Class Notes For Understanding the Essentials of Critical Care Nursing, 2nd Edition

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[Perrin2e IRM]Chapter 1 What Is Critical Care?RESOURCE LIBRARYCOMPANION WEBSITECase Study: Critical Care NursingNursing Care PlanNCLEX Review QuestionsMedia LinksMedia Link ApplicationsLearning Outcome 1Define critical care.Concepts for Lecture1.Critical careis the direct delivery of medical care to a critically ill or injuredpatient. The care is often delivered in a specialized unit with advanced technologyavailable.This care is provided by aspecially trained team of professionals.2.Critical careis defined by the Department of Health and Human Services (2001)as the “direct delivery of medical care for a critically ill or injured patient. To beconsidered critical an illness or injury must acutely impair one or more vital organ

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systems such that a patient’s survival is jeopardized. Critical care is usually butnot always given in a critical care area such as a coronary care unit, an intensivecare unit, a respiratory care unit, or an emergency care unit.”PowerPoint Lecture Slides1.Criticalcare—“direct delivery of medical care for a critically ill or injured patient. Tobe considered critical an illness or injury must acutely impair one or more vital organsystems so that a patient’s survival is jeopardized” (Department of HealthandHumanServices, 2001).2.Elements of critical illness or injury:•Impairment of one ormore vital organs•Patient survival jeopardized•Care given in specialty unit with specialized personnel and equipmentSuggested Strategies for Classroom ExperienceAsk students to share examples of patient conditions that, according to the definitionprovided, would require critical care.Learning Outcome 2State the three levels of care provided in critical care units.

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Concepts for Lecture1.In 2003, the Society of Critical Care Medicine(SCCM)endorsed guidelines for criticalcare services based on three levels of care. These guidelines suggested that each hospitalprovide a level of care appropriate to its mission and regional needs for critical careservices because not all hospitalsare ableto meet the needs of all types of patients andseveritiesof illness.2.Level Icritical care unitspossess sophisticated equipment. Specialized nurses andphysician specialists are continuously available. Care is comprehensive for a wide varietyof disorders. Support services are readily available. These ICUs are usually located inteaching hospitals.3.Level IIunitsprovide comprehensive care for most patients but may not be able tocare formore complex types of patientssuch ascardiothoracic surgical patients.TheseICUs must have transfer arrangementsin place so that carecan be madeavailable for themost complex patients if necessary.4.Level IIIunitsprovide initial stabilization of critically ill patients but have limitedability to provide comprehensive critical care. Patients who require routine care mayremain at the facility but written transfer policies must be in place to provideoptions forcritical care for those patients who need it.

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PowerPoint Lecture Slides1.Three levels of care for critical care services are necessary.Not all hospitalsare equipped to meet the needs of all patient typesand severitiesofillness.2.Level ICritical Care UnitsMost comprehensive care availableUsuallyin teaching hospitalsSpecialty physicians, nurses, and equipment continuously availableComprehensive support servicesavailable3.Level IICritical Care UnitsLimited care for some specific patients (ex: cardiothoracic surgical patients)Must have transfer plan to Level I facilities for patients with specific disorders for whichthe unit does not provide care4.Level IIICritical Care UnitsProvide initial stabilization of critically ill patientsLimited ability to provide comprehensive critical careShould have written policies for patient transfer if required

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Suggested Strategies for Classroom ExperienceDiscuss clinical facilities in use by students in your program. What attributes are obviousin the critical care units of these facilities? What level of care is provided at each?Learning Outcome 3Compare and contrast “open” and “closed” critical care units.Concepts for Lecture1.Critical care units may be “open” or “closed.”2.In anopen ICU, nurses, pharmacists, and respiratory therapists are basedin theICUbut the physicians directing patient care may have other obligations. Thesephysicians may or may not choose to consult an intensivist to assist with themanagement of their ICU patients.3.In aclosed ICU,patient care is provided by a dedicated ICU team that includes acritical care physician. TheSCCMrecommends that primary care physiciansandconsultants collaborate and useanintensivist to intervene and direct care in urgentand emergent situations.PowerPoint Lecture Slides1.“Open” Unit•Nurses, pharmacists, and respiratory therapists are ICU-based•Physicians are not ICU-based—have other responsibilities•Theprimary physicianmay consult an intensivist to assist with patientmanagement

