Cognition Flashcards
Hypoactive delirium
Flat affect, withdrawal, apathy, lethargy, and/or decreased responsiveness
Delirium risk factors
Pre-existing dementia, Hx of baseline hypertension, Alcoholism, Admission severity of illness, Age (questionable), Sedative use (specifically benzodiazepines)
Delirium management
Antipsychotics,
THINK mnemonic,
ABCDE bundle,
Delirium assessment
Validated tool for delirium assessment used at least once per shift,
Perform, document, and communicate assessment,
Evaluate for potential risk factors,
Consider strategies for decreasing benzodiazepine usage or use alternative,
Early progressive mobility and exercise,
Evaluate pts for causes of delirium using THINK
THINK
Evaluation for pts with delirium
Toxic situations? Hypoxemia? Infection/sepsis? Immobilization? Nonpharmacologic interventions? K+ or electrolyte problems?
ABCDE bundle
Awakening and Breathing trial coordination, Choice of sedative, Delirium detection, Early progressive mobility and exercise
Unrestricted visitation in ICU
Can improve the safety of care and enhance pt and family satisfaction,
Improves communication, facilitates a better understanding of the pt, advance patient- and family-centered care, helps calm the pt, and enhances staff satisfaction
Family presence during resuscitation and invasive procedures
Pt is comforted by family members presence,
Helps family to understand the severity of their loved ones condition,
Decreases family anxiety and fear,
Allows closure and facilitates the grieving process in the event of death,
Improves medical decision making, pt care, and communication with pt family
Promote sleep and prevent alarm fatigue
Provide proper skin prep for ECG electrodes,
Change ECG electrodes daily,
Customize alarm parameters on ECG and pulse ox monitors,
Monitor only those pts with clinical indications for monitoring
Assessing pain in the critically ill pt
Attempt to obtain the pts self report of pain,
Perform a pain assessment using a validated behavioral pain scale for those unable to self report,
Avoid referring to vital signs for pain assessment,
Consider a proxy to identify behavior that may indicate pain
Moral distress
Occurs when you know the ethically appropriate action to take, but are unable to act upon it;
Occurs when you act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity
Unaddressed Moral distress
Restricts nurses’ ability to provide optimal pt care and find job satisfaction;
Causes suffering, poor communication, lack of trust, defensiveness, and lack of collaboration
The 4 A’s
Ask: you may be unaware of the exact nature of the problem but are feeling distress,
Affirm: affirm your distress and your commitment to take care of yourself. Validate feelings and perceptions with others,
Assess: identify source(s) of distress, determine severity of distress, and contemplate your readiness to act,
Act: prepare to act, take action, and maintain desired change
“Five Rights of Clinical Reasoning”
Right cues: clinical data collected and clustered by the nurse to recognize the relevance and relationship to the pt,
Right patient: identify if pt is high risk for complication of condition,
Right time: recognizing early signs of complications and initiating nursing interventions,
Right action: once a clinical judgement is made, the right action must be taken,
Right reason: understanding the rationale
Tips for data collection in ICU
What happened? (Brief history, critical numbers and when),
What is going on? (Assess vitals, O2 therapy, physical exam, drips, fluids, screens, foley, ask nurse, ask RT),
What is missing?
Reasons for transfer to ICU
Respiratory failure requiring ventilation,
Severe acid-base disturbance with critical numbers,
Loss of consciousness, failure to protect airway,
State of shock, hypotension not responding to fluids
Delirium
An acute change in consciousness that is accompanied by inattention and either a change in cognition or perceptual disturbance
What to do for pts with sleep alterations
Establish sleep/wake cycle, Cluster care, Minimize noise level, Mimic normal lighting conditions, Sedation does not mean good sleep
Consciousness
Arousal, ability to perceive, ability to direct behavior to goals
Evidence based management
Assess for presence of delirium,
Baseline risk factors to assess susceptibility:
Pre-existing dementia,
Hx of baseline hypertension,
Alcoholism,
Admission severity of illness,
Standard assessment tool to detect delirium
RASS - level of consciousness
\+4 combative; \+3 very agitated; \+2 agitated; \+1 restless; 0 alert & calm; -1 drowsy; -2 light sedation; -3 moderate sedation; -4 deep sedation; -5 unarousable; If RASS is -3 or greater, proceed to CAM-ICU; If RASS is -4 or -5, stop and recheck later
CAM-ICU
Confusion Assessment Method for the ICU
- Acute change or fluctuating course of mental status:
Is there an acute change from mental status baseline OR
Has the pts mental status fluctuated during the past 24 hrs? (No, CAM-ICU negative; Yes, proceed); - Inattention:
Squeeze my hand when I say the letter “A”, S A V E A H A A R T (0-2 errors, CAM-ICU negative; >2 errors, proceed); - Altered level of consciousness:
Current RASS score other than 0, CAM-ICU positive; RASS score 0, proceed; - Disorganized thinking:
Will a stone float on water?
