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What the patients say
What the patients
say
Janet V. Heath INTRODUCTION The aim of this review was to examine the recollections of patients on Intensive Care Units. Most of the staff working on Intensive Care Units believe that patients have few memories of their time in the unit. However, there is a considerable amount of literature on this aspect of intensive care. Much of this evidence is anecdotal but a number of intensive care units have carried out studies to look at what recollection patients have of their admission (Keep 1980, Bergbom et al 1988a, 1988b, Uprichard et al 1987, Hewitt 1970, Chew 1986, Bradburn & Hewitt 1980, Jones et al 1979, Asbury 1985). The majority of the information which will be presented is from a collection of personal accounts of health care professionals some of whom work on intensive care units. These individuals have all spent a time as patients in intensive care and have written about their memory and experiences. Hence this article looks at ‘What the patients say’. The personal accounts ofpatients admitted for a variety of conditions and requiring a wide range of treatments date from 1957 to 1987. All the patients reviewed, who are listed in Table 1, received a variety of drugs for sedation.
Airway management Respiratory system care frequently requires the passage of an endotracheal tube. Intubation may be undertaken either as an elective procedure or occasionally as an emergency and may be performed orally or nasally. Tracheostomy may be Janet Victoria Heath E.N.B. 100. Southampton General Hospital, Shirley, Southampton, SO9 4XY (Requests for offprints to JVH) Manuscript
accepted
2 July
7989
performed as an alternative to intubation in a number of clinical circumstances. Few patients are given the choice of the type ofintubation performed. Patients who have advanced warning of the need for an artificial airway may be given time to come to terms with this type of medical intervention. It is generally patients who have had progressive respiratory failure and are possibly going to require some form of long term ventilation who may be given time to contemplate having a tracheostomy. In the literature patients who have some medical or nursing knowledge often discuss their feelings towards tracheostomy, and most of them express horror at a prospect such as ‘a tracheostomy was inescapably indicated’ (Henschel 1977). After being nasally intubated for a relatively short period of time, however, a different patient comments ‘1 week later I welcomed the decision to replace the most uncomfortable nasal tube with the previously dreaded tracheostomy’ (Clarke 1985). Patients who are able to recall being intubated describe the presence of the endotracheal tube as being incredibly uncomfortable, particularly while they were being moved or turned when the nurses were not concentrating on supporting the patient’s head (Uprichard et al 1987, Parker et al 1984, Shovelton 1979, Smith 1987, Donald 1976). One patient who was having intensive care as a result of an elective procedure and had been to visit the unit pre-operatively to meet the staff describes the short time he was intubated. ‘I had been warned that the tube would be unpleasant but that proved to be an understatement.’ One author (Smith 1987) as a result of her asthma has required several admissions to intensive care units and has had experience of both
102
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Table 1 The penonal was based
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accounts
on which
meet of this work
1. C. Smith. Nurse Tutor, has no professional intensive care experience. An asthmatic who has experienced several admissions to intensive care units both as a ventilated and nonventilated patient. 2. Anonymous. A medical person. Experienced an admission to intensive care as a result of having a cardiac arrest on a medical ward. 3. I. Donald. Consultant gynaecologist. Two articles have been written by this gentleman who was electively admitted to cardio-thoracic intensive care units following surgery to his mitral valve, there being 6 years between each operation. 4. J. Bevan. Final year medical student. Admitted to intensive care as a result of polyneuropathy requiring artificial ventilation via a tracheostomy. 5. D. Shovelton. Professor of conservative dentistry. Electively admitted to the intensive care unit for post operative ventilation following a Thyomectomy for Myasthenia Gravis. 6. E. Henshall. Professor of anaesthesiology. Required several weeks of artificial ventilation due to Guillain Barr4 syndrome. 7. An unnamed American nurse. Intensive care nurse. Developed pneumonia and required ventilation and therapeutic paralysis. 8. S. Redfern. Lecturer in nursing studies. Admitted to a high care unit in Switzerland following an accident whilst climbing when she sustained a head injury, she did not require ventilation. 9. J. Clarke. Registered nurse. Spent 9 weeks on an intensive care unit as a result of Guillain Barre syndrome and was ventilated via a tracheostomy. 10. N. Cooke. Now a consultant physician. Describes his experience as a 15 year old school boy who was in intensive care due to Influenza pneumonia and had a tracheostomy but was not ventilated. 11. A. P. bandy. Analytical chemist spent several weeks in intensive care as a result of Tetanus and was ventilated via a tracheostomy.
nasal and oral endotracheal tubes. She recalls feeling soreness of the nasal mucosa in contact with nasal tubes, the degree of discomfort seeming to be related to the trauma encountered at intubation. However, she considers a nasal tube a better alternative than the oral tube which causes a constant ‘gagging’ sensation. Several patients mention that they made attempts to support their tube in the ‘optimum position’ only to have a nurse grab their hands or shout across the unit for them to stop, as their movement was misinterpreted as an attempt to extubate themselves.
The inadequacy of mouth care is a recurring complaint from patients. Some patients point out that awful as the oral tube is at least it stimulates the salivary glands and helps to keep the mouth moist. When a nasal tube is used the mouth becomes intolerably dry. Of the products available to provide oral toilet Smith (1987) says ‘Thank goodness for the glycerine and lemon sticks,’ whilst Gandy (1968) recalls ice water and lime mouth washes as being ‘a brain wave’. When nurses begin to work in intensive care they are either terrified of disconnecting the patient from the ventilator or fail to appreciate the hazards of such a procedure which they undertake innocently without any worries. However, the patients talk of the disconnection from the ventilator as an extremely frightening procedure and it seems an intolerably long time before they are reconnected. Confidence in the staff plays a vital part in this part of the patients care. Patients tell stories of their concern that if they were to become disconnected accidentally they were never sure that the ventilator alarm would acknowledge the fact, or that the nurse would respond to the alarm. A few patients mention how distressing they found the ventilator alarms as they were unable to identify whose alarm was activated, and how upset they became if the alarm was not attended to promptly (Uprichard et al 1987, Clarke 1985, Parker et al 1984, Bevan 1969). A considerable number of patients spent lengthy periods worrying about failure of the ventilator and/of disconnection. Some patients describe how they tried to help themselves settle to the ventilator by listening to the rhythmic movement of the ventilator or by watching the bellows (Uprichard et al 1984). Some patients note the importance the way the ventilator tubes, endotracheal tubes and particularly tracheostomy tubes were handled. A number of patients discuss a definite bias they had towards wanting certain nurses to be allocated to their care. These nurses were identified as being careful in handling the tracheostomy or endotracheal tubes (Bergbom et al 1988, Berg born & Haljamae 1988, Henschel 1977, Clarke 1985, Parker 1984). Despite concern of those working in intensive
INTENSIVE
care that suction is unpleasant for patients this is not frequently supported by patients. Suction through endotracheal tubes is well tolerated, several patients commented on their reactions to the procedure, being ‘amused’ or ‘interested’ at the sound of their secretions ‘gurgling’ (Shovelton 1979) on removal. Patients do comment on the discomfort experienced when disconnected from the ventilator, and when the rush of cold air from the bag hits the airways. They also highlight that some nurses are able to disconnect the ventilator tubes and perform suction carefully and painlessly which is much appreciated by the patients.
