Nutrition.

Patients often arrive at ICUs with conditions that result in either hypermetabolic states (e.g., burns, sepsis) or catabolic states (e.g., acute kidney injury). Other times, patients are in severely malnourished states (e.g., chronic heart, pulmonary, or liver disease). In general, inadequate nutrition is linked to increased mortality and morbidity rates. One contributing factor to underfeeding patients is the frequent interruptions in enteral feedings because of medication administration and multiple tests and procedures. Determining who to feed, what to feed, when to feed, and how to feed (e.g., route of administration) is crucial when caring for critically ill patients.⁵ Collaborate with the physician and the dietitian to determine how best to meet the nutritional needs of ICU patients.

The primary goal of nutritional support is to prevent or correct nutritional deficiencies. This is usually done by the early provision of enteral nutrition (i.e., delivery of calories via the gastrointestinal [GI] tract) or parenteral nutrition (i.e., IV delivery of calories).⁵ Enteral nutrition preserves the structure and function of the gut mucosa and stops the movement of gut bacteria across the intestinal wall and into the bloodstream. In addition, early enteral nutrition is associated with fewer complications and shorter hospital stays and is less expensive than parenteral nutrition.⁵ (Enteral and parenteral nutrition are discussed in Chapter 40.)

Parenteral nutrition is used when the enteral route cannot provide adequate nutrition or is contraindicated. Examples of these conditions are paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis, GI ischemia, abdominal trauma or surgery, and severe diarrhea.

Anxiety.

Anxiety is a common problem for ICU patients. The primary sources of anxiety include the perceived or anticipated threat to health or life, loss of control of body functions, and an environment that is foreign. Many patients and caregivers feel uncomfortable in the ICU with its complex equipment, high noise and light levels, and intense pace of activity. Pain, impaired communication, sleeplessness, immobilization, and loss of control all enhance anxiety.

To help reduce anxiety, encourage patients and caregivers to express concerns, ask questions, and state their needs. Include the patient and caregiver in all conversations and explain the purpose of equipment and procedures. Be sure to structure the patient’s environment in a way that decreases anxiety. For example, encourage caregivers to bring in photographs and personal items. Appropriate use of antianxiety drugs (e.g., lorazepam [Ativan]) and relaxation techniques (e.g., music therapy) may reduce the stress response that can be triggered by anxiety.⁶

Pain.

The control of pain in the ICU patient is vital. As many as 70% of ICU patients have moderate to severe unrelieved pain. Inadequate pain control is often linked with agitation and anxiety and is known to add to the stress response. ICU patients at high risk for pain include those who (1) have medical conditions that include ischemic, infectious, or inflammatory processes; (2) are immobilized; (3) have invasive monitoring devices, including endotracheal tubes; and (4) require invasive or noninvasive procedures.⁷

For some critically ill patients (e.g., those needing mechanical ventilation), continuous IV sedation (e.g., propofol [Diprivan]) and an analgesic agent (e.g., fentanyl [Sublimaze]) are effective strategies for sedation and pain control. However, patients getting deep sedation are unresponsive. This prevents you and other health care providers from fully assessing the patient’s neurologic status. To address this problem, guidelines should include a daily, scheduled interruption of sedation, or “sedation holiday.” These daily interruptions allow you to awaken the patient to conduct a neurologic examination.⁸ (Pain management is discussed in Chapter 9.)

Impaired Communication.

Inability to communicate is distressing for patients who cannot speak because of the use of sedative and paralyzing drugs or an endotracheal tube. As part of every procedure, explain what will happen or is happening to the patient. When the patient cannot speak, explore alternative methods of communication, such as picture boards, notepads, magic slates, or computer keyboards. When speaking with the patient, look directly at the patient and use hand gestures when appropriate. For patients and caregivers who do not speak English, an approved translator or translator phone service must be provided (see Chapter 4).

Nonverbal communication is important. High levels of procedure-related touch and lower levels of comfort-related touch often characterize the ICU environment. Patients have different levels of tolerance for being touched, usually related to culture and personal history. If appropriate, use comforting touch with ongoing evaluation of the patient’s response. Similarly, encourage caregivers to touch and talk with the patient even if the patient is unresponsive.

Sensory-Perceptual Problems.

Acute and reversible sensory-perceptual changes are common in ICU patients. The combination of alterations in mentation (e.g., delusions, short attention span, loss of recent memory), psychomotor behavior (e.g., restlessness, lethargy), and sleep-wake cycle (e.g., daytime sleepiness, nighttime agitation) has been inappropriately called ICU psychosis. The patient experiencing these changes is not psychotic but is suffering from delirium. It is estimated that the prevalence of delirium in ICU patients is as high as 80%.⁹ Significant risk factors for delirium include preexisting dementia, history of baseline hypertension or alcohol abuse, and severe illness on admission. Environmental factors that can contribute to delirium include sleep deprivation, anxiety, sensory overload, and immobilization. Physical conditions such as hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can lead to delirium. Last, certain drugs (e.g., sedatives [benzodiazepines], analgesics [opioids], and antimicrobials [aminoglycosides]) have been linked with the development of delirium.⁹ (Chapter 60 discusses delirium.)

Monitor all ICU patients for delirium. Assessment tools include the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist⁹ (both available at www.icudelirium.org). It is critical to address physiologic factors (e.g., correction of oxygenation, perfusion, and electrolyte problems). The use of clocks and calendars can help orient the patient. If the patient demonstrates hyperactivity, insomnia, or delusions, management with sedative drugs with anxiolytic effects (e.g., dexmedetomidine [Precedex]) can be considered.⁹ In addition, the presence of a caregiver may help orient the patient and reduce agitation. (See eTable 66-1 on the website for this chapter.)

Sensory overload can also result in patient distress and anxiety. Environmental noise levels are particularly high in the ICU.¹⁰ You can limit noise and assist the patient in understanding noises that cannot be prevented. Conversation is a particularly stressful noise, especially when the discussion concerns the patient and is held in the presence of, but without participation from, the patient.¹⁰ Reduce this source of stress by finding suitable places for patient-related discussions. Whenever possible, include the patient or the caregiver in the discussion.

You can also limit noise levels by muting phones, setting alarms based on the patient’s condition, and reducing unnecessary alarms. For example, silence the BP alarm when handling invasive lines and then reset the alarm when done. Similarly, silence ventilator alarms when suctioning. Last, limit overhead paging and all unnecessary noise in patient care areas.