Want to know more

CRITICAL CARE
Comprehensive Assessment and Management of the Critically Ill

Michele C. Balas, PhD, RN, CCRN, CRNP, BC, Colleen M. Casey, BS, RN, CCRN, Mary Beth Happ, PhD, RN

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Goal: To restore physiologic stability, prevent complications, maintain comfort and safety, and preserve pre-illness functional ability and quality of life (QOL) in older adults admitted to critical-care units.

I. Overview: Caring for an older adult who is experiencing a serious or life-threatening illness often poses significant challenges for critical care nurses. Although older adults are an extremely heterogeneous group, they share some age-related characteristics that leave them susceptible to various geriatric syndromes and diseases. This vulnerability may influence both their intensive care unit (ICU) utilization rates and outcomes. Critical care nurses caring for this population must not only recognize the importance of performing ongoing, comprehensive physical, functional, and psychosocial assessments tailored to older ICU patients but also must be able to identify and implement evidence-based interventions designed to improve the care of this extremely vulnerable population.

II. Background

A. Definition

1. Critically ill older adult: a person, age 65 or older, who is currently experiencing or at risk for some form of physiologic instability or alteration

warranting urgent or emergent, advanced nursing/medical interventions and monitoring.

B. Etiology/Epidemiology

1. More than half (55.8%) of all ICU days are incurred by patients older than 65.1

2. Older adults are living longer, are more racially and ethnically diverse, often have multiple chronic conditions, and more than one-quarter report difficulty performing one or more activities of daily living (ADLs).2 These factors may affect both the course and outcome of critical illness.

3. Once hospitalized for a life-threatening illness, older adults often:

a. Experience high ICU, hospital, and long-term crude mortality rates.

b. Are at risk for deterioration in functional ability and post-discharge institutional care.3

c. Older age is also a factor that may lead to:

i. Physician bias in refusing ICU admission. 4, 5 .

ii. The decision to withhold mechanical ventilation, surgery, or dialysis.6

iii. An increased likelihood of an established resuscitation directive. 7

d. Most critically ill older adults:

i. Demonstrate resiliency.

ii. Report being satisfied with their QOL post-discharge.

iii. Would reaccept ICU care and mechanical ventilation if needed. 3, 8, 9

e. Chronologic age alone is not an acceptable or accurate predictor of poor outcomes after critical illness.3, 9, 10

f. Factors that may influence an older adult’s ability to survive a catastrophic illness include: 3

i. Severity of illness

ii. Nature and extent of co-morbidities

iii. Diagnosis, reason for/duration of mechanical ventilation

iv. Complications length of ICU/hospital stay: 3, 5, 6, 10, 11, 12, 13, 14, 15, 16, 17, 18. 19, 20 , 21, 22

· Preadmission nursing-home residence

· Pulmonary artery catheterization

· Prehospitalization functional ability

· Gender

· Pre-existing cognitive impairment

· Delirium

· Ethnicity

· Senescence

· Ageism

· Decreased social support

· The critical care environment

III. Parameters of Assessment

A. Preadmission: Comprehensive assessment of a critically ill older adult’s preadmission health status, cognitive and functional ability, and social support systems helps identify risk factors for cascade iatrogenesis, the development of life-threatening conditions, and frequently encountered geriatric syndromes. Factors that nurses need to consider when performing the admission assessment include the following:

1. Pre-existing cognitive impairment: Many older adults admitted to ICUs suffer from high rates of unrecognized, pre-existing cognitive impairment. 23, 24

a. Knowledge of preadmission cognitive ability could aid practitioners in:

i. Assessing decision making capacity, informed consent issues, and evaluation of mental status changes throughout hospitalization. 23

ii. Making anesthetic and analgesic choices

iii. Considering one-to-one care options

iv. Weaning from mechanical ventilation

v. Assessing fall risk

vi. Planning for discharge from the ICU

b. Upon admission of an older adult to the ICU, nurses should ask relatives or other caregivers for baseline information about the older adult’s:

i. memory, executive function (e.g., fine motor coordination, planning, organization of information), and overall cognitive ability. 25

ii. behavior on a typical day, how the patient interacts with others, their responsiveness to stimuli, how able they are to communicate (reading level, writing, and speech), and their memory, orientation, and perceptual patterns prior to their illness. 26

iii. medication history to assess for potential withdrawal syndromes. 27

c. Developmental and Psychosocial Factors: Critical illness can render older adults unable to effectively communicate with the health care team, often related to physiologic instability, technology that leaves them voiceless, and sedative and narcotic use. Family members are therefore often a crucial source for obtaining important preadmission information. Upon ICU admission, nurses need to determine:

i. What is the elder’s past medical, surgical, and psychiatric history? What medications was the older adult taking before coming to the ICU? Does the elder regularly use illicit drugs, tobacco, or alcohol? Do they have a history of falls, physical abuse, or confusion?

ii. What is the older adult’s marital status? Who is the patient’s significant other? Will this person be the one responsible to make decisions for the elder if they are unable to do so? Does the elder have an advanced directive for health care? Is the elder a primary caregiver to an aging spouse, child, grandchild, or other person?

iii. How would the elder describe his/her ethnicity? Do they practice a particular religion or have spiritual needs that should be addressed? What was their quality of life like before becoming ill?

d. Preadmission functional ability/nutritional status: Limited preadmission functional ability and poor nutritional status are associated with many negative outcomes for critically ill older adults. 5, 21, 28, 29

Therefore, nurses should assess the following:

i. Did the elder suffer any limitations in the ability to perform their ADLs preadmission? If so, what were these limitations?

ii. Does the elder use any assistive devices to perform their ADLs? If so, what type?

iii. Where did the patient live prior to admission? Did they live alone or with others? What was the elder’s physical environment like (e.g., house, apartment, stairs, multiple levels)?

iv. What was the older adult’s nutritional status like preadmission? Do they have enough money to buy food? Do they need assistance with making meals/obtaining food? Do they have any particular food restrictions/preferences? Were they using supplements/vitamins on a regular basis? Do they have any signs of malnutrition, including recent weight loss/gain, muscle wasting, hair loss, skin breakdown?

B. During ICU stay: There are many anatomic/physiologic changes that occur with aging (See Table 25.1 in protocols book or topic Aging Changes). The interaction of these changes with the acute pathology of a critical illness, co-morbidities, and the ICU environment leads not only to atypical presentation of some of the most commonly encountered ICU diagnoses but may also elevate the older adult’s risk for complications. The older adult must be systematically assessed for the following:

1. Comorbidities/common ICU diagnoses

a. Respiratory: chronic obstructive pulmonary disease, pneumonia, acute respiratory failure, adult respiratory distress syndrome, rib fractures/flail chest

b. Cardiovascular: acute myocardial infarction, coronary artery disease, peripheral vascular disease, hypertension, coronary artery bypass grafting, valve replacements, abdominal aortic aneurysm, dysrhythmias

c. Neurologic: cerebral vascular accident, dementia, aneurysms, Alzheimer’s disease, Parkinson’s disease, closed head injury, transient ischemic attacks

d. Gastrointestinal: biliary tract disease, peptic ulcer disease, gastrointestinal cancers, liver failure, inflammatory bowel disease, pancreatitis, diarrhea, constipation, and aspiration

e. Genitourinary: renal cell cancer, chronic renal failure, acute renal failure, urosepsis, and incontinence

f. Immune/Hematopoietic: sepsis, anemia, neutropenia, and thrombocytopenia

g. Skin: necrotizing fasciitis, pressure ulcers.

2. Acute Pathology: Thoracic or abdominal surgery, hypovolemia, hypervolemia, hypo/hyperthermia, electrolyte abnormalities, hypoxia, arrhythmias, infection, hypo/hypertension, delirium, ischemia, bowel obstruction, ileus, blood loss, sepsis, disrupted skin integrity, multisystem organ failure.

