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Significance

Use of Sensory
Stimulation in Sedated
ICU Patients

ICU setting and mechanical ventilation cause higher

levels of anxiety, agitation, and stress
Sympathetic nervous system activated
Longer stays in the ICU

Group F: An Evidence-Based Practice

Presented by: Felicia, Jessica, Tiffany, Haley, Trudy, Paola,
Bryanna, Mariya, & Libby

PICOT Question
How can nurses integrate sensory stimulation in intubated
adult ICU patients, in order to promote lower levels of
agitation as evidenced by changes in the patients RASS
(Richmond agitation-sedation scale) during their stay at the
ICU?

Literature Findings
Nine articles were found through CINAHL and Pubmed
search engines for the purpose of this evidence-based
protocol.
Four randomized clinical trials
One interventional study
One double-blind randomized clinical trial
One pilot study
One randomized- controlled crossover trial
One study case-control trial

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Strengths of Research
Randomized study, adequate sample, size, approval from
University of Minnesotas Institutional Review Board.
(Chan, Weinert, Heiderscheit, Tracy, Skarr, Guttormson, & Savik, 2013).

Patients were able to choose the music they wanted to

listen to from several options. (Dijkstra, Gamel, van der Bijl, Bots,
& Kesecioglu, 2013).

Strengths of Research Cont.

Double-blind randomized control trial, study proposal approved by Ethics
Committe of Mazandaran University Medical Sciences (Gorji,
Araghiyansc, Jafari, Gorgi, & Yazdani, 2014)

Randomized controlled trial, data collected over eight months

(Saadatmand, Rejeh, Heravi-Karimooi, Tadrisi, Zayeri, Vaismoradi, &
Jasper, 2013).

The study was randomized and there was a large study size of 137
patients (Han, Li, Sit, Chung, Jiao, & Ma, 2008)

Limitations of Research
Unable to control for bias (Chlan, Weinert, Heiderscheit, Tracy, Skarr,
Guttormson, & Savik, 2013)

Limitations Continued
Small sample size, broad age range may be a threat to generalisability of
findings to other settings (Saadatmand, Rejeh, Heravi-Karimooi, Tadrisi,
Zayeri, Vaismoradi, & Jasper, 2013)

Inconsistency in anxiety measurement (Chlan, Weinert, Heiderscheit,

Tracy, Skarr, Guttormson, & Savik, 2013)

Small sample size; convenience sample (Dijkstra, Gamel, van der Bijl,

Lack of studies performed on sedated and mechanically ventilated

patients (Lakie, Bolhasani, Noubahar, Movahedi, & Mahmoudi, 2012)

Bots, & Kesecioglu, 2010)

Limitations Continued
Participants were asked to select from the researchers collection instead
of having the freedom to choose from their own favorite music (Han, Li,
Sit, Chung, Jiao & Ma, 2008)

The presence or absence of any long-term effects were not examined,

there was only one single 30 minute session (Han, Li, Sit, Chung, Jiao &
Ma, 2008)

Evidence-Based Nursing Recommendation

10 minute MP3 voice of a loved one twice a day
introducing speaker, place and time, what had happened,
and sweet memories and some sentences about recovery
and coming back to family in the future (Gorji, Araghiyansc, Jafari, Gorgi, &
Yazdani, 2014)

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Evidence-Based Nursing Recommendation

Evidence-Based Nursing Recommendation

The presence of family visitors and the sound of their

familiar voices during a patients stay within the ICU will
improve patient comfort, increase blood oxygen saturation
levels, and improve patient participation in care. (Yousefi, H., Naderi,

Music is an intervention that reduces anxiety and sedative

exposure in mechanically ventilated patients. Because
music is an inexpensive non-pharmacological adjunct that
critically ill patients can self-initiate, clinicians should
implement music therapy programs in their ICUs.(Chlan, Weinert,

H., & Daryabeigi, R. 2015).

Heiderscheit, Tracy, Skarr, Guttormson, & Savik, 2013)

Evidence-Based Nursing Recommendation

Evidence-Based Nursing Recommendation

In the present trial, music listening is a more sensitive

stress-reliever in terms of biological vs
clinical response. The hypothalamus-pituitary adrenal axis
stress axis is a quick sensor of music listening in
responding mechanically ventilated intensive care unit
patients, through a rapid reduction in blood cortisol.

