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