Communication Communication by intubated and ventilated patients is described as ‘frustrating’; (Uprichard 1987, Henschel 1977, Clarke 1985, Parker et al 1984, Shovelton 1979, Donald 1976, Anon 1969, Bentley et al 1977). In a survey of patients who have spent some time on the intensive care unit Asbury (1985) found that 59% of the patients were ‘worried’ by the fact that they were unable to speak. Patients who recall their experiences of being intubated find the nurses’ ability to lip read a major factor in relieving their anxieties and reducing stress from being unable to speak. They certainly speak fondly of the members of staff they identify as being able to understand them and become ‘angry and frustrated at those who can’t’ (Uprichard et al 1987, Henschel 1977, Bevan 1969). Patients who had conditions such as Guillain Barre’ syndrome seem to have had the most communication problems because they could neither talk nor write, and when the disease affected their facial muscles they could not even form words with their lips. These patients speak passionately at the thrill of having a member of staff who was patient enough to spend time with a letter board watching the patient make eye contact with each letter in turn (Uprichard et al 1977, Clarke 1985). A number of patients who were able to write point out how annoying it is not being allowed to use a note pad and pencil (Anon 1969, Smith 1987, Donald 1976).
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An interesting point made by one of the doctors (Shovelton 1979) whilst a patient in an intensive care unit was that patients desperate to make themselves understood are so often up against nurses who dismiss their efforts with ‘is it important?’ and then ‘well if not try to forget it and relax’. Nurses often forget that it is not only the presence of a tube through the vocal cords which causes problems with speech, but that the state of being desperately short of breath makes communication a miserable priority (Smith 1987). Something which is often forgotten, particularly by nurses and medical staff, is that the paralysed, unconscious patient being ventilated in an intensive care unit may have perfect and often more acute hearing than normal. Noise is commented on by many patients (Asbury 1985, Clarke 1985, Parker et al 1984, Shovelton 1979, Bentley 1977, Redfern 1985, Ashworth 1977). Among the points made by patients regarding noise levels are that: Nurses raise their voices unnecessarily when talking to patients. Radios are played, usually at high volume all day and night. Staff ‘chatter’ at the same pitch all day and night. The noise of the telephone causes a degree of disturbance to some patients. Certain patients, particularly those with Guillain Barre syndrome, describe noises as sounding unbearably loud (Henschel 1977). In a survey of patients who required intensive care and were interviewed after their discharge Jones et al (1979) found that 24% of patients found noise of other patients, equipment or staff was the main factor in preventing or breaking their sleep. It must be noted that a perfectly healthy relaxed adult would have some difficulty in getting a decent sleep in a busy intensive care unit where the noise levels are at times comparable with those of a busy London street corner, a noise level of 70 decibels (Bentley et al 1977). It is not surprising that ‘Difficulty in resting or sleeping’ is a common problem (Table 2). An interesting comment about intensive care units by a leading surgeon is that: ‘Gone were the days when the sick-room meant peace and quiet
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CARE NURSING
Table 2 Aspects of intensive patients
care which
worried
Table 3 Major impressions of the intensive order of preference
the
Number of patients
Problem
27 26 25 16 16 13 13 8 7 7 7 7 6 5 3
Difficulty in resting or sleeping Thirst Oxygen mask Suction down breathing tube Physiotherapy Handling and moving various tubes Pain No view outside Amount of noise Injections Blood pressure cuff Radio Noise of machinery Conversation in ward Being on artificial breathing machine
Likes
Dislikes
Visits to the court yard Hair washes First bath Same nurses Explanation Reassurance Calendar Clock Good sleep Physiotherapists visits
Non communication Pain Noise Fear of oxygen deficiency No windows in the unit Total dependency Insomnia Blood gases Unable to clean own teeth Darkness in the room
This is a list compiled by June Clarke who was on an intensive care unit in Australia for 9 weeks as a result of Guillain Barre Syndrome.
Figures taken from a study done in 1980 by Bradburn and Hewitt.
Visiting There is an increasing
with voices lowered and curtains the sun and noise’ (Paton Continuing accounts
1969).
to staff talking
patients’ conditions.
care include
at the bedside
Regardless
of which
patient they were discussing the patient by whose bed they were standing found it disturbing. when staff consider
the patient
Even
may hear and
reduce their voices to a ‘mutter’ it is still a source of concern ground
to the patient.
of my existence
‘. . . in the black backI heard the word para-
lysis’ (Anon 1969). This patient was admitted the intensive care unit for ventilation cardiac morphine
arrest
and consequently
to
following a
was receiving
and alcuronium.
By comparison
one patient
who spent many
weeks on an intensive care unit in Australia paralysed and ventilated
found it interesting
to hear
the doctors talking about her treatment and in fact she contributed to the planning of her own care. This case is, however,
unique in the litera-
ture. June Clarke (1985) was able to communicate with the staff caring for her regarding such aspects of her care as sedation, posture, feeding and personal hygiene, and has indicated and dislikes (Table 3).
units
to allow
her likes
tendency for intensive care
free visiting
and
patients families to participate pite some relatives
that most of the patients’
of their stay in intensive
some reference about
drawn against
with the theme of communication
it must be mentioned
care unit: in
the bedside being
spending
certain
present
for
patients only
to encourage
in their care. Deslengthy recall
moments
periods at their family (Uprichard
1987, Parker et al 1984). This disruption
of the
patients’ ability to judge time is not uncommon. Some
of the less sedated,
more
orientated
patients recall their relief when waking momentarily and hearing their loved ones at the bedside. Certainly
touch and hand holding is appreciated
by the patients (Uprichard et al 1987, Clarke 1985, Parker 1984, Shovelton 1979, Anon 1969, Donald
1976, Murphy
1984).