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2.“Closed” Unit•ICU team with critical care physician•Primary care physician and consultants collaborate•Intensivistisgiven authority to manage patient’s care in urgent andemergent situationsSuggested Strategies for Classroom ExperienceAsk students to reflect upon the ICUs in the facilities in which they have clinicalexperience. Are the units open or closed? What attributes, specifically, indicate thisstatus?Learning Outcome 4Explain why critical care units are one of the most common sites for health care errors.Concepts for Lecture1.Critically ill patients require complex, carefully coordinated care. When a carepattern is complex, failure in one part of the system can unexpectedly affectanother.Therefore, if anything goes wrong, and an error is identified, it can bedifficult to prevent deterioration of the situation because of theextremecomplexity of care in critical care areas.2.The Institute of Medicine (IOM) postulates that technology increases errors forseveral reasons:

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•Technology changes tasks by shifting the workload and eliminatinghuman decision making.•Althoughtechnology decreases workload during nonpeak hours, it oftenincreases it during peak hours or during system failure(e.g.,when thecomputerized medication scanning device fails and documentation mustbe done on paper and then entered electronically later when the system isworking).•When technology controls performance of tasks automatically, users nolonger know how to perform functions without it (e.g.,calculation ofmcg/kg/min for drug doses) when the system fails.•Errors can occur when equipment is not standardized and demandsprecisionfor use(e.g.,ICU nurses use many different brands of IV pumpsor ventilators).3.Safety of all patients is a concern, but safety for vulnerable, critically ill patients isparamount. In one 24-hour examination of errors in ICUsworldwide, nearly 75%reported errors,including:•dislodgement of lines, catheters, and drains•medication errors•failure of infusion devices•failure or dysfunction of a ventilator•unplanned extubation while ventilator alarms were turned off

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4.Since release of the IOM reportTo ErrIs Human(2000), there has been a focuson identifying and correcting system problems that increase potential for errors sothatrisk forerrors can be reduced. Recommendations for error reduction include:•utilizing constraints—an example of this is when the height, weight,andallergies of a patient must be on file to obtain a medication for the patient•installing forcing functions or system-level firewalls—for example,concentrated potassium chloride (KCl) is no longer available on hospitalunits•avoiding reliance on vigilance—forcing use of checklists, protocols,andrechecking with another professional (e.g.,time-outs prior to surgery andchecking doses of insulin with another RN prior to administration)•simplifyingand standardizingkey processes5.Providers can enhance safe, effective care and limit risks to critically ill patientsby:•developing a multidisciplinary approach to patient care—Care shouldbe delivered by a multidisciplinary team headed by a full-time critical-care-trained physician and consisting of at least an ICU nurse, arespiratory therapist, and a pharmacist. Outcomes for patients are betterwhen multidisciplinary teams collaborate and work well together.•encouraging a culture of safety—Thisencompasses seven essentialproperties: teamwork, evidencebased practice, communication, patient-centered care, leadership, learning,and justice. In a critical care unit that

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has embraced a culture of safety, practitioners have a responsibility totheir patients to make their errors known, have them corrected, and sharethem with the patient, his family, and other practitioners. With practiceimprovement as the goal rather than punishment of the health careprovider who committed the error, the reporting of the error promotesexamination of factors that contributed to the error and changes in practicefor the future.•instituting closed units—These are units in whichonly intensivists treatpatients.•providing adequate staffing—This does not imply only looking atnumbers of patients/nurse, but also to assigning a nurse with appropriatecompetencies to meet the needs of the assigned patients.•limiting work hours—TheIOM recommends that nurses work no morethan 60 hours per weekand no more than12 hours in any 24-hour period.PowerPoint Lecture Slides1.Technology increases errorsbecause:•Iteliminates need forhuman decisionmaking•Itincreasesworkload when it fails or is inadequate•Nursesforgethow to calculate drips without technology•Equipment is highly sophisticated, nonstandard,and demands precision for use

