and stimulative to all those
involve in the process of care and/or being under care.

Prof. Dr. RS Mehta, BPKIHS 50

• To serve the health care needs of patients, there must
be a collaborative and respectful interaction among
health care professionals, with recognition and
understanding of the contributions of each provider to
the team.

Prof. Dr. RS Mehta, BPKIHS 51

Thank you

Prof. Dr. RS Mehta, BPKIHS 52