‘I also heard the
voice of my wife, her presence
and composure
also reassured me’ (Anon 1969). Asbury
(1985)
questioned
a group of patients
he followed up and found that 8 1 yO of them felt the amount of visits they had was ‘just right’. This was in a unit with ‘open visiting which is encouraged
in the afternoon’.
have examined
None of the studies
the implications
of children visit-
ing people in the intensive care unit. Keeping
the patient in touch with reality can
be helped by just that-touch. Sally Redfern, a nurse recovering from a head injury, highlights the need to communicate with patients by tactile stimuli (1985). ‘It surprised
me how much
I valued human
,
INTENSIVE
touch. I wanted my hand doctors, nurses, visitors.’
held by everyone,
Many patients comment that they recognised the presence of their family as their hands were held. It is a sad reflection on nursing that we do not touch patients more, or just sit at their beside and hold patients hands for 5 minutes rather than the increasing preoccupation of putting patients ‘in a world of monstrous machines’ (Schroeder 197 1)
Sensory deprivation and temporal disorientation Impaired ability to distinguish the passage of time is commented on by many patients (Keep et al 1980, Uprichard et al 1987, Hewitt 1970, Bradburn & Hewitt 1980, Henschel 1977, Clarke 1985, Parker et al 1984, Shovelton 1979, Redfern 1985, Kornfeld 1969, Keep 1977). It may be due to sedation, a broken or disrupted sleep pattern and sensory deprivation. The use of clocks which are large and easy to see, digital or clear calendars and the provision of large windows in the intensive care unit are all ways in which this problem may be alleviated. Sensory deprivation is a topic which is increasingly documented. However do nurses really do much about it? The studies by Keep, James and Inman (1980, 1977), deal primarily with the problems that have developed as a result of intensive care units in areas built without windows. These authors investigated the difference in recall as described by patients from two separate intensive care units, in Norwich and Plymouth. The units were comparable in design and work load, however the unit in Norwich had no windows and therefore there was no natural light whilst the unit in Plymouth had a similar layout but with the addition of large windows. It was demonstrated that the patients they reviewed after discharge from the unit certainly had recollection of their stay and that those patients who had been deprived of light and of views outside the unit had a less pleasant memory of events (Table 4). Some of the patients described thinking they were in very strange places such as ‘on or inside a
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105
Table 4 Comparison of recall described by patients who had been either in a unit with windows or one without Norwich (no windows) 60 patients Patients remembering admission to the unit Patients remembering discharge from the unit Orientated as to day of week Orientated as to time of day Sleep disturbance Visual disturbance Hallucinations and delusions
Plymouth (windows) 55 patients
11 (18%)
17 (31%)
44 (73%)
50 (91%)
3 (5%)
13 (24%)
5 (9%) 15 (25%) 14 (23%)
22 (44%) 9 (16%) 9 (16%)
29 (48%)
13 (23%)
Keep, James and lnman 1980.
ship, or inside a large fish and even at a party at the hospital bar!’ Where patients are nursed in intensive care units with no or very little natural light it is important to create a day and night pattern for the patients. A reduction in the amount of fluorescent lighting may be appreciated, since this lighting is commented upon by some patients as unpleasant and uncomfortable (Shovelton 1979, Smith 1987, Bevan 1969, Redfern 1985, Ashworth 1977). A problem frequently referred to by patients is dreaming and auditory and visual hallucinations. These are troublesome to the patients and can increase their disorientation and anxiety. Commonly reported dreams are of prisons, torture and depersonalisation (Keep et al 1980, Uprichard et al 1987, Chew 1986, Asbury 1985, Parker et al 1984, Donald 1976, Bevan 1969, Schroeder 197 1, Anon 1969, Dunn 1987, Park 1985). Whatever the cause of the dreams and hallucinations it is difficult to prevent patients experiencing them. Nurses should, however, strive to remember that distressed patients may be hallucinating and gentle, sympathetic reassurance may help. After their discharge from hospital some patients continue to have problems with their sleep pattern and some continue to dream.
106
INTENSIVE
CARE NURSING
Patients’ families should be warned that patients may have weird dreams and possibly hallucinate, and that this is a result of the illness and treatment.
noid, feeling that I was being deliberately neg lected.’ June Clarke (1985) describes the transfer to a ward as ‘a difficult and frightening experience.’
Patient comfort
Conclusion
Many patients eagerly await being turned to have their linen changed and their position altered. Passive movements of immobile limbs are often recalled as being uncomfortable yet nearly all patients comment on how much better they felt afterwards (Uprichard et al 1987, Clarke 1985, Schroeder 1971). June Clarke (1985) spent 2 months ventilated on an Australian intensive care unit due to Guillain Barre syndrome. Her stay was made more pleasurable by being wheeled out on to the patio to lie on her bed in the sunshine with a portable ventilator and an intensive care nurse in attendance. Both of the patients who spent considerable time on the intensive care unit as a result of Guillain Barre syndrome described the wonderful sensation of being lowered into a bath whilst ventilated and being able to get relief from the discomfort from their painful limbs. A point brought out by several patients is the seeming injustice in life that the rare time that they felt comfortable was the precise time that the radiographer arrived to perform the chest X-ray.
In response to the question ‘Do patients remember any thing about intensive care?’ They do. There are certainly instances where individuals cannot remember anything about their admission to intensive care (Dunn 1987). Most of the personal accounts that have been published show that patients not only remember a variety of experiences but by taking the time to write about their experiences provide valuable data from which intensive care nurses may learn. Reviewing ‘what the patients say’ has provided the opportunity to gain some insight into what patients experience. Applying the information gained from these patients we should examine a number of our practices in intensive care.
Discharge Patients who spent short periods on the intensive care unit, such as those admitted for elective ventilation for example following open heart surgery, recall their transfer to the ward in such terms as a ‘triumph’, or returning to the ward in a ‘blaze of glory’ (Anon 1969, Donald 1976). However, those who were in the intensive care unit for much longer periods had problems when they were transferred to the ward and had to make the transition from individual nursing care to being one of many other patients on a ward. They regularly describe feelings such as those described by Henschel (1977) and Bevan (1969) who both use the phase ‘I became almost para-
- Talking at patients’ bedsides should be directed to the patient, be relevant to that patient, and any comments likely to cause the patient distress should be avoided. - Each patient should receive constant reassurance, and reminders of time and date, and explanations of where he or she is and why should be repeated frequently. This should be reinforced by physical contact, such as holding a patients hand. - The use of large clocks and calendars is recommended as a means of identifying time and date (Uprichard et al 1987, Redfern 1985, Dunn 1987). - Family pictures and photographs placed around the patients bed are believed to reduce anxiety. They make the bedside less clinical and help to keep the patient in touch with his family (Clarke 1985). A selection of photographs of the patient before admission is believed to be beneficial to the staff in helping them relate to the patient as an individual (Clarke 1985, Park et al 1985). Physiotherapy is accepted by patients; chest physiotherapy is not pleasant for patients but
INTENSIVE
thev do apDreciate how much better thev feel afterwards. However, staff do need to perfect the 1.
technique
of handling
netting
patients
patients’
from
their
tubes and disconventilators
causing
little or no discomfort. Passive
exercises
are
performed
ante and briefly between nurses,
and are often seen as a tedious
less part these
of care.
