Sedation and Rapid Sequence Intubation Flashcards
versed –decreases ____, -it will affect your _______________ almost every time
bp, blood pressure
paralytics are aka NMBA: _____________________________
succintylcholine, rocuronium, vecuronium
Paralytics are also known as NMBA
Paralytics are NOT given during _____________
One nurse must be dedicated to the monitoring of the patient while he or she is undergoing the procedure
Common drugs given for moderate sedation include ___________________________________
moderate sedation
Ketamine, Diprivan/propofol and versed/midazolam
Vecuronium:
-has a long half life (about an _____)
-is often used during _____________
IS MORE LONG TERM, NOT USED for _____
WHEN PATIENTS CODE –___________________________ –THIS IS GIVEN TO PREVENT SHIVERING
hour
therapeutic hypothermia
RSI
THERAPEUTIC HYPOTHERMIA
Rocuronium
-has longer half life (about ______)
BETTER FOR ____________________________________
TYPICALLY NOT USED FOR THE NORMAL PEOPLE BC IT LASTS ______ MINUTES, IF YOU DON’T GET THE AIRWAY YOU MIGHT HAVE TO BAG THEM FOR ____________.
30 min, DIALYSIS AND BRAIN INJURY PATIENTS, 30, 30 MINUTES
HYPERKALEMIA IS A BIG DEAL –HIGH POTASSIUM LEVELS, BRAIN INJURY PATIENTS ARE ALSO NOT GREAT CANDIDATES FOR THIS DRUG,
succinylcholine
__________________:
-has a short half-life (less than ______), is either off or on, can cause ______
-avoid use of this in ______ patients. Why?
Succinylcholine
10 min
hyperkalemia
dialysis
Are neuromuscular blocking agesnts used in moderate sedation?
no. you NEVER GIVE NMBA WITHOUT SEDATION
Primary use of atropine is:
To slow the GI tract
To prevent patients from needing to go to the bathroom during moderate sedation
To dry sections and keep heart rate above 60
To alleviate pain
to dry secretions and keep HR >60
Atropine may cause dry mouth and difficulty voiding. t/f
true
What are s/s of anticholingeric toxidrome?
Altered mental status, mydriasis (blindness), red flush skin, hot dry skin, dry mucous membranes
Toxicity and Overdose: atropine
If overdose occurs, ____________ is the antidote.
physostigmine
What condition is atropine contraindicated to give with?
glaucoma
___________
-found in your crash cart
-used for bradycardia or to decrease the risk of bradycardia during surgery
-blocks the muscarinic response to ________________ by decreasing salivation, bowel movement, and GI secretions
-Slows motility of the GI tract
-Decrease saliva, perspiration, and gastric and pancreatic secretions
-Decreases the risk of aspiration
Atropine , acetylcholine,
Phenergan/promethazine is given how ?
IM ONLY -Cancause phlebitis and tissue necrosis in the vein
Metoclopramide/Reglan
-decreases the risk of ___________
-enhances _______________
-Fun fact: often will make patient feel ______________________________
aspiration
gastric emptying
the desire to leave immediately
anti-emetic:
Phenergan/Promethazine
-decreases risk of ________
-includes sedation
-high rate of ____________________
aspiration, necrosis with extravasation.,
anti-emetic:
Ondansetron/Zofran
-decreases risk of ____________
-Can result in _____________
aspiration,
prolonged qt interval (arrhythmia)
1 focus is ____________________ status
Never leave the patient. If you are designated to ___________ you may NOT perform any other role. *** Look up moderate sedation on the OK BON website. This is specifically listed.
monitor the patient, cardiac and respiratory
you can ventilate them with ______________ so that there is actually a seal. to go ahead and intube, yes you will probably need to remove ___________.
dentures, dentures
End tidal Co2 (ETC02) is an indicator of:
How well a patient is sedated
How well a patient is breathing
How much o2 is attached to hemoglobin molecules
The rhythm of the heart
how well a patient is breathing
ETco2: Measures the exhaled oxygen with each breath and is an indicator of _____ _________.
adequate ventilation
What is required during moderate sedation?
