SERIOUS PATIENT CARE FROM A PSYCHOLOGICAL PERSPECTIVE 
The peculiar environment of intensive care units (ICU) patients tends to become habitual for service personnel, is reversed in fear, anxiety, depression, disturbed sleep-wake and ultimately disorientation and agitation between 30 and 70% of patients who are admitted to them.
These pathological expressions of mental status can occur if we consider that in these units, the patient is subjected to situations that determine the loss of autonomy making it dependent, almost total health team, and otherwise limit the the company of their families, their usual environment must be intimate with people that are unknown at the time of admission. The
psychiatric patients with these conditions added a new problem that significantly affects their recovery spreads to some vital functions, so that the challenges of intensive care medicine is becoming more common psychological care to critical patients.
Monitoring the psychic sphere for the early detection of abnormalities should be common practice in the ICU.
The organization of psychological care are focused on three key strands.
a) Patient life-threatening situation.
b) Personal care
c) Companion and family grave.
a) The patient in life-threatening situation.
Patients admitted to the ICU are under stress for very different reasons including the factors considered intrapersonal, interpersonal, and extrapersonal.
intrapersonal factors are given by the frustration at the limitation of activity, the peripheral or central venous access, drainage, awareness to the restriction spontaneous inter alia in the physiological order, while the psychosocial and cultural important are insufficient explanations and misinterpretation of medical interventions and the inability to actively cooperate treatment.
interpersonal factors related to the receipt by the patient's inconsistent explanations, inability to communicate, loss of confidence and critical care nurse.
The critically ill patient often speaks of himself, but hardly verbalize their concerns, desires, failures, disappointments, threats and greater emotional commitment to radically changing the idea that so far has had on their future.
The patient's coping style to your situation depends largely on how communication occurs with medical deduction here the importance of that act.
Several studies confirm the fact that silence does more harm than communicating information. Patients who feel that they are not enough has been said, often suffer from a feeling of insecurity due to limited not so much about their diagnosis and prognosis, for lack of information about what may happen in the near future.
The decision to shut the diagnosis does not eliminate the disease. This is not the unpleasant experience of being informed what is going to dismay to enfermo.Lo resulting predicament is how to provide such information.
The right to truth is claimed as a fundamental human right and an expression the respect that is owed. Denying the truth is seriously ill from living as a protagonist in a crucial phase of his life. Telling the truth
a patient is not always easy. This does not mean you need to lie, but it is not always necessary and in any place to tell the truth, no matter what is said. You can remain silent, saying nothing but never lie. The prospect of an end may be near a stage of growth. In the awareness of death can make important decisions (legal, economic, human), essential dialogues with spouse, children, friends, adjourned for a lifetime and are now in a particularly intense spirituality.
young regularities in the development of his personality is characterized by structuring your life plan and then consider the possibility of death is regularly accompanied by anxiety, fear, agitation and sometimes suicidal actions in a second time these crises can be substituted for compliance or inevitability of death colored by apathy and complete indifference towards the surroundings.
Moreover experiential manifestations are closely related to the structuring personological.
Besides these there are other factors resulting from the characteristics of space where they are admitted, ie the entorno.Tanto the excess as the monotony of stimuli produce a search of the subject of alternative stimuli that activate the reticular system. The sensory perception disorders arising from these situations can result in manifestations in people such as disorientation to time, place, person, Confucianism acute risk of violence to self or others, risk of injury, irritability, perceptual narrowing, etc.
b) Personal care in critical patient care.
intensive care units have been considered a psychologically stressful environment because of the critical patient care is often associated with emergency difficult decisions, frequent deaths, noisy atmosphere and ethical dilemmas.
The literature shows work on this problem in the nursing staff, however there are very few references to the intensive care. In recent times has been described as the most embarrassing event that derived from the fatigue they are exposed to these professionals who can lead them to feel burned, the burning-out syndrome called, prompted by several circumstances, including the following:
1. The characteristics of the patients will be treated, a serious condition which is linked to stress or emotional overload, representative on one side the narrow margin of time available for diagnostic and therapeutic performance.
2. Undeclared or unexpected, just subject to programming, which are mixed with periods of calm in high stress situations.
3. The field where its action takes place in the team staff untrained.
4. The limited availability of adequate means at their disposal.
5. The lack of recognition of the specialty by other specialists in hospitals.
6. Low status of the profession for intensivists.
7. The call care to critically ill patients leads to situations of deprivation of sleep and rest with little time to devote to other educational and research activities.
8. The common experiences before death.
9. Lack of training in situations where decisions must be ethical.
10. Complex and extensive training in theory and technical skills combined with rapid advances in medicine.
11. Feelings of responsibility to the families of inpatients.
12. The lack of harmony in the health care team with a totally seamless communication and organized among professionals involved in the care and treatment of critically ill patient.
13. The workload more demand than supply at the level of resources (ie, the concept of the last bed.)
The tech medicine today is very great lack of communication also depends on the lack of time, insufficient training in communication skills in undergraduate education. However, the vulnerability and insecurity are factors characterizing patients who have threatened his life and exerted a significant influence on the course of their disease. A proper doctor patient relationship can reduce fear, anxiety and uncertainty that make them so vulnerable to these patients. Lack of communication leads to painful estrangement and alienation of the patient. Do not allow technology to increase the therapeutic options of medical stop use the word (verbal communication), hands (nonverbal communication) and humanity (empathy) in their relationships with patients, thus reducing their ability to cure or alleviate.