The
oatients
comments
noint
1
necessity
out
1
the
patients
should
care and preparation
hand.
reluct-
and worth-
by a number imnortance a
of and
of this treatment.
Turning great
with
other care by so many
Many
be performed
with
of the patient
describe
it
as
before-
frightening
and
due to the effects of sensory deprivation (Uprichard et al 1987, Chew 1986, Herschel 1977, Parker et al 1984, Smith 1987, Bevan 1969, Anon 1969, Ashworth 1977, Keep 1977, Dunn 1987, Shulman 1984). Anyone involved with lifting or moving an intensive care patient should take time out to lie blindfold on an intensive care bed, to listen to the noise, be turned without warning and undergo a few minor procedures such as mouth care, oral suction, fitting of anti-embolism stockings, passive movements or other such activities. uncomfortable
Much
of intensive
with technical difficult patients.
personal
to devote
nurses’
time
and activities,
a large amount
is spent and it is
of time to these
But as is clearly stated by them it is the contact that is so valued when they are
in need of intensive Most
care
equipment
care.
of the reports
are from
those
with
some
idea about what was going on during their illness, it must be even more bewildering and frightening for those individuals who have no hospital experiences to draw upon. Finally
‘Patients journey
as
stated
by
do remember through
intensive
be their last voyage’.
Mackereth
(1987),
and are affected by their Thus
care, which it is the duty
could
well
of nurses
to ensure we provide care and attention which cause the least possible discomfort and distress to those people
requiring
our care.
References Anon 1969 Both ends of the stethoscope. 264
The Lancet 2: 262-
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1 o?
Anon Personal Papers 1969 At the receiving end. The Lancet 1129-1131 . Asbury A J 1985 Patients memories and reactions to intensive care. Care of the critically ill. Vol I No. 2 p 12-13 Ashworth P 1977 Sensory input and altered consciousness
Nursing 8: 350-353 Bentley S, Murphy F, Dudley H 1977 Perceived noise in surgical wards and an intensive care area an objective analysis. British Medical Journal 1503-1506
Bergbom-Engberg I, Haljamae H 1988 A retrospective study ofpatients recall of respirator treatment. (2), Nursing care factors and feelings ofsecurity/insecurity. Intensive Care Nursinp 4(3): 95-101 Bergbom-Engberg I, Haileiderg B, Wickstrom I, Haljamae H 1988 A retrospective study of patients recall ofrespirator treatment (1): Study design and basic findings. Intensive Care Nursing 4(2): 56-61 Bevan J 1969 Personal paper; Polyneuropathy. The Lancet . ._._
1: 191u
Bradburn B, Hewitt P 1980 The effect of the intensive therapy ward environment on patients subjective impressions, a follow up study. Intensive care medicine 1980,7: 15-18 Clarke J 1985 Coping with Guillain Barre syndrome. (A personal experience.) Intensive Care Nursing l(1): 13-18 Chew S 1986 Psychological reactions of Intensive Care Patients. Care ofthe Critically Ill. 2(2): 62-65 Donald I 1976 At the receiving end. Scottish Medical Journal 21: 49 Dunn C 1987 Staying in touch. Unpublished Candy A P 1968 ‘From both ends ofthe stethoscope’. An attack ofTetanus. The Lancet 567-568 Henschel E 0 1977 The Guillain-Barre syndrome, A
personal experience. Anaesthesiology 47: 228-231 Hewitt P B 1970 Subjective follow-up of Patients from a Surgical Intensive Therapy Ward. British Medical Journal 4: 66%673 Jones S, Hoggart B, Withey J, Donaghue K, Ellis B 1979 What the Patients say. A study ofreactions to an intensive care unit. Intensive Care Medicine 1979,5: 89-92 Keep P J 1977 Stimulus deprivation in windowless rooms.
Anaesthesia 32: 598-600 Keep P, James J, Inman M 1980 Windows in the intensive therapy
unit. Anaesthesia
35: 257-262 View of the Intensive Care Unit. The Lancet 1: 108-l 11 Mackereth P 1987 Communication in critical care areas, competing for attention. Nuning 15: 575-578, 1987 Murphy N 1984 Critical care nurse becomes critical care patient. Nursing Forum, Vol. 21 (4) 178-181 Park G, Chew S L, Shelly M 1985 Morpheus revisited. Anaesthesia Vol40, No 11 1128-l 129
Kornfeld D S 1969 Psychiatric
Parker M, Schelhamer S, Schubert W, Parillo J 1984 Perceptions ofa critically ill patient experiencing therapeutic paralysis in an intensive care unit. Critical Care Medicine
12: 64-7 1
Paton A 1969 Personal View. British Medical Journal 591 Redfern S 1985 Taking some of my own medicine. Care of the critically ill 1: 5, p 6 Schroeder H G 1971 Psycho-reactive problems ofintensive therapy. Anaesthesia Vol. 26: 128-35 Shovelton D 1979 Reflections on an intensive therapy unit. British Medical Journal 737-738 Shulman C 1984 Communication a conscious effort. Nursing, 1984,673-677
108
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Smith C 1987 In need ofintensive care-a personal perspective. Intensive care nursing. Vol. 2(3): 116-122 Uprichard E, Martin A, Evans S 1987 Guillain-Barre syndrome-patients and nurses perspective. Intensive Care Nursing 2(3): 123-134
Bibliography Anon 1987 The need for sleep. Nursing Standard 23-9-1987 Ashworth P 1987 The needs ofthe critically ill patient. Intensive Care Nursing 3: 182-192
Atkinson B L 1987 The Intensive Care Unit. Nursing 15: 547-551 Gloss J 1988 Patients sleep wake rhythms in hospital. Nursing Times, 84 2: 54 Lenihan J 1979 The History of Intensive Care. Nursing Focus 1979 l(2): 75-76 North N 1988 Psychosocial aspects of coronary artery bypass surgery. Nursing Times. Vol84, No 1 26-29 Schroeder H G 1971 Psycho-reactive problems ofintensive therapy. Anaesthesia 26, 1: 28-35 Tinker J 1978 General Intensive Care, in ‘Intensive Care’, London. Nursing Times Publication Tomlin P 1977 Psychological problems in intensive care. British Medical Journal 441-443
say
Janet V. Heath INTRODUCTION The aim of this review was to examine the recollections of patients on Intensive Care Units. Most of the staff working on Intensive Care Units believe that patients have few memories of their time in the unit. However, there is a considerable amount of literature on this aspect of intensive care. Much of this evidence is anecdotal but a number of intensive care units have carried out studies to look at what recollection patients have of their admission (Keep 1980, Bergbom et al 1988a, 1988b, Uprichard et al 1987, Hewitt 1970, Chew 1986, Bradburn & Hewitt 1980, Jones et al 1979, Asbury 1985). The majority of the information which will be presented is from a collection of personal accounts of health care professionals some of whom work on intensive care units. These individuals have all spent a time as patients in intensive care and have written about their memory and experiences. Hence this article looks at ‘What the patients say’. The personal accounts ofpatients admitted for a variety of conditions and requiring a wide range of treatments date from 1957 to 1987. All the patients reviewed, who are listed in Table 1, received a variety of drugs for sedation.