Consent prior to medications
Continuous monitoring
An RN who has no other responsibilities at that time must have the job to solely monitor the patient
Crash cart with emergency medications, airway and ventilator equipment, defibrillator, IV supplies (should already have a minimum of one patent IV)
100% o2 source and administration supplies such as airways manual BVM and suction equipment
ECG monitor and display, non invasive blood pressure monitor, pulse ox, thermometer, stethoscope, ETCO2, A PROVIDER CAPABLE OF INTUBATING*****
ETco2: Measures the exhaled oxygen with each breath and is an indicator of _____ _________.
(ONLY GIVE MEDICATIONS THAT CAN ___________________ IN THE PRESENCE OF A PROVIDER SKILLED AND QUALIFIED IN INTUBATION. NEVER GIVE THIS WITHOUT THIS PERSON IN THE ROOM!)***
REMOVE RESPIRATORY DRIVE
Which of the following procedures would be appropriate under moderate sedation?
Cholecystectomy
Breast Augmentation
Closed reduction of the wrist
Open fracture reduction of the right femur
closed reduction of the wrist
Client can *respond to verbal stimuli*retains protective reflexes (gag reflex) *is easily arousable *maintains own airway
moderate sedation
anesthesia that does not result in loss of consciousness
moderate sedation
treatment for malignant hyperthermia
STOP SURGERY
Give Dantrolene (this is a muscle relaxer)
What is the dose and how fast is it given? (look this up)
100 % o2
Get ABGs
Infuse ICED saline
Cooling blankets
Indwelling temperature sensing foley catheter
THIS IS A LIFE THREATENING EMERGENCY
INHERITED MUSCLE DISORDER requiring screening questions
malignant hyperthermia
what is the reversal for malignant hyperthermia?
dantrolene
anesthesia:
______ is the #1 priority in all situations
Titrate meds CAREFULLY and SLOWLY
______________ can deteriorate quickly with sedation and should be monitored closely for cardiac complications
With the use of anesthesia, ALWAYS inquire about ________________.
damages CNS
Airway patency, Elderly individuals, malignant hyperthermia
ALWAYS GIVE ___________ BEFORE ____________ WITH THE EXCEPTION OF IF THEY ARE COMBATIVE
SEDATIVE, PARALYTIC
during moderate sedation you will never give a _______
paralytic
Loss of sensation WITHOUT loss of consciousness -used for a particular part of the body
local anesthesia
Loss of sensation, consciousness and reflexes -Used for MAJOR surgery requiring complete muscle relaxation
general anesthesia
what do you need to monitor for with propofol?
CNS depression, respiratory depression, hypotension, fever, sepsis, hyperlipidemia
Can NOT be given IVP by a nurse in OK but it CAN be managed on a pump.
propofol
propofol:
Rapid increases in administration rate can cause ______________________! ***
cardiorespiratory depression. only increase doses every 3-5 minutes bc of this
what do you need to monitor with propofol?
triglyceride levels
propofol tubing has to be changed ?
q 12 hrs bc of bacteria
propofol is known as ?
jackson juice, milk of amnesia, or diprivan
What can happen if we give them flumazenil?
seizures
What are the side effects of benzos?
CNS depression
hypotension, resp depression
paradoxical agitation
What are benzos used for?
sedation, anxiety, seizures
What scales do you use to assess sedative benzos?
SAS or RASS
What is the antidote for benzodiazepines?
flumazenil
Patient controls when med is given
Special infusion pump
Patient pushes a button for a prescribed bolus of pain medication
Safe and effective pain management
PCA pump
What are nursing care interventions for hydromorphone?
Prepare to give o2-Give SLOWLY (2-5 minutes)-Note that the potency of hydromorphone to morphine is 7:1-Avoid giving to opiod naïve patients
Antidote: Naloxone/Narcan
What are the side effects of hydromorphone?
Respiratory depressionHypotension
what are nursing interventions for morphine?
Apply o2 PRN
Monitor vitals and intervene PRN
Use lower doses in older adults
what can morphine’s side effects be?
resp depresion
n/v
How fast should you give morphine?
Give SLOWLY over 4-5 min
occasionally used for sedation, but mostly for pain, what happens if you give it too fast?
chest wall rigidity
Is more pressure-protective than other opiods
fent
what are side effects of fent?
Bradycardia, Hypotension, CHEST WALL RIGIDITY, muscle rigidity, constipation, itching
What is a typical IV dose of fent?
