Sedation and Rapid Sequence Intubation Flashcards by Glen McCormick

versed –decreases ____, -it will affect your _______________ almost every time

bp, blood pressure

How well did you know this?

Not at all

Perfectly

paralytics are aka NMBA: _____________________________

succintylcholine, rocuronium, vecuronium

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

HYPERKALEMIA IS A BIG DEAL –HIGH POTASSIUM LEVELS, BRAIN INJURY PATIENTS ARE ALSO NOT GREAT CANDIDATES FOR THIS DRUG,

succinylcholine

How well did you know this?

Not at all

Perfectly

__________________:
-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

How well did you know this?

Not at all

Perfectly

Are neuromuscular blocking agesnts used in moderate sedation?

no. you NEVER GIVE NMBA WITHOUT SEDATION

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Atropine may cause dry mouth and difficulty voiding. t/f

true

How well did you know this?

Not at all

Perfectly

What are s/s of anticholingeric toxidrome?

Altered mental status, mydriasis (blindness), red flush skin, hot dry skin, dry mucous membranes

How well did you know this?

Not at all

Perfectly

Toxicity and Overdose: atropine

If overdose occurs, ____________ is the antidote.

physostigmine

How well did you know this?

Not at all

Perfectly

What condition is atropine contraindicated to give with?

glaucoma

How well did you know this?

Not at all

Perfectly

___________
-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,

How well did you know this?

Not at all

Perfectly

Phenergan/promethazine is given how ?

IM ONLY -Cancause phlebitis and tissue necrosis in the vein

How well did you know this?

Not at all

Perfectly

Metoclopramide/Reglan
-decreases the risk of ___________
-enhances _______________
-Fun fact: often will make patient feel ______________________________

aspiration
gastric emptying
the desire to leave immediately

How well did you know this?

Not at all

Perfectly

anti-emetic:

Phenergan/Promethazine
-decreases risk of ________
-includes sedation
-high rate of ____________________

aspiration, necrosis with extravasation.,

How well did you know this?

Not at all

Perfectly

anti-emetic:
Ondansetron/Zofran
-decreases risk of ____________
-Can result in _____________

aspiration,
prolonged qt interval (arrhythmia)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

ETco2: Measures the exhaled oxygen with each breath and is an indicator of _____ _________.

adequate ventilation

How well did you know this?

Not at all

Perfectly

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 _____ _________.

How well did you know this?

Not at all

Perfectly

(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

How well did you know this?

Not at all

Perfectly

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 an acute 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

1. 10 point scale ranging from ______ (4+) to _____________ (-5) 2. Patient is assessed for _____ seconds 3. Light sedation: _________ 4. 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

1. Agitation 2. Inappropriate use of paralytics 3. Increased metabolic demand 4. Increased risk of myocardial ischemia

consequences of not enough sedation

1. accumulation of medication 2. increased hospital stay 3. pneumonia 4. delayed ventilator weaning 5. 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?

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 drugs combined. 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 the only species that will deliberately deprive themselves of sleep without 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

3. 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