Airway management Respiratory system care frequently requires the passage of an endotracheal tube. Intubation may be undertaken either as an elective procedure or occasionally as an emergency and may be performed orally or nasally. Tracheostomy may be Janet Victoria Heath E.N.B. 100. Southampton General Hospital, Shirley, Southampton, SO9 4XY (Requests for offprints to JVH) Manuscript
accepted
2 July
7989
performed as an alternative to intubation in a number of clinical circumstances. Few patients are given the choice of the type ofintubation performed. Patients who have advanced warning of the need for an artificial airway may be given time to come to terms with this type of medical intervention. It is generally patients who have had progressive respiratory failure and are possibly going to require some form of long term ventilation who may be given time to contemplate having a tracheostomy. In the literature patients who have some medical or nursing knowledge often discuss their feelings towards tracheostomy, and most of them express horror at a prospect such as ‘a tracheostomy was inescapably indicated’ (Henschel 1977). After being nasally intubated for a relatively short period of time, however, a different patient comments ‘1 week later I welcomed the decision to replace the most uncomfortable nasal tube with the previously dreaded tracheostomy’ (Clarke 1985). Patients who are able to recall being intubated describe the presence of the endotracheal tube as being incredibly uncomfortable, particularly while they were being moved or turned when the nurses were not concentrating on supporting the patient’s head (Uprichard et al 1987, Parker et al 1984, Shovelton 1979, Smith 1987, Donald 1976). One patient who was having intensive care as a result of an elective procedure and had been to visit the unit pre-operatively to meet the staff describes the short time he was intubated. ‘I had been warned that the tube would be unpleasant but that proved to be an understatement.’ One author (Smith 1987) as a result of her asthma has required several admissions to intensive care units and has had experience of both
102
INTENSIVE
Table 1 The penonal was based
CARE NURSING
accounts
on which
meet of this work
1. C. Smith. Nurse Tutor, has no professional intensive care experience. An asthmatic who has experienced several admissions to intensive care units both as a ventilated and nonventilated patient. 2. Anonymous. A medical person. Experienced an admission to intensive care as a result of having a cardiac arrest on a medical ward. 3. I. Donald. Consultant gynaecologist. Two articles have been written by this gentleman who was electively admitted to cardio-thoracic intensive care units following surgery to his mitral valve, there being 6 years between each operation. 4. J. Bevan. Final year medical student. Admitted to intensive care as a result of polyneuropathy requiring artificial ventilation via a tracheostomy. 5. D. Shovelton. Professor of conservative dentistry. Electively admitted to the intensive care unit for post operative ventilation following a Thyomectomy for Myasthenia Gravis. 6. E. Henshall. Professor of anaesthesiology. Required several weeks of artificial ventilation due to Guillain Barr4 syndrome. 7. An unnamed American nurse. Intensive care nurse. Developed pneumonia and required ventilation and therapeutic paralysis. 8. S. Redfern. Lecturer in nursing studies. Admitted to a high care unit in Switzerland following an accident whilst climbing when she sustained a head injury, she did not require ventilation. 9. J. Clarke. Registered nurse. Spent 9 weeks on an intensive care unit as a result of Guillain Barre syndrome and was ventilated via a tracheostomy. 10. N. Cooke. Now a consultant physician. Describes his experience as a 15 year old school boy who was in intensive care due to Influenza pneumonia and had a tracheostomy but was not ventilated. 11. A. P. bandy. Analytical chemist spent several weeks in intensive care as a result of Tetanus and was ventilated via a tracheostomy.
nasal and oral endotracheal tubes. She recalls feeling soreness of the nasal mucosa in contact with nasal tubes, the degree of discomfort seeming to be related to the trauma encountered at intubation. However, she considers a nasal tube a better alternative than the oral tube which causes a constant ‘gagging’ sensation. Several patients mention that they made attempts to support their tube in the ‘optimum position’ only to have a nurse grab their hands or shout across the unit for them to stop, as their movement was misinterpreted as an attempt to extubate themselves.
The inadequacy of mouth care is a recurring complaint from patients. Some patients point out that awful as the oral tube is at least it stimulates the salivary glands and helps to keep the mouth moist. When a nasal tube is used the mouth becomes intolerably dry. Of the products available to provide oral toilet Smith (1987) says ‘Thank goodness for the glycerine and lemon sticks,’ whilst Gandy (1968) recalls ice water and lime mouth washes as being ‘a brain wave’. When nurses begin to work in intensive care they are either terrified of disconnecting the patient from the ventilator or fail to appreciate the hazards of such a procedure which they undertake innocently without any worries. However, the patients talk of the disconnection from the ventilator as an extremely frightening procedure and it seems an intolerably long time before they are reconnected. Confidence in the staff plays a vital part in this part of the patients care. Patients tell stories of their concern that if they were to become disconnected accidentally they were never sure that the ventilator alarm would acknowledge the fact, or that the nurse would respond to the alarm. A few patients mention how distressing they found the ventilator alarms as they were unable to identify whose alarm was activated, and how upset they became if the alarm was not attended to promptly (Uprichard et al 1987, Clarke 1985, Parker et al 1984, Bevan 1969). A considerable number of patients spent lengthy periods worrying about failure of the ventilator and/of disconnection. Some patients describe how they tried to help themselves settle to the ventilator by listening to the rhythmic movement of the ventilator or by watching the bellows (Uprichard et al 1984). Some patients note the importance the way the ventilator tubes, endotracheal tubes and particularly tracheostomy tubes were handled. A number of patients discuss a definite bias they had towards wanting certain nurses to be allocated to their care. These nurses were identified as being careful in handling the tracheostomy or endotracheal tubes (Bergbom et al 1988, Berg born & Haljamae 1988, Henschel 1977, Clarke 1985, Parker 1984). Despite concern of those working in intensive
INTENSIVE
care that suction is unpleasant for patients this is not frequently supported by patients. Suction through endotracheal tubes is well tolerated, several patients commented on their reactions to the procedure, being ‘amused’ or ‘interested’ at the sound of their secretions ‘gurgling’ (Shovelton 1979) on removal. Patients do comment on the discomfort experienced when disconnected from the ventilator, and when the rush of cold air from the bag hits the airways. They also highlight that some nurses are able to disconnect the ventilator tubes and perform suction carefully and painlessly which is much appreciated by the patients.
