critical care psychosis, nursing care for patient affected with physchophysiological and psychosocial

problems in critical care unit

Sub- MEDICAL SURGICAL NURSING

CRITICAL CARE PSYCHOSIS
INTRODUCTION
ICU psychosis or critical care psychosis is a disorder in which patients in an intensive care unit (ICU)
or a similar setting experience a cluster of serious psychiatric symptoms. Another term that may be used
interchangeably for ICU psychosis is ICU syndrome. ICU psychosis is also a form of delirium, or acute
brain failure.
Intensive Care Unit syndrome (ICU syndrome/delirium) is a well-known problem in intensive care
patients. It has been shown that acute confusion or delirium, especially in elderly patients, increases the
length of hospital stay, as well as mortality. The prevalence of delirium in critical care units varies
considerably, ranging from 2 to 57%. The pathogenetic mechanisms of the ICU syndrome/delirium are
not well understood and the matter is still controversial. However, according to the syndrome's
development seems to depend on a complex interaction between the patient's previous psychological
problems, the psychological trauma inflicted by the illness, the stress induced by the environment and
the ICU's treatment and care. Moreover, various physical factors related to abnormal blood
biochemistry values and drugs affecting the functions of the brain appear to be important .

Definition
Psychosis 'a severe mental derangement especially when resulting in delusions and lack of contact with
external reality.’
• The term ICU psychosis implies that the signs and symptoms are associated with a psychiatric
disorder, which is the origin of a true psychosis.
• Assumed that behavioural signs and symptoms are associated with psychiatric disorder. Rarely are the
indications of delirium related to psychiatric disorder.
These disorders are mainly: delirium; anxiety disorders, from simple anxiety to panic disorder with
agitation; adaptation disorders with depressive mood; brief psychotic disorders with persecution ideas

EPIDEMIOLOGY
The vast majority of psychotic episodes in ICUs are organic mental disorders, specifically delirium with
or without preexisting dementia. The incidence of such episodes depends on the patient, the ICU and
illness. Overall, the incidence of delirium is reported to be 2 to 40% of patients in SICUs (20-30% are
open heart surgery patients), 2to 20% of patients in CCUs and MICUs, 4 to 57% in burn units and 5 to
15% in general medical and surgical wards. The incidence is approximately double for those over 60
while delirium is infrequently seen in those under 16.
Other disorders
The incidence in ICUs of psychosis not attributable to organic mental disorders is unknown. One early
prospective study of postoperative patients in general surgical wards showed that 22% of those
interviewed suffered from psychosis during a hospital stay. Diagnoses included delirium in 7.8% of the
patients, delirium and dementia in 5.3%, psychotic depressions in 4%, schizophrenia in 1.2%, hysterical
psychosis in 2.2% and a paranoid state in 1.1%.
ICU psychosis affects 60-80% of ventilated patients and 20-50% of non-ventilated patients. Patients
suffering from ICU psychosis also have a higher chance of staying on a ventilator for a more extended
period and having a restraint episode, an increased risk of self-extubation, and urinary catheter
removal. Patients with ICU psychosis also are at risk for increased mortality after discharge from the
hospital. It should also be noted that studies suggest that 50% of patients suffer from symptoms of
either anxiety, depression, or post-traumatic stress disorder (PTSD) following treatment in an intensive
care unit.

Delirium ‘is an acute reversible organic mental syndrome with disorder of cognitive function,
increased or decreased psychomotor activity and a disorder of sleep wake cycle.’ Greek word de-
lira means ‘off the track’ • Rarely are the indications of delirium related to actual psychiatric
disorders

ETIOLOGY AND RISK FACTORS

The literature on the etiology of delirium in the ICU suggests a broad variety of causative factors. In
addition to physiological disturbances, other causes suggested include psychological stressors, sleep
deprivation, noise, and other environmental factors.

Predisposing factors

Certain individuals are at higher risk for developing delirium. Generally accepted predisposing factors
are alcoholism, drug addiction, cerebral damage, previous episodes of delirium and chronic
cardiovascular, metabolic, respiratory, and renal illness. Patients over 60 are more likely to develop
delirium. Additional preoperative risk factors for postcardiotomy delirium include severe functional
class impairment, an active and dominant personality, and depression

Physiological Causes
The fundamental causal influences for delirium are medical factors and have been comprehensively
reviewed the most common factors include the following: metabolic disturbances, electrolyte
imbalances, withdrawal syndromes, acute infection (intracranial and systemic), pain seizures, head
trauma, vascular disorders, and intracranial space-occupying lesions. Many medications like steroids
and substances cause delirium through intoxication or poisoning and withdrawal eg. Lorazepam,
morphine, midazolam, Phenergan, benedryl etc. Tertiary-referral ICUs are more likely to have patients
with multiorgan dysfunction, increasing the likelihood of development of delirium in these centers.
Patients who have undergone cardiotomy have a unique set of iatrogenic factors contributing to the
development of delirium. In less acute settings, most patients will have multiple contributors.

Premorbid Cognitive Status

The only premorbid factors that have been reliably shown to predict delirium are prior cognitive level
and age. It is argued that age disposes a patient to delirium through changes in pharmacokinetics and
pharmacodynamics, reduced capacity for homeostatic regulation, and structural brain disease and
physiological processes associated with aging. Several studies have demonstrated high correlations
between premorbid cognition and postoperative confusion, disorientation, reduced consciousness, and
even mortality.