Therefore, the objective is: no more little white lies, but more pious ways of telling the truth to enable the role act seriously ill at this stage of his life.
This communication process is individualized, but it is necessary to consider some elements to guide us to design strategies to support the process of exchange with the patient.
1. Psychological structure of the patient's premorbid personality. In this regard it is essential know the patient's coping styles in situations of life-long commitment and emotional-affective reactions that have resulted, thus providing the patient the possible responses to the process of sharing with your doctor for assistance. It is very important to highlight the value of the family because to some extent the patient's relationship will also depend on the characteristics of the dynamics in which it is inserted.
2. Disease severity. He or she will be easier to establish the communication process with their patients as more likely to have the same recovery. Communication also varies with the patient under the changes that occur in the situation the psychological to the extent that the first symptoms of the disease, when complications appear or when he realizes that there is little chance of recovery.
3. Age. are marked differences that exist in establishing communication with an elderly person with a severe disease, because in our culture, old age per se is perceived as a disease. The opposite happens with young patients from the very fact of being young will try more aggressive treatments and therefore it is necessary to dwell further on the information is vital for the active participation of that advantage in the therapeutic process psychophysical its full potential.
4. Emotional reaction to the sick: this element is very important to consider it primarily in trauma patients frequently require the attentions of the UCI. Some body parts have an important symbolic meaning, for example: the face, genitals, and considering the characteristics of our culture we must assume that not everyone adopts a consistent position when given a choice of quantity over quality of life . Closely related to this is then the type of treatment which will make the more mutilating it will force us to be more explicit in the information that is provided. In a similar situation we face the side effects in certain patient tratamientos.Al if your state allows it should be explained before why these behaviors, most unpleasant.
5. Social role: is relevant to note the role that society plays the patient, their life projects, future prospects, to ask what effect it may have not have the information necessary to cause uncertainty about their future and family.
c) The patient's family grave.
When the family arrives in the intensive care you do with instability in its emotional dynamics, first because one of its members have become ill with imminent danger to life and because the organization of medical services which contacts you can command respect and sometimes fear as the frightening ignorance of medical procedures that limit their autonomy .
family faces a crisis characterized by:
1. Stress, anxiety, fear, disbelief and anxiety.
2. Changes in the distribution of roles within the family.
3. Existing bureaucratic health system.
4. Misinformation.
5. Limited communication with his family.
is important to consider that the family lost its balance and functionality this may affect the patient's task therefore is to help nursing staff to behave with typical autonomy system is helping to his patient.
A phrase, a word, even non-verbal forms of communication may reduce anxiety levels of a family.
When these considerations are ignored in the family, you can produce angry reaction:
- Against The sick considered real or imaginary causes of disease, the abandonment of the family (in case of death), for outstanding issues, for having brought misfortune with the disease in the family circle.
- against other family members: because of old wounds, feelings of guilt (eg in case of an accident, relatives and friends to spread the disease over time are gradually abandoning the patient).
- Contra health professionals: against decisions made against the failure or limitations of medical science to cure his family, to announce bad news, for control of the situation, difficulties in communication (limited capacity listening, insensitivity, indifference).
- Against the "messenger" who announces the bad news.
- because of their loss of influence over the situation taking forward now in the possession of the medical and nurses.
- Because of a lack of communication (lack of listening, coldness, insensitivity, indifference).
- against external forces or chance.
- Rage Against the workplace to the occupation of the patient, justified or not.
- against God, against their abandonment.
happens very often that the family used to address the problem by assuming that their relative patient ignores the seriousness of his condition and the secrecy of his forecast for what to avoid as possible aware of any physician seeking solidarity in the conspiracy of silence that set in relation to their family. When the doctor becomes a participant is established between him and his patient in isolation. Therefore the physician must address and bring the family refuse to think of how important it is to share the truth to significantly reduce stress levels, at least we can keep the promise and the hope that conveys the assurance that your family will not be neglected .
All these elements come into analysis when performing the evaluation and diagnosis of family dynamics. This diagnosis must be fast, dynamic, accurate, causal, longitudinal and developmental regulation of the system for escorts.
For patients who are in the ICU, the companion has a role very important from an emotional standpoint. This family should be assessed taking into account:
- Levels of disease states (anxiety and depression).
- Background emotional rapport with the patient and characteristics of family dynamics.
Attendants should guide the family before going to see his family in relation to communication with the same standards. These rules are easy to play and must be directed to:
Ø Try not to harass the family insisting on questions about his health. Ø Talk
always positive terms of confidence, contain their emotions, not expressing grief in his presence.
Ø Try to guide the family on the day and time as well as events that make you stay in touch and together with their family, because patients often become disoriented. Ø
You should not be talking about problems or concerns, anxiety, stress and depression can extend the stay in the unit and even worse the picture. Ø
Unify your criteria as far as possible with medical personnel, because the goal is common: the healing of the sick.
Bibliography.
1. De la Torre Prados MV, Alcantara AG, Mérida de la Torre F, Morell Ocaña M, Daga Ruiz D, Ruíz L. Ash Psychological profile, cardiovascular and endocrine-metabolic response professional practitioner in the area of \u200b\u200bcritical care medicine 1998, 22 (5) :229-38.
2. Blasco J, Huet J. It's stressful intensive care unit for intensive care. Intensive Care Med 1998, 22 (5) :226-8.