Communication Communication by intubated and ventilated patients is described as ‘frustrating’; (Uprichard 1987, Henschel 1977, Clarke 1985, Parker et al 1984, Shovelton 1979, Donald 1976, Anon 1969, Bentley et al 1977). In a survey of patients who have spent some time on the intensive care unit Asbury (1985) found that 59% of the patients were ‘worried’ by the fact that they were unable to speak. Patients who recall their experiences of being intubated find the nurses’ ability to lip read a major factor in relieving their anxieties and reducing stress from being unable to speak. They certainly speak fondly of the members of staff they identify as being able to understand them and become ‘angry and frustrated at those who can’t’ (Uprichard et al 1987, Henschel 1977, Bevan 1969). Patients who had conditions such as Guillain Barre’ syndrome seem to have had the most communication problems because they could neither talk nor write, and when the disease affected their facial muscles they could not even form words with their lips. These patients speak passionately at the thrill of having a member of staff who was patient enough to spend time with a letter board watching the patient make eye contact with each letter in turn (Uprichard et al 1977, Clarke 1985). A number of patients who were able to write point out how annoying it is not being allowed to use a note pad and pencil (Anon 1969, Smith 1987, Donald 1976).
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103
An interesting point made by one of the doctors (Shovelton 1979) whilst a patient in an intensive care unit was that patients desperate to make themselves understood are so often up against nurses who dismiss their efforts with ‘is it important?’ and then ‘well if not try to forget it and relax’. Nurses often forget that it is not only the presence of a tube through the vocal cords which causes problems with speech, but that the state of being desperately short of breath makes communication a miserable priority (Smith 1987). Something which is often forgotten, particularly by nurses and medical staff, is that the paralysed, unconscious patient being ventilated in an intensive care unit may have perfect and often more acute hearing than normal. Noise is commented on by many patients (Asbury 1985, Clarke 1985, Parker et al 1984, Shovelton 1979, Bentley 1977, Redfern 1985, Ashworth 1977). Among the points made by patients regarding noise levels are that: Nurses raise their voices unnecessarily when talking to patients. Radios are played, usually at high volume all day and night. Staff ‘chatter’ at the same pitch all day and night. The noise of the telephone causes a degree of disturbance to some patients. Certain patients, particularly those with Guillain Barre syndrome, describe noises as sounding unbearably loud (Henschel 1977). In a survey of patients who required intensive care and were interviewed after their discharge Jones et al (1979) found that 24% of patients found noise of other patients, equipment or staff was the main factor in preventing or breaking their sleep. It must be noted that a perfectly healthy relaxed adult would have some difficulty in getting a decent sleep in a busy intensive care unit where the noise levels are at times comparable with those of a busy London street corner, a noise level of 70 decibels (Bentley et al 1977). It is not surprising that ‘Difficulty in resting or sleeping’ is a common problem (Table 2). An interesting comment about intensive care units by a leading surgeon is that: ‘Gone were the days when the sick-room meant peace and quiet
104
INTENSIVE
CARE NURSING
Table 2 Aspects of intensive patients
care which
worried
Table 3 Major impressions of the intensive order of preference
the
Number of patients
Problem
27 26 25 16 16 13 13 8 7 7 7 7 6 5 3
Difficulty in resting or sleeping Thirst Oxygen mask Suction down breathing tube Physiotherapy Handling and moving various tubes Pain No view outside Amount of noise Injections Blood pressure cuff Radio Noise of machinery Conversation in ward Being on artificial breathing machine
Likes
Dislikes
Visits to the court yard Hair washes First bath Same nurses Explanation Reassurance Calendar Clock Good sleep Physiotherapists visits
Non communication Pain Noise Fear of oxygen deficiency No windows in the unit Total dependency Insomnia Blood gases Unable to clean own teeth Darkness in the room
This is a list compiled by June Clarke who was on an intensive care unit in Australia for 9 weeks as a result of Guillain Barre Syndrome.
Figures taken from a study done in 1980 by Bradburn and Hewitt.
Visiting There is an increasing
with voices lowered and curtains the sun and noise’ (Paton Continuing accounts
1969).
to staff talking
patients’ conditions.
care include
at the bedside
Regardless
of which
patient they were discussing the patient by whose bed they were standing found it disturbing. when staff consider
the patient
Even
may hear and
reduce their voices to a ‘mutter’ it is still a source of concern ground
to the patient.
of my existence
‘. . . in the black backI heard the word para-
lysis’ (Anon 1969). This patient was admitted the intensive care unit for ventilation cardiac morphine
arrest
and consequently
to
following a
was receiving
and alcuronium.
By comparison
one patient
who spent many
weeks on an intensive care unit in Australia paralysed and ventilated
found it interesting
to hear
the doctors talking about her treatment and in fact she contributed to the planning of her own care. This case is, however,
unique in the litera-
ture. June Clarke (1985) was able to communicate with the staff caring for her regarding such aspects of her care as sedation, posture, feeding and personal hygiene, and has indicated and dislikes (Table 3).
units
to allow
her likes
tendency for intensive care
free visiting
and
patients families to participate pite some relatives
that most of the patients’
of their stay in intensive
some reference about
drawn against
with the theme of communication
it must be mentioned
care unit: in
the bedside being
spending
certain
present
for
patients only
to encourage
in their care. Deslengthy recall
moments
periods at their family (Uprichard
1987, Parker et al 1984). This disruption
of the
patients’ ability to judge time is not uncommon. Some
of the less sedated,
more
orientated
patients recall their relief when waking momentarily and hearing their loved ones at the bedside. Certainly
touch and hand holding is appreciated
by the patients (Uprichard et al 1987, Clarke 1985, Parker 1984, Shovelton 1979, Anon 1969, Donald
1976, Murphy
1984).
