Page 170 - ACCCN's Critical Care Nursing

Psychological Care 147

SLEEP PROMOTION AND MAINTENANCE ● Provide the daily bath to suit patient needs rather than
In the absence of conclusive evidence to support sleep organisational needs (either before settling for the
promoting interventions in ICU, recommendations are night or during normal waking hours).
based on practices that would be likely to improve sleep
in health, e.g. noise reduction, limiting the number of
interruptions to which patients are subjected and main- Practice tip
tenance of an environment that is generally conducive to
normal night-time sleep. Individualised approaches to all The importance of sleep to critically ill patients cannot be over-
aspects of care are best and this is particularly important stated. Enabling the patient to experience good quality and
when promoting and maintaining sleep in the critically quantities of sleep should be a major priority for critical care
ill. The following information, based on research and nursing. Demonstrate your commitment to improving rest and
expert opinion, provides some general advice which may sleep for intensive care patients by incorporating sleep into the
promote and maintain sleep and at the very least create treatment reminder system used in the unit of your practice
conditions conducive to rest. setting (e.g. FASTHUG becomes FASSTHUG).
Comfort Measures
Environmental
● Ensure pain relief is offered and administered if pain
is suspected. ● Reduce noise levels especially during rest times and
● Reduce anxiety by providing information and the at night (this may require a unit-wide change in prac-
opportunity to have questions answered. Anxiolytics tice) as several studies conducted in critical care have
such as benzodiazepines may also be required. highlighted the association between noise levels and
● Provide night time sedation as required (remember sleep disruption. 114,143,144 Continuous noise levels in
sedation is not natural sleep and patients may only adult critical care areas consistently exceed hospital
appear to be asleep however it is possible to be sedated noise standards, for example, the Environmental
and asleep). Protection Agency (EPA) 35dB(A) at night and
● Provide a light massage unless contraindicated. 139 45dB(A) during the day 145 and the Australian Stan-
● Offer guided relaxation and imagery (audio guided dard AS/NZS 2107/2000 minimum 40dB(A) and
relaxation and imagery sessions may be maximum 45dB(A). 146-148
purchased). 140 ● Ensure lights are sufficiently dimmed and window
● Provide an extra cover for warmth (metabolic rate blinds drawn during rest times and at night and that
typically drops during sleep). lighting is bright and blinds opened at all other times.
● Request the patient’s family to provide some of the It is known that critically ill patients’ melatonin
patient’s own personal belongings such as pillows and metabolism is non-circadian so it is particularly
toiletries. important to attempt to use lighting that encourages
● Ear plugs and eye covers may assist some patients, normal circadian rhythm. 149,150 Generally critical care
however it should be highlighted that studies have areas contain fluorescent lights which may emit up to
shown that neither provide protection from excessive 600 lux. Light levels between 50 and 100 lux at night
151
141
noise and light levels. Patients provided with ear even for relatively brief periods are known to suppress
plugs and eye covers should have the ability to remove melatonin production, a vital hormone in the promo-
them without assistance if they wish.
tion of sleep and maintenance of circadian rhythm. 123
Care Activities It is well known that artificial lights emit light with
sufficient short wave content to affect melatonin
● Attend to nursing care at the beginning of the night secretion.
to reduce the likelihood of disturbing during the night
for example:
● redress wounds and empty drainage bags Practice tip
● wash, clean teeth and change gown and sheets
● reposition with suitable pressure support Ask your patient (or his/her relatives) about his/her usual night-
measures time ‘settling routine’ for sleep. Try to emulate the routine as
● level the transducer at the phlebostatic axis to closely as possible. Ask the patient if this improved their sleep.
ensure accurate haemodynamic monitoring
without the need to disturb the patient 142
● ensure intravenous lines and drains are accessible
● Plan care activities to allow the patient 1.5–2 hour Treatments
periods of undisturbed time during the night. (Nego-
tiate with other health care personnel to allow these ● Discuss the need for alternative mechanical ventila-
uninterrupted periods at night and during daytime tion settings at night with the medical team. Hyper-
rest times). ‘Cluster care’, for example, time medica- ventilation caused by inappropriately high inspiratory
tion administration and blood samples to coincide pressure can cause hypocapnia which may lead to
with pressure area care. central apnoeas and sleep disturbance. 152