Environmental Causes

Sensory deprivation: A patient being put in a room that often has no windows, and is away from family,
friends, and all that is familiar and comforting.

Sleep disturbance and deprivation: The constant disturbance and noise with the hospital staff coming at
all hours to check vital signs, give medications, etc.
Continuous light levels: Continuous disruption of the normal biorhythms with lights on continually (no
reference to day or night).

Stress: Patients in an ICU frequently feel the almost total loss of control over their life.

Lack of orientation: A patient's loss of time and date.

Medical monitoring: The continuous monitoring of the patient's vital signs, and the noise monitoring
devices produce can be disturbing and create sensory overload.

Psychological Factors
The thesis that psychological distress may cause a confused and delirious state has been tempting
because the type and degree of stress on a patient in the ICU is remarkable. Patients are simultaneously
subjected to a threat to life, the awe of medical procedures, an inability to communicate needs, a new
and threatening environment, and the loss of personal control. Early researchers studied preoperative
psychological characteristics, including personality traits and coping styles. Later research has
examined other psychosocial factors, such as marital distress, preoperative anxiety and depression,
ambivalence about surgery, and history of psychosis.

Pathophysiology

The pathophysiology is not fully elucidated and may not be due to a single pathway given the wide
variety of causes. It is generally thought to be an interplay between unique patient characteristics such
as advanced age, and cognition, and physiological insults. Many theoretical mechanisms have been
proposed that range from neurotransmitter dysregulation, neuroinflammation with microglial activation,
oxidative stress, neuronal aging, and sleep-wake cycle dysfunction, among other theories.
Derangements of different neurotransmitter pathways have been seen in the pathophysiology of
delirium and other psychosis, most importantly, dopamine and acetylcholine. Dopamine excess and
acetylcholine depletion have been found linked to delirium. Other neurotransmitters like glutamate,
gamma-aminobutyric acid, serotonin, and endorphins also play a role.
Inflammatory markers produced during a critical illness like cytokines, chemokines, tumor necrosis
factor-alpha initiate a sequence of events leading to microvascular compromise, thrombin formation,
and endothelial damage. Inflammation can cause brain dysfunction by decreasing cerebral blood flow
due to the formation of microaggregates of fibrin, platelets, neutrophils, red blood cells in the cerebral
microvasculature.
Another hypothesis is the reduction of cerebral oxidative metabolism leading to alteration of
neurotransmission. Failure of cerebral oxidative metabolism is found to be important in the
pathogenesis of multiple organ dysfunction in critical illness.
Neurotransmitters level and function are directly influenced by plasma concentration of many amino
acids, and decreased availability of neutral amino acids can lead to delirium in patients admitted to ICU.
There may be some cross-talk between proposed pathways that explain the different phenotypic
presentations of delirium (hyperactive, hypoactive, and mixed), but not enough evidence exists at this
time to definitively describe the pathophysiology behind this condition
Sub types of delirium 1 – Hypoactive delirium • Global and non-specific cerebral dysfunction •
Characteristics – withdrawal, lethargy, lack of responsiveness, disorientation • Often related to
processes such as infection, hypoxia, hypothermia, hypothyroidism, hyperglycaemia, hepatic &
renal insufficiencies (Type often mistaken for depression – note disorientation is common with
delirium, but is not a feature of depression)
Sub types of delirium 2 – Hyperactive delirium • More specific causes, affecting only certain
neurotransmitters in the brain – associated with adverse effects of drug intoxication, chemical
withdrawal, and anticholinergic agents • Characteristics – extreme agitation, emotional lability,
continual movement, disorientation, unable to follow commands, unintelligible / inappropriate
verbal responses, pain is exaggerated (Which type is the most harmful for the patient?)
Mixed Delirium – 2 types • Patients can fluctuate between both types. A number of cerebral
mechanisms are being affected because two or more causal factors are occurring almost
simultaneously

CLINICAL MANIFESTATIONS

The time of onset of delirium depends on the disorder's etiology. In the ICU, delirium may occur as
the patient emerges from coma, during or immediately after operations; or, as is most may complain
of restlessness and irritability, insomnia, lethargy, kinesthetic sensations, vivid, frightening dreams
and difficulty thinking. Staring at a blank wall or gentle pressure on the closed eyelids may cause
formed images of people or scenery. As the disorder progresses, impairments in attention, level of
consciousness, speech, thinking, perception, orientation, memory, judgment and insight become
more prominent.

 Abnormal behavior such as aggression or passivity

  Emotional or personality changes, with frequent mood changes, including anger,
agitation, anxiety, apathy, depression, fear, euphoria, irritability, suspicion
 Slurred speech and language difficulties
 Saying things that don’t make sense
 Changes in feeling (sensation) and perception
 Loss of attention
 Inability to concentrate
 Changes in movement (restlessness or slow movement)
 Changes in sleep patterns
 Memory loss
 Disorganized thinking
 Incontinence
 Signs of medical illness (such as fever, chills, pain, etc.) or medication side effects

In moderate to severe delirium, the patient may be obviously psychotic, displaying increased
psychomotor activity, paranoid delusions and hallucinations (agitated delirium). Equally important
is the withdrawn, mute patient with quiet delirium who is easily missed by the casual observer. Self
injury by falling out of bed or attempting to escape is an all too frequent complication.

Diagnostic evaluation

History and physical examination

 ICU patient’s general and systemic physical examination including neurological examination findings
recorded in case notes is available to a psychiatrist for review who should however conduct any such
examination that may be indicated at the time of attending the call.