‘I also heard the
voice of my wife, her presence
and composure
also reassured me’ (Anon 1969). Asbury
(1985)
questioned
a group of patients
he followed up and found that 8 1 yO of them felt the amount of visits they had was ‘just right’. This was in a unit with ‘open visiting which is encouraged
in the afternoon’.
have examined
None of the studies
the implications
of children visit-
ing people in the intensive care unit. Keeping
the patient in touch with reality can
be helped by just that-touch. Sally Redfern, a nurse recovering from a head injury, highlights the need to communicate with patients by tactile stimuli (1985). ‘It surprised
me how much
I valued human
,
INTENSIVE
touch. I wanted my hand doctors, nurses, visitors.’
held by everyone,
Many patients comment that they recognised the presence of their family as their hands were held. It is a sad reflection on nursing that we do not touch patients more, or just sit at their beside and hold patients hands for 5 minutes rather than the increasing preoccupation of putting patients ‘in a world of monstrous machines’ (Schroeder 197 1)
Sensory deprivation and temporal disorientation Impaired ability to distinguish the passage of time is commented on by many patients (Keep et al 1980, Uprichard et al 1987, Hewitt 1970, Bradburn & Hewitt 1980, Henschel 1977, Clarke 1985, Parker et al 1984, Shovelton 1979, Redfern 1985, Kornfeld 1969, Keep 1977). It may be due to sedation, a broken or disrupted sleep pattern and sensory deprivation. The use of clocks which are large and easy to see, digital or clear calendars and the provision of large windows in the intensive care unit are all ways in which this problem may be alleviated. Sensory deprivation is a topic which is increasingly documented. However do nurses really do much about it? The studies by Keep, James and Inman (1980, 1977), deal primarily with the problems that have developed as a result of intensive care units in areas built without windows. These authors investigated the difference in recall as described by patients from two separate intensive care units, in Norwich and Plymouth. The units were comparable in design and work load, however the unit in Norwich had no windows and therefore there was no natural light whilst the unit in Plymouth had a similar layout but with the addition of large windows. It was demonstrated that the patients they reviewed after discharge from the unit certainly had recollection of their stay and that those patients who had been deprived of light and of views outside the unit had a less pleasant memory of events (Table 4). Some of the patients described thinking they were in very strange places such as ‘on or inside a
CARE NURSING
105
Table 4 Comparison of recall described by patients who had been either in a unit with windows or one without Norwich (no windows) 60 patients Patients remembering admission to the unit Patients remembering discharge from the unit Orientated as to day of week Orientated as to time of day Sleep disturbance Visual disturbance Hallucinations and delusions
Plymouth (windows) 55 patients
11 (18%)
17 (31%)
44 (73%)
50 (91%)
3 (5%)
13 (24%)
5 (9%) 15 (25%) 14 (23%)
22 (44%) 9 (16%) 9 (16%)
29 (48%)
13 (23%)
Keep, James and lnman 1980.
ship, or inside a large fish and even at a party at the hospital bar!’ Where patients are nursed in intensive care units with no or very little natural light it is important to create a day and night pattern for the patients. A reduction in the amount of fluorescent lighting may be appreciated, since this lighting is commented upon by some patients as unpleasant and uncomfortable (Shovelton 1979, Smith 1987, Bevan 1969, Redfern 1985, Ashworth 1977). A problem frequently referred to by patients is dreaming and auditory and visual hallucinations. These are troublesome to the patients and can increase their disorientation and anxiety. Commonly reported dreams are of prisons, torture and depersonalisation (Keep et al 1980, Uprichard et al 1987, Chew 1986, Asbury 1985, Parker et al 1984, Donald 1976, Bevan 1969, Schroeder 197 1, Anon 1969, Dunn 1987, Park 1985). Whatever the cause of the dreams and hallucinations it is difficult to prevent patients experiencing them. Nurses should, however, strive to remember that distressed patients may be hallucinating and gentle, sympathetic reassurance may help. After their discharge from hospital some patients continue to have problems with their sleep pattern and some continue to dream.
106
INTENSIVE
CARE NURSING
Patients’ families should be warned that patients may have weird dreams and possibly hallucinate, and that this is a result of the illness and treatment.
noid, feeling that I was being deliberately neg lected.’ June Clarke (1985) describes the transfer to a ward as ‘a difficult and frightening experience.’
Patient comfort
Conclusion
Many patients eagerly await being turned to have their linen changed and their position altered. Passive movements of immobile limbs are often recalled as being uncomfortable yet nearly all patients comment on how much better they felt afterwards (Uprichard et al 1987, Clarke 1985, Schroeder 1971). June Clarke (1985) spent 2 months ventilated on an Australian intensive care unit due to Guillain Barre syndrome. Her stay was made more pleasurable by being wheeled out on to the patio to lie on her bed in the sunshine with a portable ventilator and an intensive care nurse in attendance. Both of the patients who spent considerable time on the intensive care unit as a result of Guillain Barre syndrome described the wonderful sensation of being lowered into a bath whilst ventilated and being able to get relief from the discomfort from their painful limbs. A point brought out by several patients is the seeming injustice in life that the rare time that they felt comfortable was the precise time that the radiographer arrived to perform the chest X-ray.
In response to the question ‘Do patients remember any thing about intensive care?’ They do. There are certainly instances where individuals cannot remember anything about their admission to intensive care (Dunn 1987). Most of the personal accounts that have been published show that patients not only remember a variety of experiences but by taking the time to write about their experiences provide valuable data from which intensive care nurses may learn. Reviewing ‘what the patients say’ has provided the opportunity to gain some insight into what patients experience. Applying the information gained from these patients we should examine a number of our practices in intensive care.
Discharge Patients who spent short periods on the intensive care unit, such as those admitted for elective ventilation for example following open heart surgery, recall their transfer to the ward in such terms as a ‘triumph’, or returning to the ward in a ‘blaze of glory’ (Anon 1969, Donald 1976). However, those who were in the intensive care unit for much longer periods had problems when they were transferred to the ward and had to make the transition from individual nursing care to being one of many other patients on a ward. They regularly describe feelings such as those described by Henschel (1977) and Bevan (1969) who both use the phase ‘I became almost para-
- Talking at patients’ bedsides should be directed to the patient, be relevant to that patient, and any comments likely to cause the patient distress should be avoided. - Each patient should receive constant reassurance, and reminders of time and date, and explanations of where he or she is and why should be repeated frequently. This should be reinforced by physical contact, such as holding a patients hand. - The use of large clocks and calendars is recommended as a means of identifying time and date (Uprichard et al 1987, Redfern 1985, Dunn 1987). - Family pictures and photographs placed around the patients bed are believed to reduce anxiety. They make the bedside less clinical and help to keep the patient in touch with his family (Clarke 1985). A selection of photographs of the patient before admission is believed to be beneficial to the staff in helping them relate to the patient as an individual (Clarke 1985, Park et al 1985). Physiotherapy is accepted by patients; chest physiotherapy is not pleasant for patients but
INTENSIVE
thev do apDreciate how much better thev feel afterwards. However, staff do need to perfect the 1.
technique
of handling
netting
patients
patients’
from
their
tubes and disconventilators
causing
little or no discomfort. Passive
exercises
are
performed
ante and briefly between nurses,
and are often seen as a tedious
less part these
of care.
