The unpopular patient in the intensive care unit

Angela Teece

Lecturer in Adult Nursing, University of Leeds @Angela Teece

My involvement in an EBN Twitter chat that discussed issues surrounding the use of restraint with agitated patients in critical care (Freeman and Teece, 2017), led to producing a poster for my School’s postgraduate research student conference. Whilst discussing the poster, I began to reflect on the ways in which some patients are seen as more desirable to care for than others.

Delirium is defined as a rapid onset, reversible, fluctuating condition characterised by inattention, changes in cognition, disordered sleep-wake cycle, and increased or decreased
psychomotor activity (American Psychiatric Association, 2013). It is a common form of organ failure in critical care patients, affecting approximately 45-87% of the population (Cavallazzi et al., 2012). Hyperactive delirium presents as psychomotor agitation, hypervigilance and intolerance of interventions. In my experience as a critical care sister, when allocating staff to patients, nurses would frequently ask to care for a ‘proper ICU patient’. This often meant a patient in multi-organ failure dependent on a range of technology to sustain life. A delirious patient can be just as challenging to nurse. However, it demands a different skill and mindset from the nurse. Instead of minute adjustments to drugs and ventilation, the nurse is tasked with ensuring the comfort and safety of an agitated patient, making rapid clinical judgements to ensure oxygenation and perfusion are maintained in a patient who is intolerant of conventional ICU monitoring.

So why are these patients devalued by nurses? Surely this should be an opportunity to engage with a distressed and frightened patient? To help support patient and family? To be labelled ‘not a proper ICU patient’ surely has a detrimental effect on the care of the patient through suggesting they do not deserve ICU care (Lowbridge and Hayes, 2013).A culture change is necessary to ensure that the care of patients suffering failure of perhaps the most important organ, the brain, is prioritised. To achieve this, doctors and senior nurses should recognise and give practical help and support to nurses, and more emphasis in education should be placed on developing the skills to care for delirious patients – empasing that they are a ‘proper ICU patient.’

AMERICAN PSYCHIATRIC ASSOCIATION, D. S. M. T. F. 2013. Diagnostic and statistical manual of mental disorders: DSM-5, Arlington, Va;London;, American Psychiatric Association.

CAVALLAZZI, R., SAAD, M. & MARIK, P. E. 2012. Delirium in the ICU: an overview. Annals of Intensive Care, 2, 1-11.

FREEMAN, S. & TEECE, A. 2017. Critical care nursing: caring for patients who are agitated. Evidence – Based Nursing, 20, 101.

LOWBRIDGE, K. L. & HAYES, L. 2013. The unpopular patient. British Journal of Nursing, 22, 448-448.

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