3. ICU/Environmental Factors: Deconditioning, poor oral hygiene, sleep deprivation, pain, immobility, nutritional status, mechanical ventilation, hemodynamic monitoring devices, polypharmacy, high-risk medications (e.g., narcotics, sedatives, hypnotics, nephrotoxins, vasopressors), lack of assistive devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the oropharyngeal airway, poorly regulated glucose control, Foley catheter use, stress, invasive procedures, shear/friction, intravenous catheters.

4. Atypical Presentation: Commonly seen in older adults experiencing the following: myocardial infarction, acute abdomen, infection, and hypoxia.

IV. Nursing Care Strategies

A. Preadmission: Based on their preadmission assessment findings, nurses should consider:

1. Obtaining appropriate consults (i.e., nutrition, physical/ occupational/speech therapist).

2. Implementing safety precautions.

3. Using pressure-relieving devices.

4. Organizing family meetings.

5. Providing older adults with a consistent primary nurse.

B. During ICU: Nursing interventions that may benefit:

1. Multiple organ systems:

a. Encouraging early, frequent mobilization/ambulation.

b. Providing proper oral hygiene.

c. Ensuring adequate pain control.

d. Reviewing/assessing medication appropriateness.

e. Avoiding polypharmacy/high-risk medications (See Table 25.2 in protocol book* or topic Preventing Adverse Drug Reactions).

f. Securing and ensuring the proper functioning of tubes/catheters.

g. Actively taking measures to maintain normothermia.

h. Closely monitoring fluid volume status.

2. Respiratory

a. Encourage and assist with coughing, deep breathing, incentive spirometer use; use alternative device when appropriate (e.g., PEP).

b. Assess for signs of swallowing dysfunction and aspiration.

c. Closely monitor pulse oximetry and arterial blood gas results.

d. Consider the use of specialty beds.

e. Advocate for early weaning trials and extubation as soon as possible.

f. Exercise standard VAP precautions. 30 :

1. Keep the head of the bed elevated to more than 30 degrees.

2. Provide frequent oral care.

3. Maintain adequate cuff pressures.

4. Assess the need for stress ulcer prophylaxis.

5. Turn the patient as tolerated.

6. Maintain general hygiene practices.

3. Cardiovascular

a. Carefully monitor the older adult’s hemodynamic and electrolyte status.

b. Closely monitor the older adult’s EKG with an awareness of many conduction abnormalities seen in aging. Consult with physician regarding prophylaxis when appropriate.

c. Advocate for the removal of invasive devices as soon as the patient’s condition warrants. The least restrictive device may include long-term access.

d. Recognize that both pre-existing pulmonary disease and manipulations of the abdominal and thoracic cavities may lead to unreliability of traditional values associated with central venous and pulmonary artery occlusion pressures.29

e. Because of age-related changes to the CV system, the nurse should acknowledge. 29:

i. Older adults often require higher filling pressures (i.e., CVPs in the 8 to 10 range, PAOPs in the 14 to18 range) to maintain adequate stroke volume and may be especially sensitive to hypovolemia.

ii. Over-hydration of the older adult should also be avoided because it can lead to systolic failure, poor organ perfusion, and hypoxemia with subsequent diastolic dysfunction.

iii. Certain drugs commonly used in the ICU setting may prove to be either not as effective (e.g., isoproterenol and dobutamine or more effective (e.g., afterload reducers).

4. Neurologic/Pain

a. Closely monitor the older adult’s neurologic/mental status.

b. Screen for delirium and sedation level at least once per shift.

c. Implement interventions to reduce delirium. 21, 31, 32, 33, 34, 35:

i. Promote sleep, mobilize as early as possible, review medications that can lead to delirium, treat dehydration, reduce noise or provide “white noise,” close doors/drapes to allow privacy, provide comfortable room temperature, encourage family and friends to visit, allow the older adult to assume the preferred sleeping positions, discontinue any unnecessary lines or tubes, and avoid the use of physical restraints using least restraint for minimum time only when absolutely necessary.

ii. Maximize older adults’ ability to communicate their needs effectively and interpret their environment.