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2.Technology can affect patientcare•Nurses may fail to touch patients•Best assessment occurs when nurses assess in addition to what technologyprovides•Technology can predispose to errorsin delivery of care•Technology devices may fail and contribute to error (extubation, failure ofinfusion devices, etc.)3.Patient safety strategies for prevention and early detection of errors•utilizing constraints—height, weight,and allergies required before a medicationcan be obtained for the patient•installing forcing functions or system-level firewalls—concentrated potassiumchloride (KCl) is no longer available on hospital units•avoiding reliance on vigilance—forcing use of checklists, protocols,andrechecking with another professional (e.g.,time-outs prior to surgery andchecking doses of insulin with another RN prior to administration)•simplifying and standardizing key processes4.Providers can enhance safe, effective care and limit risks to critically ill patientsby:•developing a multidisciplinary approach to patient care•encouraging a culture of safety•instituting a closed unit

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•providing adequate staffing•limiting work hoursSuggested Strategies for Classroom ExperienceAsk students why it is important to check insulin doses with another professional nurseprior to administration of the drug. (If necessary, remind them that insulin is considereda high-alert medication according to the Institute for Safe Medication Practices.)Ask students why it is important not to have concentrated potassium chloride available onthe unit.What risks are involved with intravenous administration of this medication inparticular?Learning Outcome 5Describe the relationship between the patient and nurse intheAACN’s synergy model.Concepts for Lecture1.The AACN believes that critical care nursing should be defined more by theneeds of the patients and those of their families than by the environment in whichcare is delivered or the diagnoses of the patients. An underlying assumption of thesynergymodel is that optimal patient outcomes occur when patient and familyneeds are aligned with nurse competencies.

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PowerPoint Lecture Slides1.Critical care nursing practice should be defined more by the needs of patients andthose of their families than by the environment in which care is delivered or thediagnosis of the patients.Patient/Family Needs + Nurse Competencies = Optimal Patient OutcomesSuggested Strategies for Classroom ExperienceAsk students to think about why it would be preferable to have an expert critical carenurse care for a 78-year-old fresh cardiothoracic surgical patient with a history ofdiabetes and chronic lung disease,whereasa competent critical care nurse might beassigned to a chronic postoperative cardiothoracic surgical patient.Learning Outcome 6Discuss the competencies of critical care nurses as defined by thesynergy model.Concepts for Lecture1.According to the synergy model, critical care nurse competencies can bedescribed along a continuum from competent to expert. These competenciesinclude the following:•clinical inquiry—The critical care nurse should provide care based onthebest available evidence rather than tradition.•clinical judgment—The nurse should engage in clinical reasoning accordingto hisorher level of expertise. For example, a competent critical care nurse is

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able to collect and interpret basic information and then follow algorithmswhen providing care,whereasan expert nurse can see the “big picture” andanticipate patient needs.•caring—According totheAACN, this encompasses “nursing activities thatcreate a compassionate, supportive, and therapeutic environment for patientsand staff, with the aim of promoting comfort and preventing unnecessarysuffering.”•advocacy—This refers to the nurse’s respect and support for the rights andbeliefs of the critically ill patient (AACN).•systems thinking—The critical care nurse manages the existing environmentand resources for the benefit of patients and their families.•facilitator of learning—The nurse should facilitate both informal and formallearning for patients, families, and members ofthehealth care team.•response to diversity—The nurse should be sensitive to diversity amongpatients and providers and incorporate appropriate cultural and spiritual valuesinto care.•collaboration—The nurse will work with others in order to achieve optimaland realistic patient goals.PowerPoint Lecture Slides1.According to the synergy model, critical care nurse competencies include thefollowing:clinical inquiryclinical judgment

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caringadvocacysystems thinkingfacilitator of learningresponse to diversitycollaborationSuggested Strategies for Classroom ExperienceDividethe classinto groups and assign each group one of the critical care nursecompetencies from the synergy model. Ask each group to identify levels of functionlikely for the competent nurse and the expert nurse for the assigned competency.Learning Outcome 7Describe ways to enhance communication and collaboration among members of thehealth care team.Concepts for Lecture1.Optimum patient outcomes requirecommunicationandcollaborationby amultidisciplinary team.Skilled communicationincludes determining appropriatecontent for the message and delivery of the content. One method of skilledcommunication advocated by the Institute for Healthcare Improvement (IHI) istheSBAR technique(situation, background, assessment, recommendation).oS: Situation

