Topic 2 Sedation Flashcards
Transmission of pain signals into the brainstem, thalamus, and cerebral cortex by way of the?
“fast” pain pathway and “slow” pain pathway
Predisposing Factors of Pain
•Disease, procedures, monitoring devices, nursing care, trauma
•Many factors influence pain perception
- Expectation
- Previous pain experiences
- Emotional state
- Cognitive status
Predisposing Factors of Anxiety
•Inability to communicate, noise, light, excess stimulation
•Examples include?
- Endotracheal tube
- Monitor alarms
- Lack of mobility
- Unfamiliar surroundings
- Uncomfortable room temperature • Sleep deprivation
Acute pain activates?
•Chronic pain?
Acute pain activates sympathetic nervous system •Chronic pain, less activation
- Acute pain travels via?
* Chronic pain travels via?
- Acute pain travels via A-delta fibers
* Chronic pain travels via C fibers
most abundant receptors?
Nociceptors most abundant receptors
• Mechanical stimuli
• Chemical stimuli
• Thermal stimuli
Physiology of Anxiety
- Anxiety is confined within the brain
* Purely psychogenic disorder; no actual tissue damage •Linked to reward and punishment center
Positive Effects of Pain/Anxiety
- Increases performance levels
- Removes one from potential harm
- Fight-or-flight response
Negative Effects of Pain/Anxiety
- 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.
Assessment of Pain
- 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.
Subjective Assessment Tools
•Characteristics of pain?
- Precipitating cause
- Severity
- Location and radiation
- Duration
- Alleviating or aggravating factors
Subjective PQRST
Chest pain characteristics
P = provocation or position Q = quality R = radiation S = severity or associated symptoms T = timing or triggers
Subjective Assessment Tools (4)
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
Objective Assessment Tools
•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
Assessment of Agitation
Hyperactive psychomotor functions
Treatment of Agitation
- Hyperactive psychomotor functions • Tachycardia • Hypertension • Movement - Treatment of Agitation •Sedate to limit hyperactive psychomotor functions. •Low dose
Sedation Assessment—Tools
- 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
Continuous Monitoring of Sedation
•Assess brain activity
•Application of EEG to bedside
•Interpretation of values
- 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
Key word: inattention
Delirium
Delirium
- Acutely changing mental status
- Key word: inattention
- Types
- Hyperactive—agitated, combative, disoriented
- Hypoactive—quiet delirium
- Mixed—fluctuating between the two
- Many risks
ABCDE Bundle for Preventing Delirium
- Awakening
- Breathing Coordination
- Choice of Sedation
- Delirium monitoring
- Early mobility and exercise
Delirium
•Assessment
- 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
Nonpharmacological Management of pain
- Environmental manipulation
- Guided imagery
- Music therapy
- Aromatherapy
- Animal-assisted therapy
Management—Opioids
- 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
Opioids Concerns
- Respiratory depression
- Hypotension
- CNS depression
- Hallucinations
- Constipation (gastric ileus and retention)
- Geriatric
Patient-Controlled Analgesia (PCA)
- 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
Management—Epidural
And Contraindications
•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
Spinal Analgesia Side Effects
- Spinal analgesia
- Spinal analgesia with local anesthetics
- 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
Management—NSAIDs and Acetaminophen
•NSAIDs may decrease need of opioid
•Risks of GI bleeding and renal (ibuprofen) or liver
(acetaminophen) insufficiency
intravenous form of acetaminophen
Ofirmev
Analgesics
- 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
Management—Sedatives
- Pharmacological treatment for anxiety
- Benzodiazepines
- Propofol
- Dexmedetomidine
- Titrate to an end point (sedation scales or tools)
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
D. Intravenous nonsteroidal agent
Neuromuscular Blockade-paralysis
•Indications
-Monitor with?
- 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
Nursing Care for Neuromuscular Blockade
- 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
Management Challenges
•Invasive procedures
- Substance abuse
- Restraining devices
- invasive procedures • Procedural or conscious sedation - Substance abuse • May have higher-than-normal threshold • Alcohol withdrawal syndrome (AWS) - Restraining devices • Complications from immobility
Management Challenges for Elderly patients
- Physical changes associated with aging
- Comorbidities
- Multiple medications
- Physical frailty
- Cognitive or sensory deficits
- Start LOW, Go SLOW
