Topic 2 Sedation

Question 1

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

Answer 1

“fast” pain pathway and “slow” pain pathway

Question 2

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

Answer 2

• Expectation
• Previous pain experiences
• Emotional state
• Cognitive status

Question 3

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

Answer 3

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

Question 4

Acute pain activates?

•Chronic pain?

Answer 4

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

Question 5

• Acute pain travels via?

* Chronic pain travels via?

Answer 5

• Acute pain travels via A-delta fibers

* Chronic pain travels via C fibers

Question 6

most abundant receptors?

Answer 6

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

Question 7

Physiology of Anxiety

Answer 7

• Anxiety is confined within the brain

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

Question 8

Positive Effects of Pain/Anxiety

Answer 8

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

Question 9

Negative Effects of Pain/Anxiety

Answer 9

• 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.

Question 10

Assessment of Pain

Answer 10

• 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.

Question 11

Subjective Assessment Tools

•Characteristics of pain?

Answer 11

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

Question 12

Subjective PQRST

Chest pain characteristics

Answer 12

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

Question 13

Subjective Assessment Tools (4)

Answer 13

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

Question 14

Objective Assessment Tools

Answer 14

•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

Question 15

Assessment of Agitation
Hyperactive psychomotor functions
Treatment of Agitation

Answer 15

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

Question 16

Sedation Assessment—Tools

Answer 16

• 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

Question 17

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

Answer 17

• 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

Question 18

Key word: inattention

Answer 18

Delirium

Question 19

Delirium

Answer 19

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

Question 20

ABCDE Bundle for Preventing Delirium

Answer 20

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

Question 21

Delirium

•Assessment

Answer 21

• 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

Question 22

Nonpharmacological Management of pain

Answer 22

• Environmental manipulation
• Guided imagery
• Music therapy
• Aromatherapy
• Animal-assisted therapy

Question 23

Management—Opioids

Answer 23

• 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

Question 24

Opioids Concerns

Answer 24

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

Question 25

Patient-Controlled Analgesia (PCA)

Answer 25

* 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

Question 26

Management—Epidural | And Contraindications

Answer 26

``` •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 ```

Question 27

Spinal Analgesia Side Effects - Spinal analgesia - Spinal analgesia with local anesthetics

Answer 27

``` - 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 ```

Question 28

Management—NSAIDs and Acetaminophen

Answer 28

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

Question 29

intravenous form of acetaminophen

Answer 29

Ofirmev

Question 30

Analgesics

Answer 30

* 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

Question 31

Management—Sedatives

Answer 31

* Pharmacological treatment for anxiety * Benzodiazepines * Propofol * Dexmedetomidine * Titrate to an end point (sedation scales or tools)

Question 32

``` 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 ```

Answer 32

D. Intravenous nonsteroidal agent

Question 33

Neuromuscular Blockade-paralysis •Indications -Monitor with?

Answer 33

``` - 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 ```

Question 34

Nursing Care for Neuromuscular Blockade

Answer 34

- 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

Question 35

Management Challenges •Invasive procedures * Substance abuse * Restraining devices

Answer 35

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

Question 36

Management Challenges for Elderly patients

Answer 36

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