Environmental Stressors

We often heal better when we can rest, relax and sleep.([FOOTNOTE=Parthasarathy S, Tobin MJ. Sleep in the intensive care unit. Appl Physiol Intensive Care Med. 2009:191-200.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs Q. 2003;26(3):179-189.],[ANCHOR=],[LINK=])  Ironically, that can be difficult in one of the places where it's most needed: the ICU.^1,2 Bright lights, a cacophony of ventilators and beeping alerts, and the hustle of busy caregivers may bring your patients anything but calm.^1,2

Disrupted sleep is common among critically ill patients. ^1,2,([FOOTNOTE=Olofsson K, Alling C, Lundberg D, Malmros C. Abolished circadian rhythm of melatonin secretion in sedated and artificially ventilated intensive care patients. Acta Anaesthesiol Scand. 2004;48(6):679-684.],[ANCHOR=],[LINK=]) Studies have shown most ICU patients' circadian rhythms to be diminished or lost.^1,2,3  Their sleep may be fragmented, with frequent awakenings and decreased REM and deep sleep.^1,2,3

Such sleep deprivation has been associated with sympathetic activation, increased blood pressure and compromised immunity.^1.2.3 Among many causes of poor sleep, ICU noise and frequent nursing assessments and interventions have been reported to account for 30% of awakenings.^1,2,3

Other factors can include bright lights, pain, medications and anxiety.^1,2,3

Delirium and patient stress may also be affected by the ICU environment.([FOOTNOTE=Biancofiore G, Bindi ML, Romanelli AM, Urbani L, Mosca F, Filipponi F. Stress-inducing factors in ICUs: what liver transplant recipients experience and what caregivers perceive. Liver Transpl. 2005;11(8):967-972.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Hewitt J. Psycho-affective disorder in intensive care units: a review. J Clin Nurs. 2002;11(5):575-584.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Gelling, L. Causes of ICU psychosis: the environmental factors. Nurs Crit Care. 1999;4(1):22-26.],[ANCHOR=],[LINK=]) Research has shown that in addition to medical factors (e.g medication, sleep deprivation and age) and discomfort (as from restricted mobility or tubes in the patient's nose and mouth), social interactions can have a large impact on risk of psycho-affective problems in the ICU.^4,5,6  Difficulty communicating and being understood, separation from loved ones, and dehumanizing experiences, such as loss of privacy, can contribute to stress.^4,5,6

Some noise and activities are of course necessary in the course of ICU operations, but there may be things you can do to provide a more soothing environment to reduce anxiety, agitation and sleep deprivation in your patients.([FOOTNOTE=Wenham T, Pittard A. Intensive care unit environment. Continuing Education Anaesth Crit Care Pain. 2009;9(6):178-183.],[ANCHOR=],[LINK=])

Lighting

Exposure to natural light can help orient patients and improve their circadian rhythms.⁷  Artificial lighting should also mimic the 24-hour day to encourage better sleep.⁷  Since some light is usually necessary for ICU operations, consider using dimmable lighting that can be positioned out of patients' line of sight, such as countertop and reading lamps.⁷

Noise

Noise levels in the ICU can exceed recommended standards and levels conducive to rest, clear communication and sleep.⁷  Loud noises can also be disorienting and contribute to delirium.([FOOTNOTE=Pugh RJ, Jones C, Griffiths RD. The impact of noise in the intensive care unit. Intensive Care Med Yearbook of Intensive Care Med. 2007:942-949.],[ANCHOR=View Abstract],[LINK=http://link.springer.com/chapter/10.1007/978-3-540-49433-1_85])  Nighttime sound levels below 40 decibels, about the volume of a soft whisper, are recommended to allow sleep.⁷  That may mean taking a little extra caution to keep conversations quiet, set equipment to silent operating modes where possible, even to oil squeaky hinges and cart wheels. Dimming lights at night may help encourage quiet.⁷  And be careful with those items you're carrying—dropping something on the floor can register a startling 92 decibels.⁷