 Additional assessment may include extended neuropsychological assessment or specific scales over
and above bedside assessment of MSE. These assessments can be carried out either by the psychiatrist
or any other trained personnel.
 Additional laboratory tests can be ordered to consolidate the clinical impression and to aid the
management and may include biochemical tests (such as drug levels), electrophysiological tests such
as electroencephalogram, or brain scan such as magnetic resonance imaging.
 History will reveal deficits in attention and awareness with at least one alteration in cognition (per
DSM-5 criteria for delirium). These changes often develop within a short time frame and are
frequently noted to fluctuate during the day. An existing or emerging neurocognitive disorder must not
better explain these changes. Of note, indeed, inattention and change in cognition cannot be explained
as a baseline neurocognitive disorder such as dementia or a seriously reduced level of arousal due to
sedative administration or coma.
 Classic assessment of orientation to person, place, situation, and time may not be enough for
evaluation of delirium, as patients can be alert and oriented to all of these but still meet criteria. The
course of delirium can last days to months. Additional symptoms include positive psychotic
symptoms, confusion, lethargy, and drowsiness, among other symptoms.
 A complete neurological and physical exam should be performed and may reveal clues suggesting the
cause of psychosis. The presence of a fever, for example, provides clues of an infectious etiology,
whereas focal neurological deficits may indicate a neurological or vascular cause of the delirium other
psychosis.
Thorough patient history may reveal other clues, including a history of substance or alcohol abuse that
may suggest intoxication, withdrawal, or relevant vitamin deficiency.
Investigations
Laboratory and radiographic testing should be done in the light of the patient's history and
physical exam, with the following investigations providing a partial list of what should be
considered:
 Routine lab monitoring
 Investigation of possible/likely infectious causes (urinary tract infection, meningitis, etc.)
 Investigation of possible/likely metabolic disturbances (hypoglycemia, electrolytes, ammonia,
etc.)
 Investigation of possible/likely intoxication or withdrawal (urine drug screen)
 Investigation of possible/likely neurological or vascular insults (imaging)
 Investigation of vitamin deficiencies
 Investigation of endocrinopathies

Treatment and management

Monitoring
ICU Delirium Assessments:
The Confusion Assessment Method-ICU (CAM-ICU) and the Intensive Care Delirium Screening
Checklist (ICDSC) are both extensively validated and used for delirium diagnosis and evaluation of
delirium over time. They allow the assessment of attention, orientation, memory. Of note, both tools
allow nonpsychiatric ICU personnel to diagnose the complication rapidly and reliably and can be
adopted even when the patient is unable to speak due to endotracheal intubation.
The CAM-ICU provides two steps. In the first one, the level of consciousness/arousal is evaluated
through a standardized sedation scale such as the Richmond Agitation-Sedation Scale (RASS). This
latter is a 10-point scale ranging from +4 to -5, where a RASS value of 0 indicates a calm and alert
patient; RASS scores of -4 and -5 are indicative of coma and cannot be further assessed for delirium.
All other individuals (moderately sedated, RASS score -3 or more alert) should also be evaluated
through the second step assesses patients for four characteristics of delirium. The categories include
acute onset of altered mental status, inattention, disorganized thinking, or altered level of
consciousness. Three out of four features are required for a diagnosis of delirium. The tools, validated
in 1990, has been updated by Marcantonio et al.[23] in 2014, in the 3-Minute Diagnostic Assessment
for Delirium (3D-CAM). It is an algorithm easy to perform and can be used by personnel with minimal
additional training.
Through the ICDSC, the level of consciousness is firstly evaluated on a 5-point scale (A to E) that
ranges from unresponsive (A) to exaggerated response (E). Patients who are scored in the categories
'A=No response' or 'B=Response to intense and repeated stimulation' are no further assessed. The other
patients (C to E levels of consciousness) are checked for information collected during the previous 24
hours, investigating eight items (rated present or absent) with a total score of 0 to 8. A score of 4 or
greater is considered diagnostic of delirium.
Other evaluations
In addition to the tools for ICU detection, a careful clinical assessment must be performed. For instance,
it is mandatory to perform frequent vitals and/or neuro checks.
Pharmacological and Non-pharmacological Management Strategies:
It is generally accepted that there are no identified therapies (medications or interventions) proven to
decrease the duration of delirium. As a consequence, treating the underlying physiological insult is of
key importance. Also, other interventions should be considered for delirium management:
 Treatment of the underlying cause
  Correction of potential electrolyte disturbances
 Removal of offending pharmacological agents
 Maintain proper sleep/wake cycles
 Manage pain
 Address sensory impairments (hearing, vision)
 Encourage family visits and frequent reorientation.
 Early mobilization
Interventions for symptomatic ICU treatment can be divided into pharmacological and non-
pharmacological strategies.
Medications
There is much debate regarding the utility of antipsychotics and other medications such as
physostigmine, rivastigmine, and donepezil in preventing and decreasing the duration of delirium. In
the ICU setting, although there is no evidence that treatment with haloperidol will reduce the duration
of delirium, it is the most commonly adopted treatment. Moreover, there is some evidence that atypical
antipsychotics may be useful.
 Antipsychotics. This category includes haloperidol and atypical antipsychotics. Haloperidol is
a dopamine (D2) receptor antagonist. It is given at the dosage of 2-10 mg (IV every six h); it is
useful, especially in the hyperactive form. Atypical antipsychotics used for this purpose are
olanzapine (IM 5-10 mg; max: 30 mg/d), risperidone (0.5-8 mg), quetiapine (orally 50 mg; max
400 mg/d), and ziprasidone. A special issue concerns antipsychotics-related toxicity. For
instance, cardiotoxicity such as QT interval (QT) prolongation, torsade de pointes, hypotension
is reported at high doses haloperidol, whereas a dosage of 2 mg can be safely administered. Of
note, caution should be taken when antipsychotics are used with other QT-
prolonging medications. Other commonly used classes of drugs that are associated with QT
prolongation include, but are not limited to, antiarrhythmics, antibiotics, antiemetics, and
antidepressants as well as methadone, lithium, octreotide, and tacrolimus, among others. A
baseline EKG and further assessment may be warranted. Antipsychotics can also induce
extrapyramidal symptoms (EPSs) expressed as parkinsonism featuring dystonic reactions or
akathisia. Rarely, haloperidol can cause neuroleptic malignant syndrome, whereas insomnia and
agitation can often be observed. In the case of atypical antipsychotics, EPSs can manifest at
high doses. Again, olanzapine and quetiapine may induce excessive sedation, whereas
ziprasidone is more associated with QT prolongation.
 Dexmedetomidine: This alpha-2-adrenergic agonist with sedative, analgesic, and anxiolytic
actions is useful in adults under MV when hyperactive delirium can obstacle the weaning. Due
to the low-quality evidence of investigations assessed, a panel of experts did not recommend its
use. Side effects include bradycardia and hypotension or hypertension.
 Short-acting benzodiazepines (BDZs). These agents, such as midazolam and lorazepam, can
have a neurogenic effect. They are exclusively useful in patients with alcohol or sedative
withdrawal, or for delirium resulting from seizures.
 Other drugs. Although rivastigmine, donepezil, physostigmine has been proposed for ICU
delirium management, evidence of effectiveness is currently very scarce.
Non-pharmacological interventions