Are there fish in the sea?
Does one pound weigh more than two?
Can you use a hammer to pound a nail?
Hold up this many fingers (2),
Now do the same thing with the other hand
>1 error, CAM-ICU positive; 0-1 error, CAM-ICU-ICU negative
Wake up and breathe protocol
Every 24 hrs: SAT safety screen Fail, wait 24 hrs; pass, proceed Perform SAT Fail, restart sedatives at 1/2 dose; pass, proceed SBT safety screen Fail, wait 24 hrs; pass, proceed Perform SBT Fail, full ventilate support; pass, consider extubation
SAT safety screen/SAT failure
SAT safety screen: No active seizures, No alcohol withdrawal, No agitation, No paralytics, No myocardial ischemia, Normal intracranial pressure;
SAT failure:
Anxiety, agitation, or pain,
Resp rate > 35/min,
O2 sat
SBT safety screen
SBT safety screen:
No agitation,
O2 sat >88%,
FiO2
Hyperactive delirium
Agitation, restlessness, attempting to remove catheters, and/or emotional lability
SBT failure
Resp rate >35/min,
Resp rate
Stop!
Do any meds (esp benzos) need to be stopped or lowered?
Is the pt on the minimal amount of sedation necessary?
Do any titration strategies need to be used, such as a targeted sedation plan or daily sedation cessation?
Do the sedative drugs need to be changed?
Think!
Toxic situations, CHF a, shock, dehydration, deliriogenic meds, new organ failure, hypoxemia, infection or sepsis, immobilization, K+ or electrolyte problems?
Non-pharmacologic interventions employed (glasses, hearing aids, reorientation, sleep protocols, noise control)?
Medicate (perhaps)
Haloperidol and atypical antipsychotics: Traditionally recommended medication class to treat delirium; Little evidence to support treatment; All pts receiving antipsychotics should be routinely monitored for side effects, especially QT prolongation
Medical futility
Any effort to achieve a result that is possible but that reasoning or experience suggests is highly improbable and that systematically cannot be reproduced
Fentanyl
Sublimaze
Analgesia;
Induction and maintenance of anesthesia;
Moderate sedation;
Causes loss of consciousness and eliminates pain;
Continuously monitor VS, have resuscitative equipment ready, use mechanical ventilation;
IM or IV 50-100 mcg
Morphine
Analgesia;
Relieves moderate to severe pain;
Sedation;
Reduction of bowel activity;
Activates MU and kappa receptors to produce analgesia;
Monitor VS, I and O, assess bladder for distention, auscultation lungs;
IM: 10 mg; IV: 2-5 mg
Hydromorphone
Dilaudid
Analgesia; Relieves moderate to severe pain; Interacts with the opioid MU receptors for pain relief; Assess resp status; PO: 2.5-10 mg
Naloxone
Narcan
Analgesia; Treatment of opioid overdose, reversal of resp depression, reversal of opioid induced constriction; Competes for opioid receptors; Monitor heart rhythm and function; IV: 1 mg/kg
Propofol
Diprivan
Anxiolytic;
Induction of anesthesia;
Assess BP and HR;
For induction: 20-40 mg/min until sedated up to 250 mg
Lorazepam
Ativan
Anxiolytic;
Anxiety, seizures, insomnia, muscle spasm, ETOH withdrawal, panic disorder, induction of anesthesia;
Enhances action of GABA in the CNS;
Assess for CNS depression, resp status, VS, have resuscitative equip available;
PO: 1-2 mg TID; IV: 2 mg
Haloperidol
Anxiolytics;
ICU agitation;
Assess HR, blood glucose, s/s infection;
IV int: 2-10 mg q30m-6h; IV inf: 3-25 mg/hr
Dexmedetomidine
Anxiolytic;
Delirium, sedation prior to surgery;
Monitor VS, I and o, and for agitation;
1 ug/kg followed by 0.2-0.7 ug/kg/hr
Pain induced stress
Possibly due to no universally recommended pain assessment available;
Rest is decreased when pain is present, causing stress
Clinical judgement/reasoning
Ability to collect data, analyze data, put the data in the context of the pt, and determine the best action to take