The
oatients
comments
noint
1
necessity
out
1
the
patients
should
care and preparation
hand.
reluct-
and worth-
by a number imnortance a
of and
of this treatment.
Turning great
with
other care by so many
Many
be performed
with
of the patient
describe
it
as
before-
frightening
and
due to the effects of sensory deprivation (Uprichard et al 1987, Chew 1986, Herschel 1977, Parker et al 1984, Smith 1987, Bevan 1969, Anon 1969, Ashworth 1977, Keep 1977, Dunn 1987, Shulman 1984). Anyone involved with lifting or moving an intensive care patient should take time out to lie blindfold on an intensive care bed, to listen to the noise, be turned without warning and undergo a few minor procedures such as mouth care, oral suction, fitting of anti-embolism stockings, passive movements or other such activities. uncomfortable
Much
of intensive
with technical difficult patients.
personal
to devote
nurses’
time
and activities,
a large amount
is spent and it is
of time to these
But as is clearly stated by them it is the contact that is so valued when they are
in need of intensive Most
care
equipment
care.
of the reports
are from
those
with
some
idea about what was going on during their illness, it must be even more bewildering and frightening for those individuals who have no hospital experiences to draw upon. Finally
‘Patients journey
as
stated
by
do remember through
intensive
be their last voyage’.
Mackereth
(1987),
and are affected by their Thus
care, which it is the duty
could
well
of nurses
to ensure we provide care and attention which cause the least possible discomfort and distress to those people
requiring
our care.
References Anon 1969 Both ends of the stethoscope. 264
The Lancet 2: 262-
CARE NURSING
1 o?
Anon Personal Papers 1969 At the receiving end. The Lancet 1129-1131 . Asbury A J 1985 Patients memories and reactions to intensive care. Care of the critically ill. Vol I No. 2 p 12-13 Ashworth P 1977 Sensory input and altered consciousness
Nursing 8: 350-353 Bentley S, Murphy F, Dudley H 1977 Perceived noise in surgical wards and an intensive care area an objective analysis. British Medical Journal 1503-1506
Bergbom-Engberg I, Haljamae H 1988 A retrospective study ofpatients recall of respirator treatment. (2), Nursing care factors and feelings ofsecurity/insecurity. Intensive Care Nursinp 4(3): 95-101 Bergbom-Engberg I, Haileiderg B, Wickstrom I, Haljamae H 1988 A retrospective study of patients recall ofrespirator treatment (1): Study design and basic findings. Intensive Care Nursing 4(2): 56-61 Bevan J 1969 Personal paper; Polyneuropathy. The Lancet . ._._
1: 191u
Bradburn B, Hewitt P 1980 The effect of the intensive therapy ward environment on patients subjective impressions, a follow up study. Intensive care medicine 1980,7: 15-18 Clarke J 1985 Coping with Guillain Barre syndrome. (A personal experience.) Intensive Care Nursing l(1): 13-18 Chew S 1986 Psychological reactions of Intensive Care Patients. Care ofthe Critically Ill. 2(2): 62-65 Donald I 1976 At the receiving end. Scottish Medical Journal 21: 49 Dunn C 1987 Staying in touch. Unpublished Candy A P 1968 ‘From both ends ofthe stethoscope’. An attack ofTetanus. The Lancet 567-568 Henschel E 0 1977 The Guillain-Barre syndrome, A
personal experience. Anaesthesiology 47: 228-231 Hewitt P B 1970 Subjective follow-up of Patients from a Surgical Intensive Therapy Ward. British Medical Journal 4: 66%673 Jones S, Hoggart B, Withey J, Donaghue K, Ellis B 1979 What the Patients say. A study ofreactions to an intensive care unit. Intensive Care Medicine 1979,5: 89-92 Keep P J 1977 Stimulus deprivation in windowless rooms.
Anaesthesia 32: 598-600 Keep P, James J, Inman M 1980 Windows in the intensive therapy
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35: 257-262 View of the Intensive Care Unit. The Lancet 1: 108-l 11 Mackereth P 1987 Communication in critical care areas, competing for attention. Nuning 15: 575-578, 1987 Murphy N 1984 Critical care nurse becomes critical care patient. Nursing Forum, Vol. 21 (4) 178-181 Park G, Chew S L, Shelly M 1985 Morpheus revisited. Anaesthesia Vol40, No 11 1128-l 129
Kornfeld D S 1969 Psychiatric
Parker M, Schelhamer S, Schubert W, Parillo J 1984 Perceptions ofa critically ill patient experiencing therapeutic paralysis in an intensive care unit. Critical Care Medicine
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Paton A 1969 Personal View. British Medical Journal 591 Redfern S 1985 Taking some of my own medicine. Care of the critically ill 1: 5, p 6 Schroeder H G 1971 Psycho-reactive problems ofintensive therapy. Anaesthesia Vol. 26: 128-35 Shovelton D 1979 Reflections on an intensive therapy unit. British Medical Journal 737-738 Shulman C 1984 Communication a conscious effort. Nursing, 1984,673-677
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INTENSIVECARENURSING
Smith C 1987 In need ofintensive care-a personal perspective. Intensive care nursing. Vol. 2(3): 116-122 Uprichard E, Martin A, Evans S 1987 Guillain-Barre syndrome-patients and nurses perspective. Intensive Care Nursing 2(3): 123-134
Bibliography Anon 1987 The need for sleep. Nursing Standard 23-9-1987 Ashworth P 1987 The needs ofthe critically ill patient. Intensive Care Nursing 3: 182-192
Atkinson B L 1987 The Intensive Care Unit. Nursing 15: 547-551 Gloss J 1988 Patients sleep wake rhythms in hospital. Nursing Times, 84 2: 54 Lenihan J 1979 The History of Intensive Care. Nursing Focus 1979 l(2): 75-76 North N 1988 Psychosocial aspects of coronary artery bypass surgery. Nursing Times. Vol84, No 1 26-29 Schroeder H G 1971 Psycho-reactive problems ofintensive therapy. Anaesthesia 26, 1: 28-35 Tinker J 1978 General Intensive Care, in ‘Intensive Care’, London. Nursing Times Publication Tomlin P 1977 Psychological problems in intensive care. British Medical Journal 441-443