 Psychological intervention, especially supportive counseling, as permitted by patient’s present state,

is helpful in alleviating fear, anxiety, and stress associated with the illness and with ICU milieu.
 Briefing ICU staffs about the anticipated response of psychiatric intervention, watching out for any
adverse response, and prompt reporting of the same are important steps to ensure quality care. If any
PRN prescription is made, it is best to specify the situation which should trigger its use.
 Briefing patient relatives about the psychiatric intervention being prescribed is equally important,
especially considering the fact that many ICU patients may be in a vulnerable condition unable to
consent in true sense. However, due care should be taken to protect confidentiality of patient
narrative, particularly when the patient has indicated so, as is often the case in suicide attempt.
 Being the place of treatment of critically and terminally ill patients, ICU is also the setting of several
ethical dilemmas and considerations, which may range from physical procedures, such as application
of restraints, to psychological procedures such as breaking bad news, preparation for end-of-life
situation and helping relatives make difficult decisions such as taking patients off life support, and
facilitation of advance directives
 Behavioral strategies. This category includes several strategies focused on patient
reorientation useful in cooperative patients with delirium. Occupational therapy and
patient, and family training have been successfully proposed for this aim.
 Mobilization. Early ICU mobility therapy can accelerate MV weaning, ICU length of stay, and
delirium duration.
 Use of restraints. Careful use of soft restraints only if and after behavioral and pharmacological
interventions fail if reasonably possible. The use of restraints should be used for the shortest possible
time and should be focused to deter a specific behavior that is impeding the delivery of care.
Prevention
In the ICU ward, there is some evidence that targeting modifiable risk factors and multicomponent
patient-centered approaches may decrease the incidence and average duration of psychosis. These
include interventions improving cognitive impairment, good sleep hygiene, mobility, vision, and
hearing. Besides, strategies for preventing infection, dehydration, constipation, and hypoxia are
mandatory. Currently, no pharmacological agents have enough evidence to recommend their use in
preventing delirium and other psychological issues. In the ICU setting, mechanically ventilated adult
patients at risk of developing delirium may benefit from dexmedetomidine infusions (e.g., 0.1 μg/kg per
hour) over BDZs infusions in regards to decreasing the prevalence of delirium. Melatonin is probably
useful for ICU delirium, but further studies are needed. There is also evidence that early mobilization of
the adult ICU patient population may reduce the duration and incidence of delirium.
A mnemonic ABCDEF bundle was proposed for assessing and preventing the complication.
 A=Assess, prevent and manage pain
 B=Both Spontaneous Breathing Trials and Spontaneous Awakening Trials
 C=Choice of sedation and analgesia
 D=Delirium: assess, prevent and manage
 E=Early mobility and exercise
Complications
Critical care psychosis in hospitalized patients is associated with several complications such as
increased hospital costs, health care complications, and increased mortality. Moreover, a recent meta-
analysis showed that the complication is linked to long-term cognitive decline in both surgical and
nonsurgical patients. Critically ill patients that develop delirium may have numerous complications
including:
 Increased of mortality
 Longer duration of MV
  Longer lengths of stay in the ICU
 Higher incidence of unintentional removal of catheters, endotracheal tubes, and urinary
catheters
 Higher incidence of ICU readmissions
 Increased risk of post-ICU cognitive impairment
In addition, there is a rise in the cost of care

 PREVENTION AND NURSING CARE FOR PATIENT

EFFECTED WITH PSYCHOPHYSIOLOGICAL AND
PSYCHOSOCIAL PROBLEMS
Stress is a potent pathogenetic factor because of the hormonal, inflammatory and neuroendocrine
responses it elicits; which may accentuate physiologic derangements. Stress stimuli are non-specific,
that is, psychological stressors display similar neurohormonal and secretagogue patterns, as well as
psycho-physiologic effects, as those described for physiological stressors

Psychophysiological alteration

The primary behaviors observed with psychophysiological responses are the physical symptoms.
These symptoms lead the person to seek health care. Psychological factors affecting the physical
condition may involve any body part. The organ systems most commonly involved and the
associated physical conditions. Longer hospital stays have been reported to be associated with
greater psychological comorbidity, particularly depression, anxiety, and organicity.