· Promote the older adult wearing glasses, hearing aids, and other appropriate assistive devices.

· Face patients when speaking to them, get their attention before talking, speak clearly and loud enough for them to understand, allow them enough time (pause time) to respond to questions, provide them with a consistent provider (i.e., a primary nurse), use visual clues to remind them of the date and time, and provide written or visual input for a message. 36, 37

· Provide older adults with alternate means of communication (e.g., providing a pen/paper; using nonverbal gestures; and/or using specially designed boards with alphabet letters, words, or pictures). 38, 39, 40

· Provide translators/interpreters as needed.

d. Provide adequate pain control while avoiding over- or under-sedation. For a full discussion, see topic, Pain Management.

5. Gastrointestinal

a. Monitor for signs of GI bleeding and delayed gastric emptying/motility.

i. Encourage adequate hydration, assess for signs of fecal impaction, and implement a bowel regimen.

ii. Avoid use of rectal tubes.

b. Advocate for stress ulcer prophylaxis.

c. Provide dentures as soon as possible.

d. Implement aspiration precautions.

i. Keep the head of the bed elevated to a high Fowler’s position, frequently suction copious oral secretions, bedside evaluate swallowing ability by a speech therapist, assess phonation and gag reflex, monitor for tachypnea.

e. Advocate for early enteral/parental nutrition if consistent with advance directive.

f. Ensure closely monitored glycemic control. 41

6. Genitourinary (GU)

a. Assess any GU tubes to ensure patency and adequate urinary output. If an older adult should experience an acute decrease in urinary output, consider using bladder scanner (if available) rather than automatic straight catheterization to check for distension.

b. Advocate for early removal of Foley catheters. Use other less invasive devices/methods to facilitate urine collection (i.e., external or condom catheters, offering the bedpan on a scheduled basis, and keeping the nurse’s call bell/signal within the older adult’s reach).

c. Monitor blood levels of nephrotoxic medications as ordered.

7. Immune/Hematopoietic

a. Ensure the older adult is ordered appropriate DVT prophylaxis (i.e., heparin, sequential compression devices).

b. Monitor laboratory results, assess for signs of anemia relative to patient’s baseline.

c. Recognize early signs of infection: restlessness, agitation, delirium, hypotension, tachycardia, because older adults are less likely to develop fever as a first response to infection.

d. Meticulously maintain infection control/prevention protocols.

8. Skin

a. Conduct thorough skin assessment.

b. Vigilantly monitor room temperature, make every effort to prevent heat loss, and carefully use and monitor rewarming devices.

c. Use methods known to reduce the friction and shear that often occurs with repositioning in bed.

d. In severely compromised patients, the use of specialty beds may be appropriate.

e. Techniques such as frequent turning, pressure-relieving devices, early nutritional support, as well as frequent ambulation may not only protect an older adult’s skin but also promote the health of their cardiovascular, respiratory, and gastrointestinal systems.

f. Closely monitor IV sites, frequently check for infiltrations and use of nonrestrictive dressings and paper tape.

V. Evaluation and Expected Outcomes

A. Patient

1. Hemodynamic stability will be restored.

2. Complications will be avoided/minimized.

3. Preadmission functional ability will be maintained/optimized.

4. Pain/anxiety will be minimized.

5. Communication with the health care team will be improved.

B. Provider

i. Employ consistent and accurate documentation of assessment relevant to older ICU patients.

ii. Provide consistent, accurate, and timely care in response to deviations identified through ongoing monitoring and assessment of older ICU patients.

iii. Provide patient/caregiver with information and teaching related to their illness and regarding transfer of care and/or discharge.