Relaxing music has been shown to influence a

persons emotional and physiological
responses. Calm and soothing music is found
to be the most appropriate in reducing anxiety
(Wong et al. 2001 in Korhan, Khorshid, & Uyar, 2011)

(Beaulieu-Boire, Bourque, Chagnon,Chouinard, Gallo-Payet, & Olivier, 2013)

Evidence-Based Nursing Recommendation

Music as a non-pharmacological nursing
intervention can be used as complementary
adjunct in the care of patients requiring
mechanical ventilator support to reduce
physiological stress responses arising from
anxiety.
(Han, Li, Sit, Chung, Jiao & Ma, 2008)

Evidence-Based Nursing Recommendation

Nature-based sounds intervention as a complementary
adjunct is safe and can be applied by clinical nurses to
allay anxiety and agitation in mechanical ventilatordependent patients without risking unwanted side effects.
Nurses can implement this intervention to achieve
relaxation for its short-term benefits. The utilization of this
intervention enables nurses to provide individualized care
and help the patient manage their anxiety and achieve
relaxation. (Saadatmand, Rejeh, Heravi-Karimooi, Tadrisi, Zayeri,, Vaismoradi, & Jasper, 2013)

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Evidence-Based Nursing Recommendation

Application/Implementation to Nursing
Practice
Design Process

The use of non-medicinal methods such as touch should

be used in order to decrease agitation and anxiety thereby
improving overall respiratory status of patients under
mechanical ventilation.
(Lakie, A. S., Bolhasani, M., Noubahar, M., Movahedi, A. F., Mahmoudi, H., 2012)

Team Development

Define Goals
Changes that can be/need to be made

Analyze Current Practice

Variety of intravenous sedative medications
Establish priority issues/concerns

Application/Implementation to Nursing
Practice
Develop Strategies for establishing new protocol, staff
training, and data collection.
Initiate Plan
Expected timeline of total implementation is 6 months to 1 year.

Cost Analysis
Cost to train the Nurses:
Average yearly salary for ICU nurses in Arizona
$76,000
Hourly Rate: $40.60
(Salary By State, 2013).

Monitor results and make required improvements.

Cost Analysis, cont.

Cost of purchasing headphones:
~60 ICU beds in Banner - University of Medical Center
(Critical Care, 2015)

100 pack of headphones: ~$119, can be as low as

$0.74 (Bulk Quantity Disposable Headphones, 2015)

Cost of Stereo/MP3 player with music

Order 50 or more: $2.51 each (Portable Fashion Mini MP3 player, 2015)

Cost analysis, cont.

Savings:
At The University of Arizona Medical Center,
2011:
Average Cost: $49,972 of all conditions
Average length of stay: 5 days
Average cost per day: $9,994.4
(AZ Hospital Care, 2011).

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Cost Analysis, cont.

Risk vs. Benefit

Savings
Propofol:
Safe Dose
0.3 mg/kg/hr for five minutes, then titrate
in 0.3-0.6 mg/kg/hr increments to
desired level of sedation
Cost of 100 ml bag of propofol (10 mg/ml
concentration): $39.85

Risk
Over stimulation
Can trigger negative emotional associations
Can cause more anxiety if the chosen stimuli is
agitating to the patient.

(Propofol Emulsion, 2015)

Risk Vs. Benefit

Benefits
Low cost
Improves healing
Touch and music therapy, has shown to decrease anxiety and
agitation

Risk Vs. Benefit

Benefits
Involves family in care
Incorporating music therapy does not burden nursing
care. (Chlan, Weinert, Heiderscheit, Tracy, Skarr, Guttormson, & Savik, 2013)
Gives the patient a sense of control over their ICU care.
(Chlan, Weinert, Heiderscheit, Tracy, Skarr, Guttormson, & Savik, 2013)

Evaluation
By the end of the nurses shift, the patient will show a
decrease in agitation, as measured by RASS, after the
introduction of music therapy
The patient will show a decrease in agitation, as
measured by RASS, after the introduction of therapeutic
touch, by the end of the nurses shift.

Evaluation Continued
By the end of the nurses shift, the patient will show a
decrease in agitation, as measured by RASS, after the
family visits and speaks to the patient in a comforting
tone.

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Summary

Summary, continued

Introduction

Description of issue

Nurses can improve patient agitation and anxiety through the use of non
pharmacological methods though sensory stimulation such as touch, music
therapy.

Mechanical ventilation causes increased levels of anxiety and agitation and

stress which leads to longer hospital stays. Currently this is only being
treated using pharmacological methods

Supportive studies
The studies support the use of non pharmacological methods, such as music
and touch, in order to decrease overall agitation and anxiety

Summary, continued

Summary, cont.

Best Practice
Initiate use of music therapy, touch, and voices of family.

Cost Analysis
By implementing this protocol, reduced anxiety in turn leads to less use of
sedative medications, thereby resulting in shorter length of stay. Shorter
length of stay saves in overall costs of patient and the facility.

Application to Facility
Protocols should be developed.
Education regarding interventions provided by a
multidisciplinary team to hospital staff

Risk vs. Benefit

References

References, continued

Benefit outweighs risk.