Nursing Diagnoses

The nursing diagnosis must reflect the complex biopsychosocial interaction that is the hallmark of
psychophysiological disorders. The patient's effort to cope with stress-related anxiety may result in
many somatic and emotional disorders. All possible disruptions must be considered when
formulating a nursing diagnosis.

The nurse must use good communication skills during the interview to enable patients to share their
experience as completely as possible. Areas of resistance and gaps in information should be noted as
possible indicators of a conflict. These may be explored more completely as trust is established in
the nurse-patient relationship.

Questions related to lifestyle and activities may help identify precipitating stressors and coping
behaviors. It is particularly important to elicit the patient's view of what is happening. This response
will provide valuable information about the patient's awareness of the relationship between mind
and body. Nonverbal behaviors also give clues about the patient's concerns. Apparent lack of
concern may reveal the use of denial suggestive of a conversion disorder.

As the diagnosis is formulated, the nurse must consider the patient's coping in the context of the
stress response. Is the patient in the stage of alarm with many coping resources at hand? Or is the
patient in the stage of resistance, using coping mechanisms but depleting personal energy resources?
Has the patient reached the stage of exhaustion, needing intensive intervention? The interventions
selected should be based on the individual's level of stress and coping responses. The six primary
nursing diagnoses for maladaptive psychophysiological responses are as follows
 1.Risk-prone health behavior -a state in which the patient is unable to modify lifestyle in order to
improve health status

2.Ineffective denial-a state in which disavowal is used to reduce anxiety but leads to the detriment of
health

3. Chronic pain-a state that continues for longer than 6 months

4. Insomnia a disruption in the amount and quality of sleep that impairs functions

5. Sleep deprivation-prolonged periods of time without sleep 6. Stress overload-excessive amounts

and types of demands that require action Nursing diagnoses related to the range of possible
maladaptive responses are presented.

Prevention

MANAGEMENT

Pre ICU prevention.

If ICU admission is elective, identify and treat predisposing factors if possible (by detoxification,
vitamins, etc). The ICU staff should be alerted to these risk factors and to the current therapeutic
regimen. Decrease surgical organic precipitating factors if possible. Diminish facilitating factors by
careful preparation of the patient and family. Planned interventions and possible adverse effects,
particularly delirium, should be described. A visit to the ICU and a meeting with the staff who will
be involved help to orient the patient and establish a working alliance. Very anxious or obviously
fearful patients stand to benefit most from this approach. It is particularly important to treat
depressive disorders before admission or surgery if at all possible, because of the increased risk of
morbidity and death.

A dominant, active patient with a low level of anxiety does not tolerate dependency or
immobilization well and must be encouraged to work with the staff to defeat his illness.

ICU prevention and treatment

Many of the measures described in this section are empirically based and have not been validated by
controlled trials. However, newer SICUs and CCUs have reported decreased incidence of
postcardiotomy delirium and improved patient reassurance by the ICU.Staff/patient relationships:

The presence of familiar staff or family members helps improve orientation, decreases anxiety about
strangers and builds trust. An empathic, humane, respectful approach and direct communication
decrease patient frustration and anxiety. Autonomy in self care should be encouraged as soon as it is
feasible.

Early recognition of delirium and psychosis:

Regular use of brief, structured questionnaires to determine attention span, orientation, memory and
perceptions aids diagnostic and orientating activities. Patients can be encouraged to report
distressing symptoms as soon as possible.

Facilitating factors:
Anxiety is decreased by adequate staff/patient relationships, the presence of a trusted relative,
adequate information and reassurance about symptoms and procedures, and orientating activities.

Sleep deprivation may be reduced by arranging nursing, investigational and visiting schedules to
provide the patient with blocks of time to reestablish more normal sleep patterns.

The sensory environment can be improved by removing unnecessary machinery from the patient's
immediate environment and providing familiar sounds (e.g., radio, television, conversation).
Windows, natural lighting, a night light and privacy are all desirable. Eye patches should be
unilateral and/or have small openings, especially in the elderly.

Immobility is a major source of frustration, sensory monotony and physical complications. The
patient should be mobilized as rapidly as possible. Unfortunately, the psychotic patient may have to
be protected by bedsides and, at times, restraints, Orientation to time, place and people is aided by
interactions with staff and the presence of familiar items, clocks, calendars and schedules all placed
in the patient's sight.

Pain management includes scheduling adequate amounts of analgesics, avoiding unnecessary

painful procedures and using distraction and staff reassurance. Patients should be warned
interventions may be painful and allowed to ventilate anger at the procedure, rather than at the nurse.
Patient communication is enhanced by an interpreter, writing tablet or alphabet board, if required.
Staff should be sensitive to patients approaching them indirectly for reassurance and explanations,
particularly following delirium.