C. Institution: include QA/QI

1. Evaluate staff competence in the assessment of older critically ill patients.

2. Utilize unit-specific, hospital-specific, and national standards of care to evaluate existing practice.

3. Identify areas for improvement and work collaboratively across disciplines to develop strategies for improving critical care to older adults.

VI. Relevant Practice Guidelines

A. Jacobi et al. (2002). Clinical Practice Guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), and American College of Chest Physicians.

B. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA) (2006). Guideline Update on perioperative cardiovascular evaluation for noncardiac surgery: Focused update on perioperative beta-blocker therapy. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology.

Nursing Standard of Practice Protocol:

Comprehensive Assessment and Management of the Critically Ill

Michele C. Balas, Colleen M. Casey, Mary Beth Happ

 

References

 

1. Angus, D. C., Kelley, M. A., Schmitz, R. J., White, A., Popovich, J. Jr., Committee on Manpower for Pulmonary and Critical Care Societies (2000). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? Journal of the American Medical Association, 284(21), 2762–2770. Evidence Level IV: Nonexperimental Study.

2. Administration on Aging (2005). A profile of older Americans: 2005. Retrieved May 23, 2006, from http://www.aoa.gov/PROF/Statistics/profile/2005/2005profile.pdf. Evidence Level IV: Nonexperimental Study.

3. Chelluri, L., Grenvik, A., & Silverman, M. (1995). Intensive care for critically ill elderly: mortality, costs, and quality of life. Review of the literature. Archives of Internal Medicine, 155(10), 1013–1022. Evidence Level V: Literature Review.

4. Joynt, G. M., Gomersall, C. D., Tan, P., Lee, A., Cheng, C. A., & Wong, E. L. (2001). Prospective evaluation of patients refused admission to an intensive care unit: Triage, futility, and outcome. Intensive Care Medicine, 27(9), 1459–1465. Evidence Level IV: Nonexperimental Study.

5. Mick, D. J., & Ackerman, M. H. (2004). Critical care nursing for older adults: Pathophysiological and functional considerations. Nursing Clinics of North America, 39(3), 473–493. Evidence Level VI: Expert Opinion.

6. Hamel, M. B., Teno, J. M., Goldman, L., Lynn, J., Davis, R. B., Galanos, A. N., et al. (1999). Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Annals of Internal Medicine, 130(2), 116–125. Evidence Level III: Quasi-experimental Study.

7. Hakim, R. B., Teno, J. M., Harrell, F. E., Jr., Knaus, W. A., Wenger, N., Phillips, R. S., et al. (1996). Factors associated with do-not-resuscitate orders: Patients' preferences, prognoses, and physicians' judgments. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Annals of Internal Medicine, 125(4), 284–293. Evidence Level III: Quasi-experimental Study.

8. Guentner, K., Hoffman, L. A., Happ, M. B., Kim, Y., Dabbs, A. D., Mendelsohn, A. B., et al. (2006). Preferences for mechanical ventilation among survivors of prolonged mechanical ventilation and tracheostomy. American Journal of Critical Care, 15(1), 65–77. Evidence Level IV: Nonexperimental Study.

9. Kleinpell, R. M. (2003). Exploring outcomes after critical illness in the elderly. Outcomes Management, 7(4), 159–169. Evidence Level IV: Nonexperimental Study.

10. Esteban, A., Anzueto, A., Frutos-Vivar, F., Alia, I., Ely, E. W., Brochard, L., et al. (2004). Outcome of older patients receiving mechanical ventilation. Intensive Care Medicine, 30(4), 639–646. Evidence Level IV: Nonexperimental Study.

11. Adnet, F., Le Toumelin, P., Leberre, A., Minadeo, J., Lapostolle, F., Plaisance, P., et al. (2001). In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema. Critical Care Medicine, 29(4), 891–895. Evidence Level IV: Nonexperimental Study.

