Delirium at the Hands of NursesSeptember 11, 2013
Amanda Anderson, BSN, RN, CCRN, works as a nurse in New York City and is pursuing a master’s in administration from Hunter-Bellevue Scahool of Nursing at Hunter College. Her last post for this blog was “A Hurricane Sandy Bed Bath.”
Leo is young but I’ve cared for him in the ICU many times. It’s late, but he’s awake, talking, in a voice like Kermit the Frog’s. My eyes traverse the path between his, the patch of hair beneath his moving lips, and the newly healed trach site on his neck. He is too long for the bed frame that supports him—we’ve taken off the footboard, and his big feet stick out from the white blanket over his legs.
Tonight, Leo is stable, but this hasn’t always been the case; I’ve known him since the beginning, months and months ago. A long and nasty alcohol addiction led to a bad case of pancreatitis and multiple interventions to save his life. The saving is what I’m most familiar with—the sedated, unstable, intubated, tenuous Leo, not this chatty, relaxed, stable Leo.
Leo is my only patient tonight, a rarity in a busy urban hospital. The unit is empty and slow, not much care to give, nothing requiring immediate attention. So, I sit with him and talk about our common ground: what Leo survived.
It isn’t often that a MICU nurse gets a chance to hear the stories of a surviving patient. This isn’t because this one doesn’t care; it’s just that not all patients actually survive, or if they do, I don’t always see them when they’re able to talk about it. Leo asks a few questions of me, and then starts to tell me about his experience—the hallucinations that he remembers from when he was sick.
As this article summarizes, studies have found that posttraumatic stress disorder (PTSD) is common in patients after an ICU stay, attributed in some cases to high sedative use and related delirium, traumatic treatments such as intubation, and other factors. In a guy like Leo—close to seven-feet tall, outfitted with lines, drains, tubes, and monitors required to save his life—sedatives were a must.
Looking at him now, listening to him tell me of how he had thought his mother and an orange-haired troll were running an illicit bowling alley around him, I laugh and think of the volume of drugs I had to give him. To save his life, to keep his oxygenation stable, to keep him in the bed. It seems impossible to imagine how Leo’s care would have looked without those sedatives.
But it does make me wonder about an ICU-land without magical drugs to fix all problems. What would nursing care look like? What nursing measures could be performed differently to better decrease anxiety and stress?
What if, every time a nurse touched a patient, she or he did so with intention, and attention to the pressure, length of touch, and purpose? What if, every time a patient like Leo was turned in order to clean soiled or bloody sheets, the turn was done with careful attention to Leo’s mental state? What if talk in the room were kept to a minimum, with only intentional conversation pointed at Leo? What if washing, changing linens, starting IVs, administering medications, were all done only after explanation to Leo—regardless of how sedated he might be at the time?
My point is this: we study and analyze the chemical and medical interventions that occur, limiting sedatives, keeping drugs to a standard of care. But nursing interventions—from spiking a bag of antibiotics to the noise of washing one’s hands in the nearby sink—are almost always done in the presence of the patient, and rarely analyzed. When patients are sedated, we sometimes feel we have free reign of the room to relax, speak freely, play music, turn and pull and push at random. But maybe those interventions make just as much of a difference as the sedatives?
Leo told me things that he hallucinated that weren’t very far from reality. Many of the images and sounds had elements of the unit in them—the noise from the loudspeaker, the many, many IV bags hanging over him, the blaring fluorescent lights. While the sedatives and the illness clouded Leo’s vision and reasoning, how much muddling did the nursing care do?
Perhaps if we place attention on the fact that patients are people with minds—sedated or not—and we respect that those minds are always at work, we will become more intentional practitioners, and have fewer patients with long-term adverse effects. While Leo’s stories kept me laughing until morning, I left knowing that underneath the chuckles, they brought him pain and confusion. Their colored plot lines blurred with the ghastly reality of his care, making me wish I could erase them for him, cleaning his memory, and that of the next patient, and the next.