This issue of Critical Care Nursing Quarterly deals with one of the most perplexing problems that nurses encounter with most complex patients. The abilities to predict which patients are likely to develop delirium, and to promptly identify and manage the condition, are vital to the ICU nurse's acumen.

The multifactorial etiologies of delirium are discussed by Marshall and Cole in the introductory article, "Delirium in the Intensive Care Unit." These experienced authors explain the processes leading to delirium and relate them to interferences with healing and recovery. Salient features of their work include newer assessment tools and clinical practice guidelines used for critical care patients who are at high risk for delirium.

"Sleep Deprivation in Critical Care Units" is addressed in detail by Honkus. Sleep stages are reviewed, and sleep medications and their effects are outlined. Suggestions are provided to assist nurses in developing a plan of care that minimizes the deleterious effects of sleep deprivation. The author emphasizes staff education and the restructuring of nursing routines to minimize sleep disruptions, making sleep a high priority for the patient.

Barber's article, "Pharmacologic Management of Integrative Brain Failure," explores the dynamics of brain failure as a complication of critical illness. Discussions of the pharmacological approaches to pain, sleeplessness, anxiety, and delirium provide helpful insights into drug selection and administration. She presents the work of several leading authorities who have studied dosing and titration of drugs in treating pain and anxiety and providing clinical sedation.

Litton's insights into delirium are considered in her work "Delirium in the Critical Care Patient: What the Professional Staff Needs to Know." The author reviews the causes of delirium with special attention to alcohol withdrawal, aging, and other comorbidities, emphasizing the value of precise nursing assessments and well-managed pharmacological therapies. Medications and their effects on neurotransmitters are addressed to assist clinical nurses in interpretation of aberrant behaviors and to guide decisions about polypharmacy for the patient with delirium.

Spirituality can be a great strength for patients experiencing pain, anxiety, and other stressors. The abilities to promote and accommodate spirituality are not merely important; in fact, according to patient satisfaction studies, these may be indeed more important in the eyes of the patient than many other characteristics of a "good nurse." The use of presence and the nurse-patient relationship for managing patient distress is the focus of Nussbaum's article, "Spirituality in Critical Care: Patient Comfort and Satisfaction," which explains the importance of spirituality as a component of ICU care processes.

Sherri Hartwick helps the reader to "put it all together" in "ICU Delirium: A Case Study." The author points out both helpful and nonhelpful nursing approaches and how educational initiatives can be used to modify staff attitudes and behaviors. A real scenario involving a vascular surgery patient is used to amplify key nursing processes in caring for patients with delirium.

A final bonus article, unrelated to the central theme of the issue, has been contributed by Angerio and Lee. This unsolicited work reviews some new research findings that suggest that sickle cell crises events are more complex than a mere vaso-occlusive phenomenon in response to hypoxia. The role of endothelin antagonists in preventing and treating a crisis event is considered.

This collection of articles represents the most vital elements of caring for a patient with actual or potential states of delirium. It is not designed to be a comprehensive work on the subjects of stress, anxiety, pain management, sleep disturbances, or delirium. To accomplish that feat, several additional issues of the journal would be required. Hopefully the articles that are highlighted in this issue, however, will energize ICU nurses to revitalize care processes aimed at preventing and controlling this devastating complication of critical illness.

Issue Editor