12. Chelluri, L., Pinsky, M. R., Donahoe, M. P., & Grenvik, A. (1993). Long-term outcome of critically ill elderly patients requiring intensive care. Journal of the American Medical Association, 269(24), 3119–3123. Evidence Level IV: Nonexperimental Study.

13. Djaiani, G., & Ridley, S. (1997). Outcome of intensive care in the elderly. Anaesthesia, 52(12), 1130–1136. Evidence Level IV: Nonexperimental Study.

14. Kass, J. E., Castriotta, R. J., & Malakoff, F. (1992). Intensive care unit outcome in the very elderly. Critical Care Medicine, 20(12), 1666–1671. Evidence Level IV: Nonexperimental Study.

15. Knaus, W. A., Wagner, D. P., Draper, E. A., Zimmerman, J. E., Bergner, M., Bastos, P. G., et al. (1991). The APACHE III prognostic system: Risk prediction of hospital mortality for critically ill hospitalized adults. Chest, 100(6), 1619–1636. Evidence Level IV: Nonexperimental Study.

16. Mayer-Oakes, S. A., Oye, R. K., & Leake, B. (1991). Predictors of mortality in older patients following medical intensive care: The importance of functional status. Journal of the American Geriatrics Society, 39(9), 862–868. Evidence Level IV: Nonexperimental Study.

17. Nicolas, F., Le Gall, J. R., Alperovitch, A., Loirat, P., & Villers, D. (1987). Influence of patients' age on survival, level of therapy, and length of stay in intensive care units. Intensive Care Medicine, 13(1), 9–13. Evidence Level IV: Nonexperimental Study.

18. Nierman, D. M., Schechter, C. B., Cannon, L. M., & Meier, D. E. (2001). Outcome prediction model for very elderly critically ill patients. Critical Care Medicine, 29(10), 1853–1859. Evidence Level IV: Nonexperimental Study.

19. Richmond, T. S., Kauder, D., Strumpf, N., & Meredith, T. (2002). Characteristics and outcomes of serious traumatic injury in older adults. Journal of the American Geriatrics Society, 50(2), 215–222. Evidence Level IV: Nonexperimental Study.

20. Shapira, O. M., Kelleher, R. M., Zelingher, J., Whalen, D., Fitzgerald, C., Aldea, G. S., et al. (1997). Prognosis and quality of life after valve surgery in patients older than 75 years. Chest, 112(4), 885–894. Evidence Level IV: Nonexperimental Study.

21. Tullmann, D. F., & Dracup, K. (2000). Creating a healing environment for elders. AACN Clinical Issues, 11(1), 34–50; quiz 153–154. Evidence Level VI: Expert Opinion.

22. Wu, A. W., Rubin, H. R., & Rosen, M. J. (1990). Are elderly people less responsive to intensive care? Journal of the American Geriatrics Society, 38(6), 621–627. Evidence Level IV: Nonexperimental Study.

23. Pisani, M. A., Inouye, S. K., McNicoll, L., & Redlich, C. A. (2003). Screening for preexisting cognitive impairment in older intensive care unit patients: Use of proxy assessment. Journal of the American Geriatrics Society, 51(5), 689–693. Evidence Level IV: Nonexperimental Study.

24. Pisani, M. A., Redlich, C., McNicoll, L., Ely, E. W., & Inouye, S. K. (2003). Under-recognition of preexisting cognitive impairment by physicians in older ICU patients. Chest, 124(6), 2267–2274. Evidence Level IV: Nonexperimental Study.

25. Kane, R. L., Ouslander, J. G., & Abrass, I. B. (2004). Essentials of Clinical Geriatrics (5th ed.). New York: McGraw-Hill. Evidence Level VI: Expert Opinion.

26. Milisen, K., DeGeest, S., Abraham, I. L., & Delooz, H. H. (2001). Delirium. In T. T. Fulmer, M. D. Foreman, & M. Walker (Eds.), Critical care nursing of the elderly (2nd ed.). New York: Springer Publishing Company. Evidence Level VI: Expert Opinion.

