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PTSD in the ICU

Long-lasting effects can follow critical care patients out of the intensive care unit

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Fast-paced, highly technological and stressful, the ICU is where patients and their families are exposed to continuous surveillance and monitoring of a rapidly changing status, intensive treatment and medications.

A critical illness diagnosis resulting in admission into an intensive care unit can have long-lasting effects for patients, their family and community of support. In fact, such an experience can cause post intensive care syndrome (PICS), a disorder seen in patients resulting from the illness and treatments during intensive care, said Susan Neville, PhD, RN, CDP, chair and professor in the Department of Nursing at New York Institute of Technology.

Today, healthcare professionals are looking for ways to care for patients and families faced with these challenges.

PICS Defined

Being a patient in an intensive care unit can be stressful, noted Linda Howard, MS, RN, CCRN, unit lead at Torrance Memorial Medical Center in California.

"Patients are very ill and have to trust and depend on the medical team to maintain all their needs. These needs may be as basic as activities of daily living to the extreme of maintaining their lives physiologically due to life-threatening illnesses," she explained.

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Patients in the ICU are surrounded by machines, tubes and unusual noises. With numerous advances in medicine, many treatments that assist in sustaining life are invasive and uncomfortable. Patients may suffer a loss of dignity and control, observed Howard.

Medications are administered to patients to assist in alleviating pain and suffering caused by their illness and treatments. However, "these same medications can cause more confusion and disorientation," said Howard. When their physiological condition improves, patients may be confused to the present situation and have little memory of recent events. In addition, their muscles are weak from illness and prolonged bed rest.

Health problems involving the patient's body, thoughts, feelings or mind that are present in the ICU and remain after critical illness is the essence of PICS, according to the Society of Critical Care Medicine. The syndrome, which may affect both ICU survivors and their families and support communities, consists of functional deficits, cognitive impairment and psychosocial problems. These deficits vary in severity and can last more than a year, said Howard.

"Many survivors have difficulties with activities of daily living or returning to their previous level of activities," she said, noting that ICU-acquired weakness occurs in 15%-50% of survivors.

In addition, cognitive impairment affects approximately 30%-80% of survivors. This includes problems with memory, paying attention and problem solving.

"The problems may be slight so that only the family or the patient may notice," Howard said.

Psychological problems include sleep disorders, depression and anxiety. Post-traumatic stress disorder is seen in some survivors.

Families at Risk

Howard listed the main risk factors for PICS as heavy prolonged sedation, delirium, immobility, sepsis and hypoxia. She noted that the minimum level of sedation may reduce the effects of PICS.

She said keeping the family updated on the patient status and allowing them to participate in the care will help to decrease PICS in the patient and family.

Lisa Sparacino, MS, RN, CCRN, instructor and lab coordinator in the Department of Nursing at New York Institute of Technology, said that regardless of the outcome, many family members experience an anticipatory loss. They also experience the same stressors as patients: exposure to sleep deprivation and continuous high noise levels.

"Family members find themselves dealing with strains on personal relationships and often the threat of loss of a job and/or failing at a personal goal. They often feel separated from the care of their loved one and helpless when attempting to support their critically-ill loved one," said Sparacino, a critical care nurse for the past 27 years.

To decrease the symptoms of PICS in family members, have them assist in the patient's range of motion activities throughout the continuum, from simple passive motion to activities of daily living, suggested Howard.

Sparacino concurred. "Involving the patient and family in the overall plan of care, as well as the day-to-day planning and interventions allows the patient and family control over what is happening," she said.

Howard remarked that family PICS decreases with knowledge of the patient's condition. She said the most important factor in minimizing PICS in family members is to maintain their own health and wellness during the stressful situation.

The Nurse's Role

To identify those at risk for PICS, nurses must develop a rapport with both patients and family members.

"They need to fully understand the patient and family's coping structure and mechanisms. They need to understand how a patient's culture, socioeconomic status and spirituality influence the coping process," explained Sparacino. "I view the process as one of grieving. Even if the outcome is positive, the patient and family still progress through the stages of grieving and loss."

When patients and family stall at a stage or do not express feelings and emotions expected during grieving and loss, they are at risk for exaggerated grief - an indicator that might lead to long-term difficulty dealing with the stressors of the critical care environment, she added.

Nurses can help patients and families dealing with PICS by starting the process in the critical care environment.

"Keeping the patient and family informed is crucial," she said. "This involves explaining and providing examples, as well as resources, such as literature and support groups. Being available when the patient and family need the information plays a key role in their ability to understand and absorb the information."

Sparacino believes honesty is the most significant factor that assists patients and families in coping with the stressors of the critical care experience. Other non-direct actions involve controlling environmental factors.

"This involves initiatives, such as planning procedures and setting alarms that meet each patient's individual needs," she said. "Remembering to keep basic nursing care initiatives as a priority allows the patient and family to feel empowered over their care."

Once the patient is discharged or leaves the critical care setting, nurses on post-ICU units and in the community should be on the alert for symptoms of ongoing or increasing stress (PTSD). Involving counseling and follow-up care in the community could decrease the incidence of PICS. In addition, the public must be educated about the syndrome.

"Most people have never heard that patients suffer long-term effects post-ICU. When a person recovers from a critical illness the public views it as a good thing. Since it is not viewed that a loss occurs, many patients and family members do not recognize that they are suffering a loss and do not seek treatment," Sparacino said.

Howard said treatment will depend on the symptoms and may include physical therapy, occupational therapy and psychological care.

"Recovery allows the patient to maximize their ability to normalize their lives and assists in reducing stress for the patient and family," she concluded.

Resource

Society of Critical Care Medicine. New resources highlight post-intensive care syndrome 2013. www.sccm.org/News/Pages/New-Resources-Highlight-Post-Intensive-Care-Syndrome.aspx

Beth Puliti is a freelance writer.


Help Patients & Families with PICS

Susan Neville, PhD, RN, CDP, chair and professor, Department of Nursing, New York Institute of Technology, shared the following ways nurses can help patients and families with post intensive care syndrome.

• Prevention and education is key

• Continually orient the patient and family to date, time and person

• Ask family to bring in photos to keep the patient connected

• Consider music therapy

• Have both patient and family keep reflection journals

• Provide as calm an environment as possible

• Control under and over stimulation as much as possible

• Lend your support and presence

• Encourage the expression of concerns and fears




     

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