Promoting Sleep and Rest in Critically Ill Patients

Sleep in the Intensive Care Unit

Patients in the intensive care unit (ICU) are susceptible to sleep deprivation. Disrupted sleep is associated with increased morbidity and mortality in the critically ill patients. The etiology of sleep disruption is multifactorial. The article reviews the literature on sleep in the ICU, the effects of sleep deprivation, and strategies to promote sleep in the ICU. Until the impact of disrupted sleep is better explained, it is appropriate to provide critically ill patients with consolidated, restorative sleep.

Sleep architecture in children with adenoidal hypertrophy

AIM

Adenoidal hypertrophy (AH) in children is associated with obstructive manifestations like mouth breathing, snoring. Unfortunately, little is known regarding sleep architecture of AH in children. The purpose of this study was therefore undertaken to investigate the polysomnographic variables in children with AH.

METHOD

47 children with AH and 11 controls underwent nocturnal polysomnography. Sleep was scored manually according to the standard set by Rechtschaffen.

RESULTS

In AH, stage 1 sleep percentage and rapid eye movement (REM) latency were increased significantly, while the sleep percentage of stage 2 and REM was decreased remarkably compared with that of controls. Arousal index in AH was much more higher than that in controls. Arousal index in REM sleep was higher than that in non-rapid eye movement (NREM) sleep in AH, but the number of arousals in REM sleep was lower than that in NREM sleep. Hypopnea events were the most common type of respiratory events, followed by obstructive events in AH and controls. Apnea/hypopnea index in AH was higher in comparison to controls. No significant difference was found between the children with AH and controls in SaO(2) nadir (%) and base mean SaO(2) (%). Apnea/hypopnea index was related to hypopnea arousal in REM sleep and hypoxemia arousal in NREM sleep.

CONCLUSION

AH is predominantly characterised by a hypopnea with little obstruction in children. Our results clearly and for the first time demonstrated that sleep architecture was abnormal in children with AH. We therefore speculate that hypopnea arousal in REM sleep and hypoxemia arousal in NREM sleep may play an important role in the course of respiratory disturbance.

Sleep disturbance: the patient care activities applied at the night shift in the intensive care unit

AIMS AND OBJECTIVES

The aim of the study was to determine the frequency and types of nursing activities on sedated and non-sedated patients in the intensive care unit at night shift.

BACKGROUND

The complex intensive care unit and nursing activities has been described as an environment in which patients enter in a physiological crisis. This is even more so when the patient is unable to communicate or heavily sedated or unable to move. Nursing activities, fear and apprehension cause low morale and sleep disturbance.

METHOD

The study was carried out on a descriptive basis in the Surgical Intensive Care Unit. Thirty sedated and 30 non-sedated patients to whom the nursing care was applied during 19.00-07.00 hours for three consecutive nights were chosen with simple random sampling. Data were gathered by means of retrospective examination of the standard nursing chart notes about the 60 patients for three consecutive nights. Data were analysed using percentage calculations and chi-square test.

RESULTS

The results demonstrate that patient records indicated a mean of 51 interactions per patient per night. Nursing activities were more frequent between 02.00 and 05.00 hours. It was detected that nursing activities such as mouth and eye care, decubitus ulcer care, change of dressing, bed bath, catheter change for three night shifts were more frequently between 24.00 and 05.00 hours. Mechanical ventilation control and endotracheal suctioning were more frequently performed on sedated patients than on non-sedated patients (P < 0.05).

CONCLUSION

These findings of this study indicate that the nursing activities in the intensive care unit were focused on the activities, which will maximize what is seen to be physiological stability.

RELEVANCE TO CLINICAL PRACTICE

This study has provided further data that identify the activities of nurses working in the intensive care unit at night shift. We hope to contribute to the development of the sleep protocol in surgical intensive care units.