27. Broyles, L., Happ, M. B., Tate, J., Swigart, V., & Hoffman, L. (2005). Neurocognitive complexity, interpersonal conflict, and inconsistent care patterns in the case of an elderly ICU patient. The Gerontologist, 45 (Special Issue II), 126. Evidence Level IV: Nonexperimental Study.

28. Roche, V. M., Kramer, A., Hester, E., & Welsh, C. H. (1999). Long-term functional outcome after intensive care. Journal of the American Geriatrics Society, 47(1), 18–24. Evidence Level IV: Nonexperimental Study.

29. Rosenthal, R. A., & Kavic, S. M. (2004). Assessment and management of the geriatric patient. Critical Care Medicine, 32(4 Suppl.), S92–S105. Evidence Level VI: Expert Opinion.

30. Kunis, K. A., & Puntillo, K. A. (2003). Ventilator-associated pneumonia in the ICU: Its pathophysiology, risk factors, and prevention. American Journal of Nursing, 103(8), 64AA–69AA. Evidence Level VI: Expert Opinion.

31. Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340(9), 669–676. Evidence Level II: Individual Experimental Study.

32. Jacobi, J., Fraser, G. L., Coursin, D. B., Riker, R. R., Fontaine, D., Wittbrodt, E. T., et al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30(1), 119–141. Evidence Level V: Review.

33. Milbrandt, E. B., Kersten, A., Kong, L., Weissfeld, L. A., Clermont, G., Fink, M. P., et al. (2005). Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients. Critical Care Medicine, 33(1), 226–229. Evidence Level IV: Nonexperimental Study.

34. Yeh, S. H., Lee, L. N., Ho, T. H., Chiang, M. C., & Lin, L. W. (2004). Implications of nursing care in the occurrence and consequences of unplanned extubation in adult intensive care units. International Journal of Nursing Studies, 41(3), 255-262. Evidence Level III: Quasi-experimental Study.

35. Zeleznik, J. (2001). Effectiveness of interventions to prevent delirium in hospitalized patients: A systematic review. Journal of American Geriatrics Society, 49(12), 1730–1732. Evidence Level VI: Expert Opinion.

36. Garrett, K., & Beukelman, D. R. (1995). Changes in the interaction patterns of an individual with severe aphasia given three types of partner support. Clinical Aphasiology, 23, 237–251. Evidence Level III: Quasi-experimental Study.

37. Lasker, J., Hux, K., Garrett, K. L., Moncrief, E. M., & Eischeid, T. J. (1997). Variations on the written choice communication strategy for individuals with severe aphasia. Augmentative and Alternative Communication, 13, 108–116. Evidence Level III: Quasi-experimental Study.

38. Connolly, M. A. (1995). Communicating with temporarily nonvocal patients. Perspectives in Respiratory Nursing, 6, 7–9. Evidence Level IV: Nonexperimental Study.

39. Patak, L., Gawlinski, A., Fung, N. I., Doering, L., & Berg, J. (2004). Patients' reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart & Lung, 33(5), 308–320. Evidence Level IV: Nonexperimental Study.

40. Stovsky, B., Rudy, E., & Dragonette, P. (1988). Comparison of two types of communication methods used after cardiac surgery with patients with endotracheal tubes. Heart & Lung, 17(3), 281–289. Evidence Level III: Quasi-experimental Study.

41. NICE-SUGAR Study Investigators. Finfer S. Chittock DR. Su SY. Blair D. Foster D. Dhingra V. Bellomo R. Cook D. Dodek P. Henderson WR. Hebert PC. Heritier S. Heyland DK. McArthur C. McDonald E. Mitchell I. Myburgh JA. Norton R. Potter J. Robinson BG. Ronco JJ. Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine, 2009; 360(13):1283-97.

Last updated - July 2009