Monday, February 1, 2010

Nursing Management of ICU psychosis

What is ICU psychosis?
ICU 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.

Why should I know about ICU psychosis?
Because it is estimated that one in every three patients who spends more than five days in an ICU experiences some form of psychotic reaction. As the number of intensive care units and the patient population in them grow, the number of individuals affected by this disorder will correspondingly increase. With patients being transferred out of the ICU more rapidly than in years past; ICU psychosis may be more common in other areas such as the regular medical floors too, and long term care facilities.

What causes ICU psychosis?
Causes can be classified into two: Environmental and medical causes
Environmental Causes
1. Sensory deprivation: A patient being put in a room alone and often not able to see windows, and is away from family, friends, is likely to experience ICU psychosis.
2. Sleep disturbance and deprivation: This is due to constant disturbance and noise with the hospital staff coming at all hours to check vital signs, and give medications.
3. Continuous light levels: Continuous disruption of the normal rhythm with lights on continually (no reference to day or night).
4. Stress: Patients in an ICU frequently feel total loss of control over their life.
5. Lack of orientation: A patient's loss of time and date.
6. Medical monitoring: The continuous monitoring of the patient's vital signs and the noise monitoring devices produce can be disturbing and create sensory overload.
Medical Causes
1. Pain which is not being adequately controlled in an ICU.
2. Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms.
3. Medication reaction or side effects: The administration of medications typically given to the patient in the hospital setting that they have not taken before.
4. Infection creating fever and toxins in the body.
5. Metabolic disturbances: electrolyte imbalance, hypoxia, and elevated liver enzymes.
6. Heart failure due to inadequate cardiac output.
7. Cumulative analgesia causing the inability to feel pain while still conscious
8. Dehydration

There are many psychiatric symptoms manifested in ICU psychosis which includes:
extreme excitement, anxiety, restlessness, hearing voices, clouding of consciousness,
hallucinations, nightmares, paranoia, disorientation, agitation, delusions, Abnormal behavior, and
fluctuating level of consciousness which include aggressive or passive behavior.
Can I prevent ICU psychosis?
The primary goal is to correct any imbalance, restore the patient's health, and return the patient to normal activities as quickly as possible. Several strategies have been put in place to help prevent ICU psychosis.
These are:
1. Providing more liberal visiting policies.
2. Providing periods for sleep.
3. Protecting the patient from unnecessary excitement.
4. Minimizing shift changes in the nursing staff caring for a patient, orienting the patient to the date and time.
5. Reviewing all medical procedures with an explanation to the patient and family about what to expect.
6. Asking the patient if there are any questions or concerns.
7. Talking with the family to obtain information regarding religious and cultural beliefs.
8. Coordinating the lighting with the normal day-night cycle.
The treatment of ICU psychosis will depends on the cause(s). Most times the actual cause of the psychosis involves many factors, and many issues will need to be addressed to relieve the symptoms. The nurse, the physician in charge of the patient along with the pharmacist can work collaboratively to review patient's medications to determine if they may be causing the delirium.