Psychological Approaches

The psychophysiological symptom defends the person from overwhelming anxiety. It provides a
way to receive help and nurturance without admitting the need for it. Recognizing the defensive
nature of the symptom, the nurse should never try to convince the patient that the problem is entirely
psychological. Likewise, the attitude that the patient needs only to get his life under control to get
better is not therapeutic. The patient has not made a conscious choice to be hypertensive or to
develop a conversion disorder.

The dilemma of these disorders is that the patient consciously would like nothing more than to be
cured but is unconsciously unable to give up the symptom. Conscious recognition of the
psychological role of the symptom defeats its purpose and is therefore vigorously resisted. An
example of this resistance is illustrated in the accompanying clinical example.

Selected Nursing Diagnoses

• Ineffective denial related to early life events, as evidenced by symptoms affecting sight and
hearing

Psychological approaches include cognitive behavioral strategies, supportive therapy, group therapy,
stress reduction, relaxation training, and complementary and alternative therapies such as
meditation, biofeedback, massage therapy, and physical activity. The nurse should be supportive and
available to talk with the patient and provide physical care.

Behavioral change and cognitive interventions for patients with psychophysiological disorders
require that the patient's underlying thoughts and feelings be recognized and examined. For
example, it has been found that more frequent "catastrophizing" responses, such as "I will never get
over this pain and my life as I know it is ruined," predict higher levels of distress and disability.
More positive responses, such as "I'm a fighter, and this is not going to get me down," tend to be
associated with better functioning. The next step is to identify and explore the patient's

The physical disorder may worsen if the therapy moves too rapidly. The nurse may recommend
changes in the environment to help the patient function more comfortably. If the patient must
consider a job change or another lifestyle change, the nurse can offer time to talk about alternatives.

Patient education

Health education is important in caring for the patient with a psychophysiological disorder. These
patients usually need instruction about medications, treatments, and lifestyle changes. The patient
and family will need information about mental health promotion , follow-up care, and crisis
management and education about ways to cope with anxiety and stress.

The effective treatment of sleep disorders requires that the underlying cause of the sleep problem be
identified. Drugs and alcohol often produce fragmented sleep, as does caffeine. Poor sleep hygiene
habits also may be a problem. All patients with sleep problems should be educated on sleep hygiene
strategies.

Physiological Support

A patient who has been relying on alcohol or drugs to cope with stress should identify and use more
adaptive coping mechanisms. A variety of physiological treatments can be implemented by the
nurse, including the following:

 Relaxation training can be very helpful in promoting adaptive psychophysiological

responses, particularly pain management and sleep.
 Encouraging physical activity is a positive way of promoting stress reduction. Ideally, it
should be an activity that the patient enjoys and can share with others.
 Nutritional counseling about healthy eating patterns may be helpful in building the person's
resistance to stress and illness. Patients who are under stress should not overuse dietary
stimulants such as caffeine. They may need education about the elements of a healthful diet
and help in planning balanced meals.
 Medications can be helpful.
 Insomnia can be treated with the medications. These drugs should be used only for a
limited time for short-term sleep management. Onset of action and elimination half-life are
important pharmacological properties that differentiate these medications. Benzodiazepines
are not recommended for patients with a history of drug use or dependence.
 Narcolepsy can be treated with dextroamphetamine (Dexedrine), mixed amphetamine salts
(Adderall), methylphenidate (Ritalin), modafinil (Provigil), and sodium oxybate (Xyrem).
 Restless legs syndrome can be treated with ropinirole (Requip) and pramipexole
dihydrochloride (Mirapex).
 Chronic pain can be treated with medications from the following medication categories:
antidepressants, anticonvulsants, benzodiazepines, opioids, lithium, stimulants, and
antipsychotics.
 Herbal therapies include chamomile, a calming herbal tea that may be taken before
bedtime, and valerian, a central nervous system depressant. Melatonin may be helpful if
insomnia is related to shift work or jet lag.

Psychosocial alterations
In the critically ill Aside from pain and noxious stimuli in ICU, research points to fear, isolation, loss of
control and negative expectations as major mediators of the high levels of stress. Fear, anxiety, agony,
self-concept alterations including body image, self-esteem and role performance disturbance, loneliness,
depersonalization, along with perceived powerlessness, hopelessness, bewilderment, and acute
confusion, to terror attacks and panic are among the better documented psychosocial alterations in the
critically ill. A need to feel safe was identified as their primal need by ICU patients, whereas, the
significance of emotional support by staff and family members has been emphasized

Psychosocial care: To meet the person’s psychosocial needs, the nurse should identify the person’s
expectations and needs, as well as their cultural and spiritual values and belief system. From where does
the person receive strength? Nurses must also provide care to help alleviate any anxiety and/or guilt in
the person. Anxiety about the unknown is common when awaiting diagnosis or test results, but
individuals also experience anxiety from not understanding the future implications of a

The nurse should encourage open discussion and the expression of fears and concerns. Feelings of guilt
and fear are very common as a person deals with the loss of the expectation and dream of a healthy,
productive life. Depression also can occur in the individual with the chronic condition. The clinician
must maintain awareness of the possibility of depression and be proactive in obtaining support for the
individual or family. The nurse also is responsible for assessing the person’s coping mechanisms as well
as available family, spiritual, cultural and community support systems. Both individual and family
strengths need to be identified. Working in collaboration with the other members of the healthcare team,
nurses can refer the person to a support group.

