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for future patients. Participants (77.4%) said they ‘would continue with the music after they went to a ‘non-ICU setting/step-down unit or home. Most of the participants said they enjoyed the music therapy and that it helped them to relax during their coronary care unit admission. Downey and Flood'” completed studies high- lighting myocardial infarction patients using ‘music in an intensive care setting, They reported that an intensive care patient may benefit from mental diversion using intermittent background ‘music. They also noted a reduction of mortality rate from 20% to 8% to 12% after music was in- troduced into the intensive care setting. ‘The literature frequently identifies pain and ‘anxiety as common concems ofall patients as well as of medical staff Pain is defined as a complex subjective phenomenon that has interacting physi- logic, psychologic, social, cultural, and spiritual components, Meinhart and McCaffery define pain as “whatever the experiencing person says it is, exiting whenever he says it does.”"**"" An ‘anxiety state is defined in terms ofthe intensity of subjective feelings of tension, apprehension, ner- ‘vousness, and worry experienced by an individual ata particular moment and by heightened activity of the autonomic nervous system that accompa- nies the feelings.” ‘Music Therapy Plan of Care Alteration in comfort: anxiety The patient will demonstrate positive psychologic outcomes Nursing intervention Alterations in comfort: pain Nursing interventions in response to music therapy: decreased anxiety/depression, decreased restlessness/agitation, increase in motivation. 1, Assess patient's level of anxiety, restlessness, agitation, and motivation. 2. Assess patient’s interest in music, 3. Assess patient's music preference. 4, Provide a quiet milieu; dim lights; close drapes; assist patient to a comfortable position. 5. Avoid interruptions fora designated period. 6. Play music for 20-30 minute intervals BID. 7. Evaluate patient’s subjective and objective responses to music. ‘The patient will demonstrate decrease in pain: verbalize improvement in pain using a 0-S scale; use less medication. 1. Assess patient’s pain using a 0-S seale in which 0 is no pain and 5 is severe pain. Medicate as prescribed. Assess pati ‘Assess patient's music preferences. Provide a quiet milieu; dim lights; close drapes; assist patient toa comfortable position. 6. Avoid interruptions fora designated amount of time. 7. Play music for 20-30 minute intervals BID. 8, Evaluate patient’s subjective and objective responses to music, yeep ‘Totas,” in her study observing anxiety levels in preoperative patients, found that high preoperative anxiety levels increase the cardiac work load and diminish cardiac reserve. Therefore, it is impera- tive that anxiety levels be reduced to prevent ad- verse physiologic and psychologic outcomes. ‘Cassem and Hackett identified anxiety as a ma- jor management problem among the critical care population. Factors that have been identified to ‘contribute to anxiety levels in patients include the admission/transfer to the ICU, the nature oft ‘ness, the environment, and the interaction with the staff. Other contributing factors are visiting hours, interrupted sleep, use of the bedpanvurinal, and noise in the unit It is believed by these authors ‘that reducing anxiety will decrease the potentially ‘Suggested Music Selections Cat Stevens—Moming Is Broken Born Free Movie Sound Track Country-Western Willie Nelson Big Bands—Smoke Rings Chariots of Fire Nat King Cole—Red Sails ‘The Sound of Music ‘Anderson—Trumpeter's Lullaby John Denver—It’s Up To You Guitar ‘Symphonic Will Ackerman—Childhood and _Kitato—Silk Road Suite George Winston ‘Memories autumn Passage —December — Winter into Spring Religious Classical Classical Mormon Tabernacle ChoirThe Bach—Air for G String Mascagni—Cavalleria (Old Beloved Songs Beethoven—Moonlight Sonsta __Rusticana Intermezzo —The Lord Is My Shepherd —Iniermezzo from Carmen Massenet—Scenes Suite ‘Alsaciennes—Sous let Tilleuls Brahms—Lullaby Mendelssohn—A Midsummer Chopin—Noetume in G Night's Dream Canteloube—Songs of the Pachelbel—Caron in D Auvergne Brezairola Respighi Debussy—Clair de Lune —Pines of Rome Dvorak—Serenade for Strings _ —The Pines of Giancolo, Largheto Saint-Saens—The Swan Haydn—Minuet from Berenice Tehaikovsky—Panorama from Lisct—Liebestraum Sleeping Beauty Marcello—Oboe Concerto in Vaughn-Williams—Fantasia on Dm Adagio Greensleeves Source: Dated from Bonny H, Savary