Patients’ sleep in an intensive care unit—patients’ and nurses’ perception

The main purpose of this study was to describe how patients treated in an intensive care unit (ICU) perceive their sleep and to compare patients' and nurses' perceptions of the patients' sleep. The study also determined the percentage of patients in the ICU who were able to fill in the Richard Campell Sleep Questionnaire (RCSQ). This instrument consists of six items and utilises a visual analogue scale (VAS). The results of five of the RCSQ questions are used to calculate a total sleep score, ranging between 0 and 100 (0=the worst possible sleep, 100=the best sleep).Approximately half of the patients were able to answer the RCSQ (n=31). The patients' rating of their sleep varied widely (total sleep score: range 0-97, mean 45.5). Patients who had received hypnotics or sedatives during the night (n=12) had a significantly lower total sleep score (mean=31.6) than the rest of the patients (mean 54.3; P=0.037). On comparing the patients' and the nurses' perceptions of the patients' sleep, no significant difference between the groups was seen. This indicates that nurses can use the RCSQ to assess the sleep of patients who are unable to report their sleep themselves.

Nurses’ clinical experiences of the inverse bed position on a neurointensive care unit—a phenomenographic study

Our knowledge of unstable critically ill patients placed in an inverse bed position on the neurointensive care unit (NICU) is fairly limited. The purpose of this study was to ascertain the variation in nurses' conceptions of the impact of clinical experiences on the care and working environments among patients with the head towards the centre of the room on an NICU. An important research question was: how is the nursing care of patients facing inwards on an NICU perceived? Interviews were conducted and analysed with 15 nurses, using the method of phenomenography. From a nursing perspective, four descriptive categories were found, which partly distinguished the nursing psychosocial environment from the physical environment. These were safety and security of mobile computer tomography (CT) on the NICU, availability and overview, integrated holistic view in an open nursing psychosocial environment and adaptation of practical equipment. In conclusion, inverse bed position is important for more individualised neurointensive nursing care among unstable patients subjected to frequent CT scans on the unit. More stable patients should be turned back to the traditional bed position in order to promote their recovery process. This new knowledge is important for the development of quality assurance, with regard to, amongst other things, the patient's dignity.

Sleep deprivation in critical care units

Sleep deprivation is a significant problem for patients in critical care units. Sleep is a complex, active process that is divided into 4 stages of non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep. Noise, lights, discomfort, pain, medications, and stress all contribute to a patient's inability to sleep. Lack of knowledge about the sleep stages, nursing routines, and frequent nursing assessment and interventions also impact the critically ill patient's ability to sleep. Education about sleep deprivation needs to be integrated into critical care courses and orientation programs. Sleep deprivation should be addressed on the multidisciplinary care plan and in health team conference, and nursing care planned accordingly. Sleep medications and their effects should be evaluated for each patient, as well as identifying medications that might be preventing or disturbing sleep.

Sleep disturbance after burn injury

This study describes sleep disturbance and related factors in a group of 74 patients at 1 week after discharge using a sleep problems questionnaire developed by the authors. Results indicated that a significant proportion of patients reported a problem with their sleep (73%). Several items were identified as highly prevalent, including frequent nighttime awakenings (87%), napping during the daytime (65%), sleeping alone (64%), experiencing pain during the night (62%), and difficulties with sleep onset (62%). Results suggest numerous possible interventions to improve patients' sleep quality. The usefulness of a more extensive questionnaire was also indicated.

Fostering hope in the elderly congestive heart failure patient in critical care

This article presents a patient-centered framework applied to the elderly patient with congestive heart failure (CHF). Although the elderly have been the focus of numerous articles, the needs of the elderly CHF patient in the critical care setting, especially concerning hope versus hopelessness, have been neglected. Guidelines for the clinical management of patients experiencing hopelessness are explored. The four dimensions of hopelessness discussed herein are experiential, spiritual/transcendence, irrational, and relational processes. Nursing diagnosis, interventions, goal-setting, and family support also are discussed. Helping the elderly CHF patient maintain hope when confronted with repeated hospitalizations is a challenge for the critical care nurse.

Adjuncts to analgesia. Sedation and neuromuscular blockade

This article provides an overview of some of the current issues involved in sedation and anxiolysis in the intensive care unit. The problems involved in trying to monitor sedation levels are discussed, as are some of the newer options available for physiologic monitoring of the central nervous system. The problem of abnormal mental states in the intensive care unit and the range of antidepressant therapy now available are also covered. The importance of sleep deprivation and the properties of the neuromuscular blockers are also discussed.