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Critical Care Nursing > Topic 2 Sedation > Flashcards

Topic 2 Sedation Flashcards

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1
Q

Transmission of pain signals into the brainstem, thalamus, and cerebral cortex by way of the?

A

“fast” pain pathway and “slow” pain pathway

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2
Q

Predisposing Factors of Pain
•Disease, procedures, monitoring devices, nursing care, trauma
•Many factors influence pain perception

A
  • Expectation
  • Previous pain experiences
  • Emotional state
  • Cognitive status
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3
Q

Predisposing Factors of Anxiety
•Inability to communicate, noise, light, excess stimulation
•Examples include?

A
  • Endotracheal tube
  • Monitor alarms
  • Lack of mobility
  • Unfamiliar surroundings
  • Uncomfortable room temperature • Sleep deprivation
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4
Q

Acute pain activates?

•Chronic pain?

A

Acute pain activates sympathetic nervous system •Chronic pain, less activation

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5
Q
  • Acute pain travels via?

* Chronic pain travels via?

A
  • Acute pain travels via A-delta fibers

* Chronic pain travels via C fibers

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6
Q

most abundant receptors?

A

Nociceptors most abundant receptors
• Mechanical stimuli
• Chemical stimuli
• Thermal stimuli

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7
Q

Physiology of Anxiety

A
  • Anxiety is confined within the brain

* Purely psychogenic disorder; no actual tissue damage •Linked to reward and punishment center

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8
Q

Positive Effects of Pain/Anxiety

A
  • Increases performance levels
  • Removes one from potential harm
  • Fight-or-flight response
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9
Q

Negative Effects of Pain/Anxiety

A
  • Raises catecholamines
  • Tachycardia and hypertension
  • Interference with healing
  • Increased oxygen consumption
  • End-organ ischemia
  • Increased respiratory effort and hyperventilation •Fighting the ventilator
  • Delay in ventilator weaning.
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10
Q

Assessment of Pain

A
  • The 2013 Clinical Practice Guidelines
  • Assess and treat promptly.
  • Use valid and reliable pain assessment tools.
  • Document findings.
  • Engage patient in management plan.
  • Provide preemptive treatment.
  • Reassess and treat to meet patient’s needs.
  • Institute quality improvement plan related to practice and outcomes.
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11
Q

Subjective Assessment Tools

•Characteristics of pain?

A
  • Precipitating cause
  • Severity
  • Location and radiation
  • Duration
  • Alleviating or aggravating factors
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12
Q

Subjective PQRST

Chest pain characteristics

A 
P = provocation or position
Q = quality
R = radiation
S = severity or associated symptoms
T = timing or triggers
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13
Q

Subjective Assessment Tools (4)

A

1) Pain score, 0 to 10 rating scale
• 0 = No pain
• 10 = Worst pain imaginable
2) FACES scale, series of faces from happy to distressed
3) Visual analog scale (VAS)
• Patient points to a level of pain severity on a 10-cm line
• Can also be done with pencil to mark severity
4) ICU Patient Communication Application (APP)
•A technology tool for patients unable to communicate
• Mechanical ventilation
• Hearing loss
• Speech limitations

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14
Q

Objective Assessment Tools

A 
•For patients who cannot communicate, no objective tool completely reflects patients’ pain level
•Examples
- Behavioral Pain Scale
- Critical-Care Pain Observation Tool
- Checklist of Nonverbal Pain Indicators
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15
Q

Assessment of Agitation
Hyperactive psychomotor functions
Treatment of Agitation

A 
- Hyperactive psychomotor functions 
• Tachycardia
• Hypertension
• Movement
- Treatment of Agitation
•Sedate to limit hyperactive psychomotor functions. 
•Low dose
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16
Q

Sedation Assessment—Tools

A
  • Sedation medication is given to reduce symptoms; dose is adjusted based on tools or scales
  • Richmond Agitation-Sedation Scale (RASS)
  • Sedation-Agitation Scale (SAS; Riker)
  • Interobserver agreement in assessment using various scales is important
17
Q

Continuous Monitoring of Sedation
•Assess brain activity
•Application of EEG to bedside
•Interpretation of values

A
  • Assess brain activity
  • Electroencephalogram (EEG)
  • Bispectral Index [BIS])
  • Application of EEG to bedside
  • Bispectral Index Score (BIS)
  • Patient State Index (PSI)
  • Interpretation of values
  • Values 0 (flat EEG) to 100 (awake)
  • 40 to 60 deep sedation plus amnesia
18
Q

Key word: inattention

A

Delirium

19
Q

Delirium

A
  • Acutely changing mental status
  • Key word: inattention
  • Types
  • Hyperactive—agitated, combative, disoriented
  • Hypoactive—quiet delirium
  • Mixed—fluctuating between the two
  • Many risks
20
Q