AZ Hospital Care. (2011). Arizona Department of Health Services. Retrieved from

Dijkstra, B. M., Gamel, C., Van der Biijl, J. J., Bots, M. L., & Kesecioglu, J. (2010). The effects of music on physiological responses and

http://pub.azdhs.gov/hospital-discharge-stats/2011/util/std/hospDXCCS/MED0257_DXCCS_All.html

sedation scores in sedated, mechanically ventilated patients. Journal of Nursing, 19, 1030-1039. doi: 10.1111/j.

Banner University Medical Center. (2015). Patient amenities. Retrieved from http://www.uahealth.com/patients-visitors/patient-

1365-277022009.02968.x

amenities

Gorji, M. A. H., Araghiyansc, F., Jafari, H., Gorgi, A. M. H., & Yazdani, J. (2014). Effects of auditory stimulation on traumatic coma

Beaulieu-Boire, G., Bourque, S., Chagnon, F., Chouinard, L., Gallo-Payet, N., & Olivier, L. (2013). Music and biological stress

duration in intensive care unit of Medical Sciences University of Mazandarn, Iran. Saudi Journal of Anaesthesia, 8(1), 69-72. doi: 10.

dampening in mechanically-ventilated patients at the intensive care unit ward: A prospective interventional randomized crossover trial.

4103/1658-354X.125940

Journal of Critical Care, 28(4):442450

Han, L., Li, J.P., Sit, J. W. H., Chung, L., Jiao, Z. Y., & Ma, W. G. (2010). Effects of music intervention on physiological stress response

Bulk Quantity Disposable Headphones. (2015). Encore Data Products, Inc. Retrieved from http://www.encoredataproducts.com/bulk-

and anxiety level of mechanically ventilated patients in China: A randomized controlled trial. Journal of Clinical Nursing, 19, 978987.

quantity-disposable-headphones/?gclid=CjwKEAjwlsSoBRDoid2ihqnjjlISJABZoG9-

doi: 10.1111/j.1365-2702.2009.02845.x

Ucx8BErMIYvvWtCdXlwsaqzNLmLmZMOWlsofmeujgRoCd9fw_wcB
Chlan, L. L., Weinert, C. R., Heiderscheit, A., Tracy, M. F., Skarr, D. J., Guttormson, J. L., & Savik, K. (2013). Effects of patient-directed

Korhan, E. A., Khorshid, L. and Uyar, M. (2011), The effect of music therapy on physiological signs of anxiety in patients receiving
mechanical ventilatory support. Journal of Clinical Nursing, 20: 10261034. doi:10.1111/j.1365-2702.2010.03434.x

music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized

Lakie, A. S., Bolhasani M., Noubahar M., Movahedi, A. F., & Mahmoudi, H. (2012). The effect of touch on the arterial blood oxygen saturation

clinical trial. Journal of the Medical American Association, 309(22), 2335-2344. doi:10.1001/jama.2013.5670.

in agitated patients undergoing mechanical ventilation. Iran Journal of Critical Care Nursing, 5(3):125-132.

Critical Care Fellowship Program Overview. (2015). The University of Arizona: Emergency Medicine. Retrieved from http://
emergencymed.arizona.edu/fellowships/critical-care/program-overview

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References, continued
Portable Fashin Mini MP3 Player. (2015). Deals Machine. Retrieved from
http://www.dealsmachine.com/best_158867.html?currency=USD&gclid=CjwKEAjwlsSoBRDoid2ihqnjjlISJABZoG9IAmxInTnMyJKgLa4f90XsxVuEvzuBEEmGfGnWQudCRoCI7vw_wcB
Propofol Emulsion. (2015). MD Wholesale Pharmacy. Retrieved from
http://www.mdwholesalepharmacy.com/Propofol-Emulsion-10-mg-mL-100-mL-SDV-Pack-of-1-p/4282918.htm

References, continued
Vanderbilt University Medical Center. (2013). Pain, agitation-sedation, and delirium protocol. Retrieved from
https://medschool.vanderbilt.edu/trauma-and-scc/files/trauma-and-scc/public_files/Manual/Pain,%20Agitation-sedation,%20Delirium
%20Protocol.pdf
Salary by State (2013). Registered Nurse ICU Salary By State. Retrieved from http://salarybystate.org/tag/icu-nurse-pay
Yousefi, H., Naderi, M., & Daryabeigi, R. (2015). The effect of sensory stimulation provided by family on arterial blood oxygen
saturation in critical care patients. Iranian Journal of Nursing and Midwifery Research, 20(1), 63-68.

Saadatmand, V., Rejeh, N., Heravi-Karimooi, M., Tadrisi, S. D., Zayeri, F., Vaismoradi, M., & Jasper, M. (2013). Enature-based sounds
intervention on agitation, anxiety, and stress in patients under mechanical ventilator support: A randomised controlled trial. International
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