Nursing Interventions for Reducing the Stresses
Experienced by Mechanically Ventilated Patients

Teresa Perkins
McKendree University

Nursing Interventions for Reducing the Stresses
Experienced by Mechanically Ventilated Patients

Mechanically ventilated patients may experience increased levels of stress due to various environmental factors in the ICU. These include equipment/alarm noise, invasive nature of treatments and the inability to communicate verbally. These stressors can cause non-favorable effects such as increased anxiety levels which can subsequently lead to somatic reactions such as tachycardia, dyspnea, increased blood pressure and patient-ventilator dyssynchrony. Prolonged anxiety levels can also induce psychological effects such as increased fear and inhibitions. This can ultimately affect the patient’s overall capacity to cope with difficult emotions and situations (Richart-Martinez & Perpina-Galvan, 2009). These effects can lead to the need for more sedation which can hinder weaning attempts. The longer a patient is mechanically ventilated the greater the risk of developing Ventilator Associated Pneumonia, (VAP), and Adult Respiratory Distress Syndrome (ARDS). VAP is a pneumonia that develops 48 hours or longer after mechanical ventilation. It results from the invasion of the lower respiratory tract and lung parenchyma by microorganisms. Intubation compromises the integrity of the oropharynx and trachea and allows oral and gastric secretions to enter the lower airways. ARDS is a life-threatening lung condition that prevents enough oxygen from getting into the blood.
The purpose of this study is to evaluate the effectiveness of stress reducing, non-pharmacologic interventions on mechanically ventilated patients when used in conjunction with pharmacologic interventions to decrease overall anxiety.
Research efforts of the past decade have produced many favorable changes in regard to how and when mechanical ventilation is utilized in the ICU setting. Studies have influenced weaning and extubation practices, the use of alternative non-invasive ventilation trials and the overall safety of mechanical ventilation protocols especially in the treatment of ARDS (Esteban, et al., 2008). Despite the advances in practice, protocols and procedures, only a small amount of research has been dedicated to dealing with and managing patient responses to mechanical ventilation. The majority of the research that has been done in this area recognizes that patients receiving mechanical ventilation undergo vast amounts of physiological and psychological stress related to the invasive nature of the treatment itself regardless of age, ethnicity or gender (Chlan, 2003).
Physiological changes that result from prolonged stress include increased heart rate, increased respiratory rate and increased blood pressure which over time can ultimately cause negative outcomes for the mechanically ventilated patient (Chlan & Savik, 2011). These changes include, but are not limited to, increased need for oxygen and disruption of medical devices (Lee, Chung, Chan, & Chan, 2005), as well as the increased need for and prolonged use of sedatives and analgesic medications. This increases the risk for medication reactions and prolonged ventilator weaning times (Woods, et al., 2004). When mechanical ventilation is prolonged there is a greater possibility that the patient will develop complications such as VAP or ARDS (Cason, Tyner, Saunders, & Broome, 2007). If these conditions arise, overall patient homeostasis is threatened and the likelihood of successful and positive outcomes for the patient decreases significantly (Woods, et al., 2004).
Various non-pharmacological adjunct interventions were identified in the research as being somewhat helpful in reducing prolonged stress in mechanically ventilated patients. One of the most common modalities explored was that of music therapy. Dijkstra, Gamel, vand der Bijl, Bots and Kesecioglu, (2010), deduced that one of the greatest benefits of music therapy lies with its ability to decrease the patient’s susceptibility to stress and anxiety by allowing a deeper level of sedation to be achieved when used either alone or in conjunction with pharmacologic treatment. Another study done by Lee, Chung, Chan, and Chan, (2005), observed that those patients receiving music therapy exhibited more “comfortable behaviors” than those who were merely given rest periods with no music therapy. Additional studies have been undertaken in which methods of distraction such as empathetic touch, relaxation techniques and verbal strategies such as reassurance, coaching and encouragement were utilized with some success in reducing stress in mechanically ventilated patients (Chlan & Savik, 2011; Tate, Dabbs, Hoffman, Milbrandt & Happ, 2012).
The limitations of these studies pertained to patient inability to accurately respond to questions and surveys due to general weakness, confusion and levels of sedation. The use of psychological measurement scales such as the state anxiety portion (SAI) of the Spielberger State-Trait Anxiety Inventory (STAI) further limited these studies due to the illiteracy or lower educational levels of some patients. Additionally, the objective nature of statements such as “comfortable behavior” (Lee, Chung, Chan, & Chan, 2005) is not easily measureable. Other studies’ limitations were in regard to where the patient was in the treatment process. Patients who were actively weaning and those who had merely just begun mechanical ventilation have varying perceptions of anxiety. This could have likely affected the measurement of stress levels of those patients (Tate, Dabbs, Hoffman, Milbrandt, & Happ, 2012).
Overall, the research shows that there is a viable place in nursing practice for the use of non-pharmacological interventions in reducing the stress of patients receiving mechanical ventilation. Interventions such as reducing light and noise in the patient’s immediate environment and providing distraction and relaxation techniques can be easily implemented. Employing verbal strategies such as encouragement and coaching, as well as the use of music therapy are currently underutilized in the critical care setting (Woods, et al., 2004). By finding ways to better utilize these techniques, nurses could have a much more significant positive impact on the overall care received by and perceived by the patient receiving mechanical ventilation. References
Cason, C. L., Tyner, T., Saunders, S., & Broome, L. (2007). Nurses' implementation of guidelines for ventilator-associated pneumonia fromt eh centers for disease control and prevention. American Journal of Critical Care, 16, 28-37.
Chlan, L. L. (2003). Description of anxiety levels by individual diffreences and clinical factors in patients receiving mechanical ventilatory support. Heart and Lung, 22, 375-382.
Chlan, L., & Savik, K. (2011). Patterns of anxiety in critically ill patients receiving mechanical ventilatory support. Nursing Research, 60, (3S), 50-57.
Dijkstra, B. M., Gamel, C., vand der Bijl, J. J., Bots, M. l., & Kesecioglu, J. (2010). The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients. Journal of Clinical Nursing, 19, 1030-1039.
Esteban, A., Ferguson, N. D., Meade, O.M., Frutos-Vivar, Fernando, Apeztegua, C., Brochard, L, Konstantinos, R., Nin, N., Hurtado, J., Tomicic, V., Gonzalez, M. Elizalde, J., Nightingale, P., Abroug, F., Pelosi, P., Arabi, Y., Moreno, R., Jibaja, M., D'Empaire, G., Sandi, F., Matamis, D., Montanez, A.M., & Anzueto, A. (2008). Evolution of Mechanical Ventilation in Response to Clinical Reserach. American Journal of Critical Care Medicine, 177, 170-177.
Lee, O. K., Chung, Y. F., Chan, M. F., & Chan, W. M. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing, 14, 609-620.

References (cont.)
Richart-Martinez, J., & Perpina-Galvan, M. (2009). Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: A review. American Journal of Critical Care, 18, 571-580.
Tate, J. A., Dabbs, A. D., Hoffman, L. A., Milbrandt, e., & Happ, M. B. (2012). Anxiety and agitation in mechanically ventilated patients. Qualitative Health Research, 22, (2), 157-173.
Woods, J. C., Mion, L. C., Connor, J. T., Viray, F., Jahan, L., Huber, C., McHugh, R., Gonzales, J.P., Stoller, J.K., & Arroliga, A.C. (2004). Severe Agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes. Intensive Care Medicine, 30, 1066-1072.