Psychosocial Considerations
1. Scope of critical care nursing practice
a. “The scope of practice for acute and critical care nursing is defined by the dynamic
interaction of the acutely and critically ill patient, the acute or critical care nurse and
the health care environment” (American Association of Critical-Care Nurses [AACN],
 Critical illness is a crisis for both the patient and family members. This crisis situation can present
numerous, oftentimes complex psychosocial issues and problems that require the expertise of
the critical care nurse working collaboratively with the multidisciplinary team. The crisis of a
critical illness may be superimposed on other chronic stressors (e.g., addiction).
c. Needs or characteristics of the patient and family influence and drive the characteristics or
competencies of the critical care nurse
Challenges of meeting psychosocial needs
i. Other conflicting priorities such as addressing the physiologic instability of the patient may
preclude or inhibit nurses from meeting the psychosocial needs of the patient and family
ii. Psychosocial needs often involve family members (an aspect unique to psychosocial needs in
contrast to physiologic needs); for example, issues such as grief and loss, and powerlessness
may pertain more to the family than to the patient in some situations (e.g., brain-dead patient)
iii. Value systems in critical care units often emphasize performing nursing tasks over attending to the
psychosocial needs of the patient and family
iv. Meeting psychosocial needs demands a coordinated, multidisciplinary approach to care
v. Critical care environment is often a barrier to effectively meeting psychosocial needs
vi. Growing evidence supports an interrelationship between psychosocial and physiologic problems
(e.g., stress and immunity)
Critically ill patients share some common, predicable psychosocial needs (e.g., the need for
reassurance and support)
ii. Specific patient psychosocial needs vary depending on patient and family
characteristics and the patient’s status on the health-to-illness continuum
iii. The more compromised the patient, the more complex the patient’s needs
iv. Critically ill patients’ psychosocial needs are based on patient characteristics,
including resiliency, vulnerability, stability, complexity, resource availability,
 participation in care and decision making, and the predictability of the illness
(AACN, 2003; Hardin and Kaplow, 2005)
v. Patient characteristics and needs influence family members’ needs and
psychosocial issues
Nursing Care

1. Interdependence—Many of the psychosocial issues and concerns of the critically ill patient are
interdependent. For example, inadequately managed pain may lead to feelings of
powerlessness, anxiety, and depression that, in turn, heighten the patient’s perception of pain
2.Powerlessness
a. Description of problem
i. Perceived lack of control over the outcome of a specific situation. The ability of
an event to engender a sense of powerlessness is influenced by the individual’s
self-esteem and self-concept and where the individual is in the life cycle.
ii. Critically ill patients lose their ability to control even the most basic of functions,
including the ability to communicate, to breath on their own, and to control
bladder and bowel function. Depending on the philosophy and organization of
the critical care environment, they may also lose the ability to participate in
decision making about their own health care and future.
b. Goals of care
i. Patient communicates needs and wishes verbally or nonverbally
ii. Patient (and family as appropriate) participates in decision making regarding the
plan of care
iii. Patient and family members do not demonstrate signs of dysfunction associated
with powerlessness, such as the following:
(a) Withdrawal
(b) Aggressive behavior
(c) Demanding behavior
(d) Excessive repetition of the same questions
(e) Placing of unrealistic demands on the staff
(f) Blaming of the staff for the patient’s condition
iv. Patient participates in decision making regarding daily care activities (e.g.,
timing of bath, sleep, visiting hours)

c. Interventions
i. Promote patient-nurse communication
(a) This intervention presents significant challenges, particularly if the patient
is intubated or speaks a language other than English (or the predominant
language at the facility)
(b) Methods of communication should be based on patient preferences and
abilities. Common communication techniques for use with intubated
patients include lip reading, picture or alphabet boards, pen or pencil
and paper, and computer.
(c) Utilize available interpreter services for non–English speaking patients
and family members
(d) Enlist help from family members and volunteers in the communication
process
ii. Involve the patient and family in the care planning process and decision making
(a) Ask the patient (or health care proxy) what level of involvement he or she would
like in the care planning process
(b) Encourage the patient and family members to keep a record of questions and
concerns
(c) Provide the patient, proxy, or a family member with daily (or more frequent)
updates regarding the patient’s status and care plan
 iii. Encourage the patient and family members to meet with spiritual support persons
if they would find this helpful
iv. Prepare the patient for procedures: Explain what will be happening, when it will
happen, and how the patient will be affected
d. Evaluation of patient care: Patient and family are active participants in care planning
and delivery (to the extent possible)
3. Sleep deprivation
a. Description of problem: Sleep deprivation in the critically ill patient involves a decrease
in the amount, consistency, and/or quality of sleep that occurs in a 24-hour period.
Sleep fragmentation occurs when the patient fails to complete a 90-minute average
sleep cycle that includes both rapid eye movement and non–rapid eye movement sleep
(Gawlinski and Hamwi, 1999).
b. Goals of care
i. Patient has at least two 90-minute periods of sleep in a 24-hour period
ii. Patient states that he or she feels rested
iii. Patient does not demonstrate signs and symptoms of sleep deprivation, including
the following:
(a) Altered mental status (e.g., confusion, delusions)
(b) Decreased alertness
(c) Irritability
(d) Aggressive behavior
(e) Restlessness
(f) Anxiety
(g) Exhaustion
c. Interventions
i. Attempt to provide at least two 90-minute periods of uninterrupted sleep in a 24-
hour period
ii. Cluster activities so that the patient is allowed periods of rest
iii. Prioritize activities to allow a stable patient to have periods without unnecessary,
frequent assessments
iv. Decrease the noise level to promote sleep
v. Decrease overhead lighting to promote sleep
vi. Provide adequate pain relief
vii. Teach the patient and family relaxation techniques to promote rest and sleep
viii. Administer pharmacologic agents as needed to promote sleep (e.g.,
benzodiazepines, diphenhydramine). Note: Long-term use of benzodiazepines
can abolish stage IV sleep.
ix. Consult with a pharmacist regarding the best drug choices for promoting sleep,
particularly for high-risk populations such as the elderly
e. Evaluation of patient care
i. Patient does not demonstrate signs or symptoms of sleep deprivation
ii. Patient states that he or she feels rested
4. Grief and loss
a. Description of problem: The grief reaction is the emotional response to a loss in which
something valued is changed or altered so that it no longer has its previously valued
traits (Gawlinski and Hamwi, 1999)
i. Grief can be experienced during a critical illness by both the patient and family
members
ii. Grief may result from loss (or potential loss) of health, body image, role, and
financial security
iii. Family members experience grief related to a patient’s death or in anticipation of
death or potential death
iv. Degree of grief experienced is related to the meaning of the loss to the
individual, the adequacy of coping responses, and the availability of support
systems
 v. Expressions of grief have wide variation and are culturally determined
b. Goals of care
i. Patient and family express feelings of grief and loss (if they choose)
ii. Patient and family are able to state the prognosis and current plan of care