50-100 mcg q1 -2 hours IV is a normal dose
if youre giving IV push of opiods or benzos –give over _________
2-5 minutes
_______: Prepare to apply o2
have a nasal canula nearby
works really well, but it wears off really quickly
HYDROMORPHONE
_________: Longer duration. May cause hypotension or prolonged sedation in patients with renal insufficiency
decreased O2 demand
increases vasodilation
give over 2-5 minutes
if given too fast –__________
MORPHINE, causes vomiting
lowers BP
__________: Fastest onset. Shortest duration
doesn’t typically lower bp really fast.
don’t slam –-__________,
give over ______ minutes
FENTANYL. chest wall rigidity, 2-5
Improved pulmonary function
Earlier ambulation
Earlier mobilization
Decreased stress response
Lower catecholamine concentration (pressors)
Lower oxygen consumption
Improved outcomes
appropriate pain management results
what are alternative therapies ?
guided imagery, music therapy, essential oils and aromatherapy, animal therapy,
Non-pharmacological therapy for pain, anxiety, and delirium
Orient with calendars and clocks
Engage the family
Role model to the family reassurance
Role model avoiding arguing with confused patients
Teach family how to do passive ROM
Teach family how to help with hygiene
Bring in pictures and keepsakes from home to improve environment
Let the patient face the window
Conceal equipment
___________: have features of both delirium
Mixed Delirium
_______________: “quiet __________” that often goes undiagnosed
theyre super confused and no one really knows bc theyre quite
Hypoactive Delirium, delirium
_______________: agitated, combative, disoriented, at elevated risk for injury because of altered thought processes and behaviors. May experience hallucinations, delusions, paranoia
Hyperactive Delirium
45-87% of patients who are critically ill experience this
If untreated may result in longer ventilation and stay
delirium
Changing or fluctuating mental status
Inattention
Disorganized thinking
Altered levels of consciousness
Elderly patients more at risk
delirium
always use the ___ dose vial
smaller
provide safety: ABC, bed rails up, intervening for ABC issue, main goal is to keep patient safe.
honestly everything, but for ketamine
______ are the only ones who can do moderate sedation
physicians
one person will monitor the patient and they will be assigned this job this is all they do, will just watch the monitor.
When RSI dose of ketamine is given
Ketamine: Nurse Job
Monitor BP, HR, respiratory status
Protect the airway (from vomiting most likely)
Use very cautiously in patients with head injury as this can increase ICP
Provide safety in the event of unpleasant hallucinations, confusion, excitement
Educate patient and family before administration
PROVIDE SAFETY
not appropriate for patients with already high ICP
ketamine
Ketamine: NMDA side effects
Can cause emergence reaction
anacute confusion state during recovery from anesthesia; patients with ED may present with disorientation, hallucination, restlessness, and purposeless hyperactive physical behavior
Hypertension
Respiratory Depression
Apnea
Nausea and vomiting
Anaphylaxis
Can increase ICP
UNDERSTAND THAT THIS MAY MAKE YOUR PATIENT GOOFY, HALLUCINATION, DISORIENTED, INCREASES BP AND ICP
ketamine
What does the RSI dose of ketamine do?
inhibit breathing
What is a common side effect of ketamine?
nightmares
Ketamine:
Anesthetic
Interrupts association pathways of the brain selectively
Provides sensory blockade
Can be used for _____ or _____
PAIN, RSI
______ = significant central opiod effect, which indicates that the patient would be better treated with:
Regional block
Ketamine
Other non-opiod therapy
Pain + LOW PDR
Measurement of pupil size and reactivity to light
Uses an infrared camera to noninvasively monitor pupil diameter changes
Allows for assessment of ______
opiod administration.
Pupil dilation reflex (pupillometry)
BIS BISPECTRAL INDEX SCORE
____= Full consciousness
_____=Deep sedation
___= Complete EEG supression
90
40-60
0
BIS has strong correlation with ?
RASS score
________________ noninvasive, objective analysis on the level of the patient’s wakefulness
BIS provides
Records spontaneous brain activity that comes from cells on the surface of the brain
Converts EEG signal into a numeric score 0-100 (100 = fully awake)
BIS monitor
What is another scale beside the CPOT and RASS, what is its scale?
