Module 1 - Critical Care Assessment Tools

Which pain assessment tool scores facial expression, upper limb movement, and compliance with ventilation on a scale of 1–4?

Behavioral Pain Scale (BPS)

Which patients are most appropriate for use of the Behavioral Pain Scale (BPS)?

Mechanically ventilated, critically ill patients who cannot self-report pain

The CPOT assesses pain using which scoring range?

0-2

Which components are assessed by the CPOT?

Facial expressions, body movements, muscle tension in upper extremities, compliance with the ventilator, and vocalization (if not ventilated)

A nonverbal ICU patient is not mechanically ventilated. Which CPOT category becomes relevant?

Vocalization

Which sedation scale ranges from +4 (combative) to –5 (unarousable)?

Richmond Agitation-Sedation Scale (RASS)

What is the primary clinical purpose of the RASS?

To determine and titrate sedation levels

Which assessment tool is used to screen for delirium in ICU patients?

CAM-ICU

What four features define delirium in the CAM-ICU?

Acute change or fluctuation in mental status, inattention, altered level of consciousness, and disorganized thinking

Which document specifies what treatments a patient wants or wants withheld?

Living Will

What is the primary purpose of a Power of Attorney (POA) for Healthcare?

To designate who makes medical decisions when the patient cannot

Which statement about POLST is correct?

POLST forms are legally binding medical orders

Who must produce a valid POLST form?

The patient or family (with clinician involvement)

How does a POLST differ from an advance directive?

It translates patient wishes into actionable medical orders, often including DNR status

When considering end-of-life decisions, the nurse should focus on which key concepts?

Patient and family rights, quality of life, and impact of technology

Which is an example of ordinary care?

Basic nutrition, hydration, or antibiotics

Which treatment is considered extraordinary care?

Dialysis or ACLS → Why? BC they impose severe physical, emotional, or financial burdens.

How does extraordinary care differ from ordinary care?

It is complex, invasive, or experimental

What is the most common withdrawal intervention at end of life?

Terminal weaning from mechanical ventilation

Which methods may be used during terminal weaning?

Titration to minimal ventilator settings, ventilator removal without airway removal, or complete extubation

During terminal weaning, medications should be titrated to relieve which symptoms?

Tachypnea, dyspnea, and accessory muscle use

Morphine is commonly used at end of life to manage which symptoms?

Anxiety, dyspnea, and pain

How does morphine reduce pain?

By depressing pain impulse transmission at the spinal cord via opioid receptors

What is the antidote for morphine overdose?

Naloxone

Which adverse effects are associated with morphine?

Constipation, hypotension, itching/rash, nausea/vomiting, respiratory depression, urinary retention

Which nursing intervention is essential when administering a morphine infusion?

Monitor blood pressure, heart rate, and respiratory status

Why should morphine be avoided in patients with renal failure?

Risk of drug accumulation and toxicity

Why should morphine be tapered gradually?

To prevent withdrawal symptoms

Midazolam acts by depressing which part of the CNS?

Subcortical level → brain structures beneath the cerebral cortex

Midazolam is commonly used for which indications?

Acute agitation, procedural sedation, and rapid sequence intubation

Which adverse effects are associated with midazolam?

CNS depression, hypotension, paradoxical agitation, respiratory depression

What is an important delirium-related concern with midazolam?

High risk of delirium

How should midazolam be titrated in ICU patients?

By 25–50% increments using a sedation scale

Lorazepam produces sedation by potentiating which neurotransmitter?

GABA

Lorazepam may cause which serious metabolic complication with prolonged IV use?

Hyperosmolar metabolic acidosis

Compared with midazolam, lorazepam causes what effect on blood pressure?

A less hypotensive effect

Which nursing actions are important when administering IV lorazepam?

Use low doses in older adults, avoid small veins, monitor acid-base balance, BP, and respiratory status

Which ethical principle supports a patient’s right to make their own medical decisions?

Autonomy

The duty to promote good and prevent harm reflects which principle?

Beneficence

“Do no harm” best describes which ethical principle?

Nonmaleficence

Fair distribution of healthcare resources is known as which ethical principle?

Justice

Truthfulness in communication with patients reflects which principle?

Veracity

Keeping promises to patients demonstrates which ethical principle?

Fidelity

Protecting patient information reflects which ethical principle?

Confidentiality

What is a priority nursing intervention to reduce ICU delirium?

Allowing uninterrupted sleep periods

How can nurses reduce sensory overload in ICU patients?

Reduce noise and light stimulation

Which items help promote patient reorientation in the ICU?

Clocks, calendars, and windows

How can family members assist with ICU patient reorientation?

Bringing meaningful items such as photographs