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•I am calling about[patient, name, location].•The problem I am calling about is[the nurse states specifics].•I have assessed the patient personally.•Vital signs are_____.•I am concerned about[the nurse states what the specific concern is].oB: Background•The patient’s immediate history is_______.•The patient’s other physical findings are[e.g., mental status].•The patient’s treatments are[e.g., oxygen therapy].oA: Assessment▪This is what I think the problem is:_____________.▪Or, I’m not sure what the problem is but the patient is deteriorating.oR: Recommendation▪I suggest[or request]that you[the nurse states the desired course ofaction].2.Two-Challenge Rule—Anothermethodof skilled communicationadopted fromthe airline industry. This rule can be usedfor managing situations in whichmembers of the health care team do not listen even when information has beenpresented in an appropriate format.When followingthe two-challenge rule, a

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nurse who disagrees with another health care provider’s proposed interventionwould respectfully state his concerns about the intervention twice then would seeka superior as soon as possible and explain his concerns.3.Collaboration—This is the link between teamwork and patient outcomes in ICU.Collaboration is a processof sharing knowledge and responsibility for patient care.Many characteristics influence collaboration.PowerPoint Lecture Slides1.Communication—Optimal patient care is not possible without skilledcommunication.2.Skilled communication has two components—appropriate content for the messageand delivery of the content.3.SBAR Technique—provides process for determining what information isappropriate and delivering it in specific mannerSituation—who you are calling about (patient name, location); state specificproblem, patient assessment, and specific concernBackground—patient’s immediate history, physical findings, and treatmentsAssessment—what you think the problem is;if unsure,state that patient isdeterioratingRecommendation—state or request desired course of action

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4.Two-Challenge Rule—a rule for disagreementaboutthe proposed course ofaction•Respectfully state concerns about the intervention twice; then seek helpfrom supervisor.•Assertive communication—nurse should state disagreement and presentconcerns respectfully; speak with a bold voice.5.Collaboration—thisisthelink between teamwork and patient outcomes in ICU.•Collaboration is a process, not a single event.•Characteristics that influence collaboration:oEmotional maturityoUnderstanding the perspectives of othersoTeam goal is patient well-beingoNegotiate respectfullyoManage conflict wisely—watch emotional responsesSuggested Strategies for Classroom ExperienceGiven a patient scenario, ask students to demonstrate use of SBAR communication to ahealth care provider.Ask students to describe what it means to them to “collaborate” on a project.

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Learning Outcome 8Explain why some health care providers believe that critically ill patients cannot giveinformed consent.Concepts for Lecture1.Obtaining informed consent has legal and ethical ramifications.When a patientgives consent, he agrees to the suggested treatment or procedure. Legally, if anurse treats or touches a patient without consent, it is considered battery, even ifthe treatment is appropriate and has no negative effects. Consent is usuallyimplied rather than written for “routine” proceduressuch asturning, dressingchanges,andmost medication administration.2.There are three components of informed consent:•The decisionmust be made voluntarily.•The decision must be madeby a competent adult.•The decision must be made by a competent adultwho understands hiscondition and the possible treatments.This means that the patient’s decision must be an autonomous choice. The patientmust be capable of rational thought and be able to recognize what the treatmentinvolves.3.Are critically ill patients able to make decisions?This is sometimes difficult todetermine because the patient may be in severe pain, may be intubated, ormaybevery depressed. Determination of the patient’s capacity to give informed consent

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does not require a legal proceeding. It is a clinical judgment. To determinecapacity, the nurse may ask:•Does the patient understand the medical condition?•Does the patient understand the options and the consequences of herdecision?•If the patient refuses to give consent for the recommended treatment, is therefusal based on rational reasons?4.Surrogate decisions:Occasionally,loss of capacity may be temporary,such aswhen a patient has been heavily medicated. When a patient is incapacitated, asurrogate health decision maker may be asked to consent for treatment of thepatient.PowerPoint Lecture Slides1.Three components of informed consent:•The decision to permit the treatment or procedure must be made voluntarily.•The decision to permit the treatment or procedure must be made by acompetent adult.•The patient must understand his condition and the possible treatments.2.An ICU patient may lack the capacity to give informed consent.Determination does not require legal proceeding—it is a clinical judgment.Loss of capacity may be temporary (pain medication).