L. Muse and Your Mind. New York: Harper & Row; 197 infarction patients. Crit Care Nurs Q.1990:13:65-72: Heitz Effects of relaxing music on state anxiety in myocard L, Symreng T, Scamman FL. Effect of music therapy in the postanesthesia care unit: a nursing intervent Livan RJ. A musical roadto recovery: musi in intensive care. Jatens Postenesthesia Nurs. 1992:7:22-31; and O' Care Nurs. 1991;7160-163. Villa Lobos—Brasileiras #5 Vivaldi—Concerto in B Fi ‘Andante M werk CA. J harmful physiologic outcomes. One such method to decrease anxiety will be implementation of mu- sic therapy. GOALS ‘The goal of music therapy is the reduction of psychophysiologic stress, pain, anxiety, and iso- lation.” This can be achieved by diverting the person's attention away from pain and refocus- ing on something more pleasant.!22"2* ‘The effects of music therapy on hospitalized surgical, obstetric, oncology, and pediatric pa- ‘tents have been well documented in nursing lit- erature. However, there are limited publications on the effects of music therapy inthe critically ill patient population."* The literature identifies a ‘Variety of advantages that music therapy offers to patients, Alvin noted that music can be used as a means of nonverbal communication when coral communication is limited because of men- tal, physical, or emotional challenges (ie, endo- tracheal tubes). Music has long been recognized as a non- threatening form of communication. Music is often referred to as the universal language because of its ability to break down cultural, educational, linguistic, and emotional barriers. Music can reduce feelings of loneliness by pro- ducing familiar, comforting stimulation reminis- cent of family, homeland, or past experiences.>* ‘Music is an effective means of providing recre- ational and social diversion from the monotony and isolation of hospitalization and may play a role inmeeting the patients” physiologic and emo- tional needs.” Itisalso a method to filter unpleas- ant and unfamiliar sounds associated with hospi- talization. Music can offer a means to reduce self-preoccupation, thereby limiting the need for excessive medication, minimizing side effects of ‘medication, and facilitating shorter recovery. RECOMMENDATIONS To start a music therapy program in an ICU, the ICU nurse needs to consider the era, tempo, volume, and tone of the music. Choosing the correct music is critical in developing music therapy as an effective intervention.* ‘Tempo is the major cause of physiologic re- sponse to music. Beats of 70 to 80 per minute, approximately the same as the heart rate, are considered soothing, whereas faster beats may create tension. High pitch creates or increases tension, and low pitch causes relaxation. Loud volume (je, greater than 130 decibels, such asa jumbo jet landing) causes pain. Music appropri- ate for reduction of anxiety should have a slow steady rhythm, low-frequency tones, orchestral effects, and relaxing melodies.” “Sedative mu- sicis defined as having regular rhythm, predict- able dynamics, harmonic consonance, and rec ognizable vocal and instrumental timbre.”"*” ‘On the other hand, Halpern and Savary”® sug gested that musical selections not have words because the patient may focus on the words and their meanings rather than allowing themselves to flow with the music. Music should not be played continuously, otherwise it is a nuisance Tather than a pleasure.” Zimmerman et al sug- ‘gested 30-minute intervals that have been shown 10 be effective in reduction of cancer pain.” ‘Two nursing diagnoses for cancer patients in the ICU include, but arenot limited to, alteration in comfort related to pain and/or anxiety. The intensive care nurse can develop a plan of care with music therapy (see box “Music Therapy Plan of Care”). The ICU nurse must first assess the level of pain or anxiety. This is most often done using a simple scale, such as for pain 0-5, where 0 is no pain and 5 is severe pain. The next step in assessment would be a music history to determine patient preference or interest. The ICU nurse should then establish a music sched- ule for the patient in which a quiet milieu can be provided to enhance the positive effects of music therapy. This schedule should be repeated at least twice a day. Certain musical compositions have been identified that promote a relaxed re~ sponse (ie, reduction in heart rate, regular deep breathing, muscular relaxation, and sleep) (see box “Suggested Music Selections”). It is essen-

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