ABCDE Bundle for Preventing Delirium

A
  • Awakening
  • Breathing Coordination
  • Choice of Sedation
  • Delirium monitoring
  • Early mobility and exercise
21
Q

Delirium

•Assessment

A
  • Acute change in mental status
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Confusion Assessment Method for the ICU (CAM-ICU) • Intensive Care Delirium Screening Checklist (ICDSC)
  • Patient care outcome—keep the patient safe
  • Drug of choice—haloperidol
22
Q

Nonpharmacological Management of pain

A
  • Environmental manipulation
  • Guided imagery
  • Music therapy
  • Aromatherapy
  • Animal-assisted therapy
23
Q

Management—Opioids

A
  • Rapid onset, ease of titration, lack of accumulation, low cost
  • Fentanyl—fastest onset
  • Morphine—longer duration
  • Hydromorphone
  • Administration: IV bolus, IV infusions, patient- controlled analgesia (PCA), patch (fentanyl)
  • Scheduled versus as-needed administration
24
Q

Opioids Concerns

A
  • Respiratory depression
  • Hypotension
  • CNS depression
  • Hallucinations
  • Constipation (gastric ileus and retention)
  • Geriatric
25
Q

Patient-Controlled Analgesia (PCA)

A
  • PCA can be effective but patient must be able to manage the pump
  • Best suited for patients with:
  • Elective surgery
  • Large surgical or traumatic wounds
  • Normal cognitive function
  • Normal motor skills
26
Q

Management—Epidural

And Contraindications

A 
•Opioid or local anesthetic-STRICT STERILITY
•Facilitates mobility and pulmonary hygiene
- Contraindications 
• Coagulopathy
• Physical instability 
• Sepsis
• Spine injury
• Infection of the skin 
• Alcohol intoxication 
• Patient refusal
27
Q

Spinal Analgesia Side Effects

  • Spinal analgesia
  • Spinal analgesia with local anesthetics
A 
- Spinal analgesia 
• Respiratory depression 
• Sedation
• Nausea and vomiting
• Urinary retention
- Spinal analgesia with local anesthetics 
• Sympathetic blockade (hypotension, venous pooling) 
• Motor weakness
• Sensory block
• Urinary retention
28
Q

Management—NSAIDs and Acetaminophen

A

•NSAIDs may decrease need of opioid
•Risks of GI bleeding and renal (ibuprofen) or liver
(acetaminophen) insufficiency

29
Q

intravenous form of acetaminophen

A

Ofirmev

30
Q

Analgesics

A
  • Acetaminophen for mild to moderate pain
  • Used in combination with opioids
  • Ofirmev is an intravenous form of acetaminophen
  • Concern for hepatic function with use of acetaminophen
31
Q

Management—Sedatives

A
  • Pharmacological treatment for anxiety
  • Benzodiazepines
  • Propofol
  • Dexmedetomidine
  • Titrate to an end point (sedation scales or tools)
32
Q 
The nurse is concerned about administering opioid medication to a patient in pain because the patient is weaning from mechanical ventilation. The nurse consults with the clinical pharmacist, who suggests trying a/an:
A. Neuromuscular blockade
B. PCA pump with fentanyl
C. Sedative such as lorazepam (Ativan)
D. Intravenous nonsteroidal agent
A

D. Intravenous nonsteroidal agent

33
Q

Neuromuscular Blockade-paralysis
•Indications
-Monitor with?

A 
- Indications
• Facilitate treatment or procedures, including emergency or difficult intubation
• Improve tolerance of mechanical ventilation, especially nontraditional modes
• Manage elevated ICP
- No sedative or analgesic properties
• Must provide sedation!
- Monitor level with train-of-four (TOF)
• Peripheral nerve stimulator
34
Q

Nursing Care for Neuromuscular Blockade

A
  • TOF testing
  • Sedation
  • Care of immobile, paralyzed patient
    • Mechanical ventilation and airway management
    • Eye lubrication
    • DVT prophylaxis
    • Repositioning and range of motion
    • Oral care
    • Urinary catheter
    • Routine vital signs and assessments
35
Q

Management Challenges
•Invasive procedures

  • Substance abuse
  • Restraining devices
A 
- invasive procedures
• Procedural or conscious sedation
- Substance abuse
• May have higher-than-normal threshold 
• Alcohol withdrawal syndrome (AWS)
- Restraining devices
• Complications from immobility
36
Q

Management Challenges for Elderly patients

A
  • Physical changes associated with aging
  • Comorbidities
  • Multiple medications
  • Physical frailty
  • Cognitive or sensory deficits
  • Start LOW, Go SLOW

Critical Care Nursing (15 decks)

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