chapter five comfort & sedation class notes

8/10/2019 Chapter Five Comfort & Sedation CLASS NOTES

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C H A P T E R 5

C A R O L D I A N E E P S T E I N , P H D , R N , F C C M

Comfort and Sedation


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Slide 2

Introduction

Pain occurs from a variety ofcauses

Goaloptimal level ofcomfort

Pain leads to complicationssuch as sleep deprivation,agitation, and PTSD

Pain is the fifth vital sign

Individualize managementof pain and anxiety totargeted outcomes


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Slide 3

Pain and Anxiety

Difficult to differentiate pain and anxiety Relationship is cyclic; one may exacerbate the other

See Figure 5-1

Pain

Unpleasant sensory and emotional experience associated withactual or potential tissue damage

It is what the patient says it is

Anxiety

Prolonged state of apprehension in response to fear

Marked by apprehension, agitation, and autonomic arousal


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Slide 4

Predisposing Factors

Influence of pain perception Expectation

Previous pain experiences

Emotional state

Cognitive status

Influences anxiety

Inability to communicate

Noise and sensory overload

Lack of mobility Unfamiliar surroundings

Sleep deprivation

Circumstances leading to ICU admit


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Slide 5

Physiology

Pain travels nervous system to the brain Acute pain activates sympathetic nervous system

via A-delta fibers

Chronic pain, less activation, via C fibers

Nociceptors most abundant receptors Mechanical stimuli

Chemical stimuli

Thermal stimuli

Very little adaptation to pain

Initiation of the inflammatory response to tissueinjury


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Slide 7

Negative Effects of Pain/Anxiety

Raises catecholamines (NE causestachychardia and HTN)

Tachycardia and hypertension

Interference with healingwound healing and general

recovery is slowed down. Increased oxygen consumptionEnd-organ ischemia, tissuesrobbed of needed oxygen.

Increased respiratory effort and

hyperventilationACID BASEISSUES, look them up.


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Slide 8

5-Step Assessment of Pain ***

American Pain Society Guidelines, cant skipany of these steps.

Assess and treat promptly; document

Engage patient in management planProvide preemptive treatment, aka

treatment of pain before it starts. want tobring the level down and keep a

therapeutic serum level steady.

Reassess and treat to meet patients needs

Institute quality improvement plan

related to practice and outcomes


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Slide 9

Critical Thinking Challenge

Why is pain assessment more challengingin critically ill patients? Because they canttell you they are in pain due to tubes and

drains etc. Patients are often heavilysedated and disoriented.

What issues have been identified withnursing assessment and management of

pain in critically ill patients?


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Slide10

Subjective Assessment Tools

Characteristic ofpain

Precipitating cause

SeverityLocation and

radiation

Duration

Alleviating oraggravating factors


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Slide11

Subjective PQRST ****

Chest pain characteristics

P = provocation or position

Q = quality R = radiation

S = severity or associated symptoms

T = timing or triggers


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Slide12

Subjective Assessment Tools

Pain score, 0 to 10 rating scale 0 = No pain

10 = Worst pain imaginable

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

FACES scale, series of faces from happy to distressed

ALWAYS ASSESS PAIN IN A TIMELY MANNER.WITHIN THIRTY MNTES AFTER GIVINGMEDICATION ETC.


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Slide13

Objective Assessment Tools

For patients who cannot communicate, no objective toolcompletely reflects patients pain level

1. Behavioral Pain Scale (Table 5-2): validated only in MVpatients: in sedated & nonverbal

3 categories2. Critical-Care Pain Observation Tool (See Table 5-3):

with or without ET tube

5 categories

3. FLACC (Face, Legs, Activity, Cry, Consolability) scale:QSEN Exemplar: pediatrics, cognitively impaired, &critically ill

4. Goal is to get between 40 and 60 on some thing.


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Slide14

Sedation AssessmentTools

Sedation medication is given to reducesymptoms; dose is adjusted based on tools orscales Richmond Agitation-Sedation Scale (RASS)

Ramsey Sedation Scale (Ramsey)

Sedation-Agitation Scale (SAS)

Inter-observer agreement in assessment

using various scales is important No tool is considered the gold standard

Goal is calm, easily aroused patient


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Slide15

Sedation AssessmentTechnology

Assess physiological changes Electroencephalogram (EEG) rarely used for assessing

sedation levels

Video EEG @ bedside to monitor for seizure activity

Application of EEG to bedside: raw score Bispectral Index (BIS)

Patient State Index (PSI)

Interpretation of values

Values 0 (flat EEG) to 100 (awake)

40 to 60 deep sedation plus amnesia

Goal is


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Slide16

Goal is to get 40-60 percent on this.


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Slide17

Delirium

Acutely changing mental status Types

Hyperactiveagitated, combative, disoriented

Hypoactivequiet delirium

Mixedfluctuating between the two

Assessment

Confusion Assessment Method-ICU (CAM-ICU)

Goalkeep the patient safe

Drug of choicehaloperidol


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Risks (See Table 5-15)

Elsevier items and derived items 2009, 2005, 2001

by Saunders, an imprint of Elsevier Inc.

Slide18

Older than 70

Nursing home transfer

Hx dementia, depression, stroke

ETOH/substance abuse Electrolyte imbalance

Hypothermia or fever

Renal/liver failure

Cardiogenic/septic shock Rectal/bladder catheters

Physical restraints

Visual or hearing impairment


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Slide19

Neuromuscular Blockade: Therapeutic Paralysis

Indications: skeletal muscle paralysis (cannot breathe,needs to be mechanically ventilated)

Facilitate treatment or procedures, including emergencyor difficult intubation

Improve tolerance of mechanical ventilation, especiallynon-traditional modes

Manage elevated ICP

Tracrium, Succinylcholine

No sedative or analgesic properties Must provide sedation!

Monitor level with train of four (TOF) response(fig.5-6)

Peripheral nerve stimulator

ulnar or facial


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Slide20

Nursing Care: Neuromuscular Blockade

TOF testing: aim is 2 out of 4 twitches

Sedation

Care of immobile, paralyzed patient (Table 5-5):

Mechanical ventilation and airway management Eye lubrication use eye drops to prevent corneal

abrasion.

DVT prophylaxis

Repositioning and range of motion

Oral care essential as oral secretions have a lot ofgerms and bacteria in them.

Urinary catheter

Routine vital signs and assessments


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Slide21

Pain Management: Opioids

Rapid onset, ease of titration, lack of

accumulation, low cost Fentanylfastest onset

Morphinelonger duration

Hydromorphone

Concerns

Respiratory depression

Hypotension due to increased venouspressure.(CHECK THIS)

AdministrationIV bolus, IV infusions,PCA, patch (fentanyl)

Epidural: Opioid or local anesthetic

Facilitates mobility and pulmonary hygiene


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Slide22

Management Challenges

Invasive procedures Procedural or conscious sedation

Review Figure 5-9

Substance abuse

May have higher than normal threshold Alcohol withdrawal syndrome (AWS)

The ICU is not the place to offer rehab to a patient. Justtreat them and make sure to manage the painadequately.

Restraining devices

Complications from immobility

Algorithms for Sedation Management:

Review Figure 5-8

chapter five comfort & sedation class notes

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