Nursing Care of Critical Care Patients Without Sedation

Q What are the evidence-based approaches to the nursing care of patients facing critical illness and mechanical ventilation without sedation?A Kali Dayton, DNP, AGACNP, replies:Sedation in the intensive care unit (ICU) poses high risks of delirium and ICU-acquired weakness, complicating awakening trials when agitation and weakness arise.1 Prolonged sedation increases hospital-acquired complications, time on the ventilator and in the hospital, and costs.2 Delirium raises the risk of self-extubation by 11.6 times and increases fall risks by up to 4 times.3 It also increases workload and burdens nurses psychologically (Figure 1).4Keeping patients awake early on is just as important to patient outcomes as early resuscitation and lung-protective ventilation strategies.5 Although safe staffing is imperative, nonsedative care does not require excessive staffing or increase nurse workload but does demand a strategic approach.6-8To prevent delirium and ICU-acquired weakness, Polly Bailey, founder of an early "awake-and-walking ICU," says, "What we do on the front end of critical illness determines the back end."9 The ABCDEF bundle is crucial for keeping patients as awake, communicative, autonomous, and mobile as possible.10 Achieving these goals goes beyond avoiding sedation; it reflects the care we implement instead. Prompt awakening after intubation, unless an indication for sedation is present, allows for interventions like communication, family engagement, and mobility.Communication is a basic human right that must be preserved even during mechanical ventilation.11 After intubation, providing tools for nonverbal communication is imperative. Avoiding sedation early on helps preserve cognition and muscular function, facilitating fine motor skills for writing or texting.A lack of communication can increase anxiety and agitation.12 Instead of addressing underlying concerns,13 sedation may mask distress and worsen trauma. Maintaining communication can protect patient autonomy and enhance care (Figure 2).14Patients often need to express in-depth thoughts and concerns that simple yes-or-no questions fail to capture. Real-life examples include "Where is my daughter?," "Where is my dog?," "I understand I am going to die. Please let me sign my pension paperwork and make sure my wife is taken care of," "I am ready to go home to Jesus," "I want to walk," "I am withdrawing from Wellbutrin," "Please make sure my cat is being fed," "Thank you for everything you are doing for me," and "I love you."The ability to communicate allows caregivers to provide targeted symptom management for issues like pain, anxiety, fear, and dyspnea.15 In 1 instance, an intubated patient able to communicate "chest pain" led to prompt intervention upon discovering a large pneumothorax. This example exemplifies how communication can save lives.It must be part of the registered nurse skill set to identify and implement appropriate tools for nonverbal communication. These tools include a pen and paper, whiteboard, letter board, digital applications, and augmentative and alternative communication tools.16 Speech language pathologists can provide expert support for more complex communication needs.17Involving loved ones substantially benefits patients in managing delirium, promoting calmness, and ensuring safety. Families can assist nonverbal communication and engage patients in motivating activities like games or video calls.18 Having at least 1 family member present overnight is essential for humanizing the ICU environment.19Liberating patients from sedation after intubation preserves cognition and muscle function, enabling independence in movement without requiring the involvement of an army of clinicians. An awake-and-walking ICU aims for patient mobilization within 12 hours after intubation unless contraindicated.9 Mobility helps alleviate dyspnea, decrease discomfort,20 mitigate pneumonia risk,21 and improve mental status.22Facilitating verticalized positions such as sitting and standing as well as mobilizing patients are key to preventing delirium23 and addressing anxiety and dyspnea.24 Evening mobility enhances sleep and reduces delirium risks.25 Optimal mobility occurs within 48 hours after intubation26 and should be frequent.27 Each additional 10 minutes of mobility can decrease a hospital length of stay by 1.2 days, resulting in improved workload.28Intensive care unit mobility falls within registered nurses' scope of practice and should form part of their skill set. Although physical and occupational therapists can offer expertise, nurses can independently initiate mobility as soon as appropriate.29 Encouraging basic and routine movements such as self-turning, engaging in activities of daily living, sitting at the edge of the bed, standing, taking steps to a chair, and walking restores a sense of normalcy in the stressful ICU setting, helping patients feel empowered in their recovery.These nonpharmacologic strategies should be prioritized early on in patients' critical illness journey. Amid the complexities of medications, devices, and interventions, keeping patients awake and mobile enhances their chances of surviving, recovering, and returning to the lives they lived before their stay in the ICU.9DAYTON