Sedation agitation scale. 1 (unrousable) to 7 (dangerous agitation)
_______ tells us if we need to turn sedation up or down.
rass
- 10 point scale ranging from ______ (4+) to _____________ (-5)
- Patient is assessed for _____ seconds
- Light sedation: _________
- Light sedation is the ____________
combative
unarousable
30-60
(-2) up to (+1)
ideal range
Rass scale is how we determine if our patients are ______ appropriately.
sedated
check _____ to see how well gut is absorbing food.
residuals
- Agitation
- Inappropriate use of paralytics
- Increased metabolic demand
- Increased risk of myocardial ischemia
consequences of not enough sedation
- accumulation of medication
- increased hospital stay
- pneumonia
- delayed ventilator weaning
- immobility
consequences of too much sedation
Goal: Maintain ______ effective sedation to achieve ______ duration of mechanical ventilation
lightest, shorter
What scale do we used for sedated patients?
CPOT
What is the max score on the CPOT?
8
What scale is used on patients who cannot communicate in the ICU?
Critical Care Pain Observation Tool (CPOT)
What is PQRST ?
provocation, quality, radiation, severity, and timing
Pain assessment:
Thorough assessment
Ongoing assessment
Reassessment
Documentation of interventions and responses
Involves collecting the patient’s report and behavioral markers
Should identify and treat possible causes of anxiety too such as _______________________________________________, pain and withdrawal from drugs.
hypoxemia, hypoglycemia, hypotension
What does the ABCDEF bundle result in?
Less time on mechanical ventilation
Less delirium
Early mobilization
Decreased length of stay in the critical care unit and the hospital
What does the ABCDEF bundle mean?
Awakening and Breathing Coordination
Delirium monitoring and management
Early exercise and mobility (rehabilitation)
Family Engagement
AND SLEEP
American College of Critical Care Medicine & Society of Critical Care Medicine Comprehensive Guidelines:
Evidence based practice
Patient centered protocols
Treat ____
Treat ______
Consider Sedation
Focus on delirium, immobility and sleep disruption in critically ill patients
Recommends:
1. Validated monitoring instruments
2. Nonpharmacological AND pharmacological interventions
3. Coordinating care around the patient’s goals
Pain, Agitation,
Results of delirium:
Sleep disturbances
Abnormal psychomotor activity
Emotional disturbances
If untreated, is a predictor of negative clinical outcomes in critically ill patients
Increased _____ , ______, ______
Long-term cognitive impairment consistent with _________
mortality
Increased length of stay
Increased cost of care
dementia-like state
for nurses :
avoid ______ when possible.
counseling can be good for nurses,
pet therapy can be good, art therapy can also be helpful,
drugs and alcohol
Agitation risk factors:
Extreme anxiety
Moderate to severe pain
Delirium
Mechanical ventilation
Smoking habits
Fun fact: Agitation increases days spent on _____
ventilator
2 years post ICU stay study:
59% of patients still experienced general anxiety, depression, and PTSD
35% had PTSD symptoms during follow up
50 % had taken ___________ drugs
40 % required psychiatric treatment since hospital discharge
psychiatric
Physiological responses to pain and anxiety:
______
Cool extremities
Diaphoresis
__________________
Increased cardiac output
Increased______ production
Pupillary ______ (mydriasis)
Nausea
Pallor and flushing
Sleep disturbance
Tachycardia
Tachypnea
_______
Constipation, Hypertension, glucose, dilation, Urinary Retention
Negative effects of pain & anxiety:
Causes feelings of breathlessness that lead to __________ with the ventilator
_________________ can be a result of dyssynchrony
dyssynchrony, Alveolar damage
Negative effects of pain & anxiety
Associated with a 10 year increase in mortality rate after PCI
__________ secondary to pain and anxiety is stressful because the rapid breathing increases patient effort
Hyperventilation
Pain:
Results from a signal cascade within the neurological network
______: comes from irritation or damage to the nervous system. bones muscles, soft tissue.
_______: Diffuse, poorly localized, often referred. from organs and blood vessels.
Is a ______ mechanism because it stimulates movement away from the thing causing harm
Somatic pain, Visceral pain, protective
Anxiety is escalated by:
Noise of alarms, equipment, personnel
Bright ambient lighting
Excessive stimulation from inadequate pain relief
Frequent ______
Repositioning
Lack of mobility
Uncomfortable __________
Sleep deprivation
Circumstances leading to admission
assessments, room temperatures
anxiety contributes to pain perception by:
Activating pain ______
Altering the cognitive evaluation of pain
Increasing aversion to pain
Increasing the report of pain
Creating feelings of ______
Leads to greater __________, especially in patients with cardiovascular disease.
