Lisa M. Ewert and Dr. Renea Beckstrand, BYU College of Nursing
When a patient is on a ventilator, it’s the critical care nurse’s role to recognize and respond to any factors that cause the patient distress. Anytime a patient is ill, the illness causes both physiological and emotional stress. However, an acute illness that is severe enough to require mechanical ventilation intensifies the physical and psychological distress with which the patient and their family must cope (1).
Stresses that could arise from mechanical ventilation include anxiety, fearfulness (including fear of dying), pain, discomfort, powerlessness and/or loneliness. When patients’ experience stress, whether it’s physical or emotional, the stress causes a sympathetic nervous system response. This leads to arterial and venous constriction, myocardial stimulation and bronchoconstriction. Bronchoconstriction increases airway resistance, thus increasing both the work of breathing and the demand for oxygen (1).
Not all patients respond or perceive stressors in the same way, in fact, the research reports that it’s the perception of the situation, not the situation itself that causes distress (2). Thus, use of available information to support patient coping can positively influence a patient’s response to mechanical ventilation.
In this study, I used a convenience sample of 5 previously ventilated patients at Utah Valley Regional Medical Center’s fifth floor medical-surgical area. All patients were over 18 years of age, spoke and read English, were hemodynamically stable as evidenced by having a normal blood pressure, heart rate, and normal temperature, and this was their first experience being mechanically ventilated (for a longer time than just during a surgery where they were under anesthesia) during this hospital admission. Pregnant women, cognitively impaired or, institutionalized individuals, and prisoners were not included in this study. To gather data, I went to the unit in the early mornings and talked with the charge nurses in order to identify hemodynamically stable patients that have recently (last 48 hours) been extubated from mechanical ventilation. I introduced myself to the patients and then explained the study (including risks and benefits) to the patients. After a consent form was signed, I began audiotaping an interview in which I began with a single question, “Tell me what your experience was being mechanically ventilated,” and then used an interview guide to help elicit further responses.
I hypothesized that being on a mechanical ventilator would be a horrible experience for all patients but that there might be some other variables that happened during this experience that made it better or worse. I wondered if finding other ways to communicate with the patient would help them feel more comfortable. For example, I thought if the nurse would take the time to try and read their lips, make hand gestures or give them something to write on, patients might feel less anxious due to the fact that they were more able to communicate their needs. For the most part, these factors didn’t help very much. One patient did say he felt he could communicate if the nurses would take the time, but the rest did not feel they could communicate their needs. Another patient said that his daughter wanted to “know this and that” and wanted him to write down his answers, but it frustrated him. He didn’t think she should be asking him all these questions when he couldn’t really answer. Writing didn’t seem to be as effective at communicating as speaking aloud to someone. A third patient told me he couldn’t even move his hands, and a fourth said, “My wife said I used sign language, but she couldn’t understand it.”
Overall, hand gestures and writing on paper were not effective means of communication. I was right in my hypothesis that not being able to communicate would be the worst part about being ventilated. All patients expressed how frightened they were when they realized they couldn’t talk. One patient expressed, “it frustrated me, cause I wanted something to drink, and they wouldn’t,…. you know you can’t tell them what you want, and they won’t give it to you anyway.” A second patient said, “It seems like they are far off, and you can’t communicate with them.” Three out of the five patients I interviewed said the worst part about being ventilated was either not being able to communicate or talk. One other said the worst part was being thirsty, which could have been resolved if he could have been able to communicate his needs and the fifth patient said the worst part about being ventilated was “feeling like you’re choking and that you have no control.”
One trend I found was that the more sedated a patient was, the better he was able to cope with his experience. One patient who had a very frightening experience said to me, “I don’t want to go through this again. It’d be easier to go six feet under I think.” He had gone into this experience thinking that he was going to “be kept under” but became fully aware of what was happening around him. On the other hand, a different patient had a far better experience being mechanically ventilated. He said of the ventilator, “I think it’s a wonderful thing they can do.” Earlier in the interview I also noticed that this particular patient also told me “they kind of keep you sedated.” Another factor that helped patients better cope with their experience was to have a nurse who encouraged them to relax. One patient was told to let the machine breath naturally for him and when he realized it was, “it was okay”. Another patient explained that the most helpful thing the nurses did was to talk to him and tell him to go back to sleep whenever he woke up and to just relax.
This project was not without obstacles. I was not able to find any women to interview, so I have no way of knowing if women perceive their experiences being ventilated any differently than men. A few patients I talked to weren’t willing to sign consent forms and some wanted me to come back later, which was time consuming. But overall, this was a great learning experience for me. I’ve just graduated and am working as a nurse now and can use the things I’ve learned from talking with patients in the future.
References
- Johnson, M.M., & Sexton, D.L. (1990). Distress during mechanical ventilation: Patient’s perceptions. Critical Care Nurse, 10(7), 48-58.
- Gries, M.L., & Fernsler, J. (1988). Patient perceptions of the mechanical ventilation experience. Focus on Critical Care, 15(2), 52-58.