c. Interventions
i. Appreciate cultural variation in expressions of grief
ii. Allow the patient and family members to express grief in their own way
iii. Provide privacy for family members and patients
iv. Provide ongoing, honest information to the patient and family regarding the
patient’s illness and expected recovery
v. Provide the patient and family with teaching regarding the normal grief
response
d. Evaluation of patient care: Patient and family express grief in a culturally appropriate
way

 CONCLUSION
Stress and negative emotions may have both immediate, as well as long-term effects on patients’
psychological and physical well-being, and have been linked to delayed physical recovery. The
provision of psychological/emotional support is one of the traditional nurses’ roles. Within the
context of holistic nursing, psychological support is viewed as a prerequisite for healing, whereas,
not meeting the psychological needs of patients has been suggested to prolong intensive care unit
(ICU) stay and to be a factor in delirium-related psychotic symptoms. Despite a recognized need for
emotional support.

 JOURNAL REFERENCE
Psychiatric disorders in intensive care units
Ampélas JF, Pochard F, Consoli SM. Les troubles psychiatriques en service de réanimation [Psychiatric
disorders in intensive care units]. Encephale. 2002 May-Jun;28(3 Pt 1):191-9
The diagnosis and treatment of psychiatric disorders in intensive care patients have been for a long time
neglected. They are nowadays better recognized and managed. These disorders are mainly: delirium;
anxiety disorders, from simple anxiety to panic disorder with agitation; adaptation disorders with
depressive mood; brief psychotic disorders with persecution ideas. The manifestations of psychiatric
disorders occur not only during the stay in intensive care unit (ICU) but also after transfer from ICU
and several months after discharge from hospital. Part of psychiatric disorders is caused by organic or
toxic causes (metabolic disturbances, electrolyte imbalance, withdrawal syndromes, infection, vascular
disorders and head trauma). Nevertheless some authors estimate that they are due to the particular
environment of ICU. The particularities of these units are: a high sound level (noise level average
between 50 and 60 dBA), the absence of normal day-night cycle, a sleep deprivation, a sensory
deprivation, the inability for intubated patients to talk, the pain provoked by some medical procedures,
the possibility to witness other patients' death. Although most patients feel secure in ICU, some of them
perceive ICU's environment as threatening. Simple environmental modifications could prevent the
apparition of some psychiatric manifestations: efforts should be made to decrease noise generated by
equipment and staff conversations, to provide external windows, visible clocks and calendar, to ensure
adequate sleep with normal day-night cycle and to encourage more human contact. Psychotropic drugs
are useful but a warm and empathetic attitude can be very helpful. Some authors described specific
psychotherapeutic interventions in ICU (hypnosis, coping strategies.). To face anxiety, many patients
have defense attitudes as psychological regression and denial. Patient's family is suffering too.
Relative's hospitalization causes a crisis in family. Unpredicted illnesses often force family members to
reorganize in order to regain their equilibrium. Every family should be proposed a psychological
support. Caregivers can be distressed as well. This stress is due to their high responsibility and the fact
that they face disease and death. Simple measures can lessen stress'effect and prevent the burn-out
syndrome . In conclusion, the importance of a liaison psychiatrist-intensive care physician collaboration
must be emphasized in order that patients and their family have a better psychological support.
Psychological management should be proposed during the hospitalization and after discharge from
hospital.
 BIBLIOGRAPHY
1. Stuart Gw, Principles And Practice Of Psychiatric Nursing;10th ed: Elsevier
publication:2018. Page-245-57
2. Providing psychological support to people in intensive care: development and
feasibility study of a nurse-led intervention to prevent acute stress and long-term
morbidity - PMC (nih.gov)
3. Psychiatric management of Patients in intensive care units - PMC (nih.gov)
4. [Psychiatric disorders in intensive care units] - PubMed (nih.gov)
5. ICU Delirium - StatPearls - NCBI Bookshelf (nih.gov)
6. Palliative Care and Psychosocial Contributions in the ICU | Hematology, ASH Education
Program | American Society of Hematology (ashpublications.org)