When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
1. Clearly explain what care is to be done before starting the activity.
2. Perform the activity and then let the patient rest without explaining the care.
3. Make sure the patient always responds and is cooperative before giving care.
4. Explain to the family that the patient will not understand or remember any of the discomfort associated with care.
1
Rationale 1: By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patient's mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by allowing the patient to hear what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once he or she has awakened.
Rationale 2: If the patient is not informed, autonomy and the right to choose have been violated; in addition, the stress of the unknown may be perceived incorrectly by the patient as an assault.
Rationale 3: Some unresponsive patients will never respond; therefore, the care would not be performed as needed. Cooperation is also not possible in some cases whereby the patient has altered thinking. Although the nurse desires these, the care should not be stopped just because they cannot be obtained. Explaining should still be done and the care should proceed as needed.
Rationale 4: The nurse cannot always reassure the family that the patient will not remember.
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