pathways, powerlessness, morbidity and mortality
anxiety is high when we don’t get enough sleep
__________ –do as many things that you can for them at a time
patients anxiety is whatever they say it is
strong correlation between pain and anxiety –our job to do pharmacological and __________ interventions
bundle your care, nonpharmacological
Pain and anxiety __________ of one another
Pain leads to anxiety. Anxiety enhances pain. Further pain worsens anxiety, etc.
exacerbate
anxiety:
Apprehension-Agitation-Autonomic arousal-Fearful withdrawal
Prolonged state of apprehension in response to a real or perceived fear
Assessed as whatever the patient reports
Inter-related with ____
Relationship between _____ and anxiety is cyclical
pain, pain,
Throughout the course of their residency, one in five medical residents will make a sleepless-related medical error that causes significant, liable harm to a patient.
One in twenty will ____ a patient due to a lack of sleep.
Medical errors are the ___________ of death among Americans after heart attacks and cancer. Sleeplessness undoubtedly plays a role in those lives lost.
If you are about to undergo an elective surgery, you should ask how much sleep your doctor as had.
One cannot “learn” how to overcome a lack of sleep and develop resilience.
kill
third-leading cause
Men who suffer from sleep disorders (sleep apnea and snoring) have significantly lower levels of _______________.
Your immune response suffers after a single night of reduced sleep
testosterone
Adults 45+ who sleep ___ hours are 200% more likely to have a ________________________ compared to those sleeping 7-8 hours.
In the Northern Hemisphere, the switch to daylight savings time in March results in most people losing an hour of sleep opportunity. When viewed across the millions of daily hospital records, this seemingly trivial sleep reduction comes with a frightening spike in heart attacks the following day.
The less you sleep, the more you are likely to _____.
Chronic sleep deprivation is one of the major contributors to ____________.
Insufficient sleep is linked to ______.
Short sleep causes the body to deplete muscle mass and ______.
<6, heart attack or stroke, eat, type 2 diabetes, obesity, retain fat
Sleep:
Vehicle accidents caused by ______ exceed those caused by alcohol and drugscombined.
After being awake for ____________, people who were sleep-deprived were as cognitively impaired as those who were legally drunk.
Students who stay up late cramming for tests experience a 40% deficit in their ability to make new memories relative to those that get a full night of sleep.
Sleep is neurological sanitation.
Getting too little sleep across the adult life span will significantly raise your risk of developing ____________ disease.
drowsy driving, nineteen hours, Alzheimer’s
Sleep:
Restores the brain’s capacity for ______
makes room for new memories.
The more sleep spindles an individual has at night, the greater the restoration of overnight learning ability come the next morning.
Is like clicking the “save” button.
Protects newly acquired information against forgetting.
Transports memories from a temporary storage hold (hippocampus) to a more secure, permanent home (the cortex).
Sleep clears out the cache of short-term memory for the new imprinting of facts, while accumulating an ever-updated catalog of past memories.
Sleep salvages memories that appeared to have been lost soon after ______.
learning, learning
Two-thirds of adults throughout all developed nations fail to obtain the recommended eight hours of nightly sleep.
The shorter your sleep, the shorter your ___________.
Human beings are theonly species that will deliberately deprive themselves of sleepwithout legitimate gain.
The physical and mental impairments caused by one night of bad sleep dwarf those caused by an equivalent absence of food or exercise.
______ is the single most effective thing we can do to reset our brain and body health each day.
life span, Sleep
- Quality sleep becomes more difficult as we _____, but it’s still as important.
age
Getting enough _____________ is even more important to our physical and mental health than diet and exercise.
quality sleep
patients in the ICU (50%) get some kind of PTSD — this is called ___________________________
post intensive care syndrome
Unrelieved pain:
Inadequate sleep
Exhaustion
Anxiety
Disorientation
Agitation
PTSD
Post Intensive Care Syndrome
____________________
____________________
Can increase morbidity
Can increase length of stay
_____ can cause more pin (previous hospital visit where pain wasn’t managed),
anxiety
patients pain level is __________________, it can be influenced by psychological social and cultural factors.
what they say it is
Perception, Expression, & Tolerance of pain are influenced by:
Psychological factors
Social factors
Cultural factors
______ is a big reason we are going to sedate a patient along with intubation
pain