Alternately, try a white noise generator—for example, a clock radio that plays ocean sounds—to decrease the impact of background sounds.⁷

Relaxation and sleep promotion

Human interaction and familiar experience from life outside the ICU may help your patients feel less anxious.^4,7

Social isolation is a major contributor to ICU stress,^4,7  so consider doing what you can to ensure space and time for patient visits with their friends and loved ones, with as much privacy as practical. If your patient is on ventilation or otherwise can't speak, consider providing a pen and paper or letter/word chart to ease communication. These visits can provide a distraction from discomfort, and also help your patient stay oriented to time and place, together with visual cues such as clocks and calendars.⁷

Encouraging your patients to listen to music they enjoy can bring familiar and pleasant sounds into their days.([FOOTNOTE=Bradt J, Dileo C, Grocke D. Music interventions for mechanically ventilated patients. Cochrane Database Syst Rev. 2010;8;(12):CD006902.],[ANCHOR=],[LINK=]) Music therapy for 20- to 30-minute periods can have both psychological and physiological benefits.⁹  A review of recent literature found evidence that music can reduce anxiety, heart rate and respiratory rate—all good indications of relaxation.⁹

Guided imagery is another tool for promoting relaxation,([FOOTNOTE=Papathanassoglou ED. Psychological support and outcomes for ICU patients. Nurs Crit Care. 2010;15(3):118-128.],[ANCHOR=],[LINK=]) and is currently offered in a number of hospitals.([FOOTNOTE=Imagery International: A Professional Association of Guided Imagery Practitioners. Hospital Offerings. Available at:https://imageryinternational.wildapricot.org/Hospitals-Offering/. Accessed March 20, 2013.],[ANCHOR=],[LINK=]) Often recommended for general stress management, guided imagery can be especially powerful in the ICU.¹⁰ A recent review of guided imagery studies in hospital settings showed that consistent use of guided imagery during the hospital stay reduces the length of stay as well as pain, anxiety, fatigue and narcotics use, as well as the associated costs.¹⁰  Using prerecorded tapes or one-hour sessions with certified Integrative Imagery facilitators, patients can experience the benefits of this technique.^10,11

Therapeutic massage and touch may also provide comfort and positive interaction.([FOOTNOTE=Henricson M, Ersson A, Määttä S, Segesten K, Berglund AL. The outcome of tactile touch on stress parameters in intensive care: a randomized controlled trial. Complement Ther Clin Pract. 2008;14(4):244-254.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Bush E. The use of human touch to improve the well-being of older adults. A holistic nursing intervention. J Holist Nurs. 2001;19(3):256-270.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Calenda E. Massage therapy for cancer pain. Curr Pain Headache Rep. 2006;10(4):270-274.],[ANCHOR=],[LINK=]) They can also measurably lower anxiety,¹²  improve circulation and quality of life¹³  and may help to reduce pain.¹⁴ Try gentle back, foot and/or arm massage for 5–10 minutes, daily or several times a week.^12,13,14

There is evidence that in addition to their relaxing effects, massage, therapeutic touch, guided imagery and music therapy can all help patients to sleep better.([FOOTNOTE=Richards K, Nagel C, Markie M, Elwell J, Barone C. Use of complementary and alternative therapies to promote sleep in critically ill patients. Crit Care Nurs Clin North Am. 2003;15(3):329-340.],[ANCHOR=],[LINK=])  Also key to better sleep are the previously mentioned improvements to the ICU environment, including addressing noise and adjusting lighting.

These interventions are recommended ahead of sedatives, which may decrease sleep quality in addition to other side effects.^1,2  A regular bedtime routine—preferably including some elements from your patient's normal home routine—can also help set the cues for sleep.²

Finally, try to minimize nighttime interventions when possible to improve your patients' day/night cues and minimize sleep interruptions.^1,2  Taken together, improvements to your patients' environment and daily experiences may benefit their health and quality of life.^1-15