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3.To determine capacity, the health care provider mayask:•Does the patient understand the medical condition?•Does the patient understand the options and consequences of the decision?•Ifthepatient refuses treatment, is refusal based on rational reasons?4.Surrogate decisions:•Some states allow next of kin to make decision.•Some states require health care proxy or durable power of attorney—advancedirective or court appointed.•Two ethical modes for surrogate decisions:•Best interest standard—decisionmaker decides what heorshebelieves is in the best interest of the patient•Substituted judgment—surrogate decides what heorshe thinkspatient would have decided if able to make the decisionSuggested Strategies for Classroom ExperienceAsk students to consider a situation in which they may be asked to be a surrogatedecision maker for someone. Ask them to discuss their feelings and concerns about usingthe“best interest standard”versus the“substituted judgment”standard. Which seemsmore comfortable to them? Why?

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Learning Outcome 9Analyze why moral distress might be a significant concern for critical care nurses.Concepts for Lecture1.Critical care nurses have the potential to developmoral distressorcompassionfatigueas a result of being placed continually in situations with high levels ofcomplexity, uncertainty,and decisional authority.2.Moral distresshas been defined as when a nurse would know the right thing todo, but would not do it because of institutional constraints or personal authority.Critical care nurses are often in situations associated with high levels of moraldistress—suchas whennurses are required to provide aggressive care to patientswhom they do not believe will benefit from the care.3.Moral distress impacts health care. Nurses leave ICUs, they lose the capacity tocare for patients, and they experience physiological and psychological problems.4.TheAACN developed a public policy statement in which the 4 A’s to rise abovemoral distress (ask, affirm, assess, act) are described.5.Conscientious refusalof an assignment is an option if the nurse believes hecannot ethically performanaction he is being asked to perform. The nurse,however,should consider administrative repercussions for his refusal. It ispossible that administration willfully support the decision;however, it is also

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possible thatthe nurse may be dismissed from the nursing position. Therefore,this option should be taken only after careful consideration of influence on thepatient/family, the nurse, and the institution.6.Compassion fatigueis a response to caring for people who are suffering. It canbe traumatizing for the care provider.Symptoms may include:•Intrusive thoughts or images of patients’ situations or traumas•Difficulty separating work life from personal life•Lowered tolerance for frustration and/or outbursts of anger or rage•Dread of working with certain patients•Depression•Increase in ineffective and/or self-destructive self-soothing behaviors•Hypervigilance•Decreased functioning in nonprofessional situations•Loss of hope7.Standards for self-care to establish and maintain wellness for care providers:•Make a commitment to self-care•Develop strategies to let go of work•Develop strategies for rest and relaxation•Plan strategies for daily stress reduction

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PowerPoint Lecture Slides1.Moraldistress—distress suffered by nursesfrom being involved in patientsituations that they perceive to be morally wrong2.Situations contributing to moral distress:•Aggressive care to patients whomnurses perceive would not benefit from thecare•Feelingsof powerlessness•Nurse unable to find meaning in patient or family suffering3.Moral distress has impact on health care•Nurses leave ICUs•Nurseslose the capacity to care for patients•Nursesexperience physiological and psychological problems4.Compassionfatigue—a “state of tension and preoccupation with the suffering ofthose being helped that is traumatizing for the helper” (Figley, 2005)5.Symptoms of compassion fatigue:•Difficulty separating work from personal life•Intrusive thoughts/imagesof patient situations/trauma•Lowered frustration tolerance—outbursts of anger

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•Dread working with certain patients—depression•Increase in ineffective and self-destructive behaviors•Hypervigilance•Decreased functioning in nonprofessional situations•Loss of hope6. Standards for self-care to establish and maintain wellness:•Make a commitment to self-care•Develop strategies to let go of work•Develop strategies for rest and relaxation•Plan strategies for daily stress reductionSuggested Strategies for Classroom ExperienceAsk students if they have ever interacted with a staff nurse who may have been sufferingfrom compassion fatigue. What attributes made the students believe this to be the case?Ask students to develop a plan for avoidance of compassion fatigue and maintainingwellness for a critical care nurse. List the suggestions on the board for discussion.Learning Objective 10Prioritize measures a nurse might utilize to prevent compassion fatigue.

