Download - 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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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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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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Goal is to get 40-60 percent on this.
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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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Elsevier items and derived items 2009, 2005, 2001
by Saunders, an imprint of Elsevier Inc.
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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Elsevier items and derived items 2009, 2005, 2001
by Saunders, an imprint of Elsevier Inc.
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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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