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Concepts for Lecture1.TheAmerican Nurses Association (ANA)Code of Ethicsindicates that “Thenurse owes the same duties to self as others, including the responsibility topreserve integrity and safety, to maintain competence, and to continue personaland professional growth.”2.Thestandards of self-carefor caregiversweredeveloped to ensure that careproviders do no harm to themselves when helping to treat others and to encourageproviders to attend to their own physical, emotional, and spiritual needs so thatthey can ensure high-quality services to those who rely on them.3.Strategies to prevent compassion fatigue:•Enhance physical well-being(tension, sleep, food and drink intake)•Enhance psychological well-being(relaxation methods, balance betweenwork and play, use stress reduction methods)•Enhance social/interpersonal well-being(identify five supportive peopleat work to call on, know when to get personal and professional help)•Enhance professional well-being(establish boundaries and set limits,balance home and work responsibilities, generate a feeling of self-satisfaction from work achievements)PowerPoint Lecture Slides1.Standards of self-care for caregivers

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•To ensure that care providers do no harm to themselves when helping totreat others•To encourage providers to attend to their own physical, emotional, andspiritual needs so that they can ensure high-quality services to those whorely on them2.Strategies to prevent compassion fatigue:•Enhance physical well-being•Enhance psychological well-being•Enhance social/interpersonal well-being•Enhance professional well-beingSuggested Strategies for Classroom ExperienceAsk class members todevelop a plan for self-care for a critical care nurse. Encouragethem to think about physical, psychological, social/interpersonal, and professional aspectsof self-care.

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[Perrin2e IRM]Chapter 2Care of the Critically Ill PatientRESOURCE LIBRARYCOMPANION WEBSITENCLEX Review QuestionsMedia LinksMedia Link ApplicationsIMAGE LIBRARYTable 2-1 Description of the Critical Care Pain Observation ToolTable 2-2 American Association of Critical Care Nurses Sedation AssessmentScaleTable 2-3 Ventilator Adjusted Motor Assessment Scoring Scale (VAMASS)Table 2-4 CAM-ICU WorksheetTable 2-5 Body Mass Index (BMI) CalculationTable 2-6 Harris-Benedict Equations for Calculating Basal Energy Expenditure(BEE)Learning Outcome 1Explain the characteristics of the critically ill patient described in the AACNsynergymodel.Concepts for Lecture1.Critically ill patients are at high risk for life-threatening problems, and nursesmust often focus on specific life-sustaining treatments. However, critically ill

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patients have basic needs as well.2.TheAmerican Association of Critical Care Nurses(AACN)defines critically illpatients as“those who are at high risk for actual or potential life threateninghealth problems. The more critically ill the patient is, the more likely he or she isto be highly vulnerable, unstable and complex, thereby requiring intense andvigilant nursing care.”3.According to the synergy model (Figure 2-1), the AACN postulates that when theneeds of the patient and family drive the competencies required by the nurse,optimal patient outcomes can be achieved. Further, the model identifieseightpatient characteristicsthat can be scored along the health-illness continuum:•Resiliency: “The ability to bounce back quickly after insult.”•Vulnerability: “Susceptibility to actual or potential stressors.”•Stability: “The ability to maintain a steady state equilibrium.”•Complexity: “The intricate entanglement of two or more systems (e.g., body,family).”•Predictability: “A characteristic that allows one to predict a certain course ofevents or course of illness.”•Resource availability: “Extent of resources the patient, family, and communitybring to the situation.”•Participation in care: “Extent to which patient and/or family engage in care.”•Participation in decision making: “Extent to which patient and/or family

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engage in decision making.”PowerPoint Lecture Slides1.Characteristics ofcriticallyillpatients (synergymodel)•Resiliency•Vulnerability•Stability•Complexity•Predictability•Resource availability•Participation in care•Participation in decisionmakingSuggested Strategies for Classroom LearningConsidering each of the characteristics of critically ill patients, ask students to think aboutand describe patients they have encountered whoexhibit these characteristics at both endsof the continuum. Discuss implications for care based on possession of thesecharacteristics.Learning Outcome 2Discuss the concerns expressed by critically ill patients.

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Concepts for Lecture1.Critical care nurses have long focused on creating environments conducive to thecomfort and healing of their patients. To that end, nurseshavetried to limitstressors for their patients. However, research has indicated that what nursesthoughtwould be stressful for patients varied considerably from what patientsreportedto be stressful to them.2.Patients described as the most stressful to them:•being thirsty•having tubes in the mouth and nose•not being able to communicate•being restricted by tubes/lines•being unable to sleep•not being able to control themselvesPowerPoint Lecture Slides1.Stressors reported by critically ill patients•being thirsty•having tubes in the mouth and nose•not being able to communicate•being restricted by tubes/lines•being unable to sleep•not being able to control themselves

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