NURS 418 - Comfort & Sedation

acute

_____ pain is accompanied by a high level of autonomic arousal

acute

_____ pain is associated with tissue pathology, injury, or surgery

the patient's self-report

the most reliable indicator of the existence and intensity of adult pain

1. numeric pain rating scale

2. visual analog scale

3. verbal intensity pain scale

4. faces pain scale

5. critical care pain observation tool

pain scales (5)

1. selecting the appropriate analgesic

2. evaluating when to administer the analgesic

3. evaluating how much to administer

4. obtaining a change in prescription when needed

nursing management of acute pain (4)

1. scheduled analgesia

2. infusion when control is difficult with scheduled doses

3. use of slow release medications for de-intensifying therapy and providing baseline analgesia

4. use of multiple approaches

Society of Critical Care Medicine (SCCM) recommendations for pain management (4)

1. preventive

2. titration

two approaches to pain management

preventive

approach to pain management: analgesics are administered before the patient complains of pain

preventive

approach to pain management: administering around the clock instead of PRN

titration

approach to pain management: adjusting and individualizing therapy based on the effect the drug is having on the patient

1. reduces the stress response

2. improves patient comfort

3. decreases anxiety

4. increases participation in care (to a point)

benefits of analgesics (4)

1. respiratory depression

2. GI motility reduction

3. additive sedation

4. nausea and vomiting

5. pruritus

risks of analgesics (5)

adjuvant therapy

drugs that have a primary indication other than pain (i.e., anticonvulsants, antidepressants, muscle relaxants) but acts as an analgesic for some conditions

1. morphine (Duramorph, MS Contin, Roxanol)

2. fentanyl (Sublimaze, Duragesic)

3. hydromorphone (Dilaudid)

4. meperidine (Demerol)

opioid analgesics (4)

morphine (Duramorph, MS Contin, Roxanol)

opioid analgesic: the gold standard for pain management in most cases

1. morphine (Duramorph, MS Contin, Roxanol)

2. meperidine (Demerol)

opioid analgesics: has active metabolites that can accumulate with renal insufficiency and lead to prolonged sedation (2)

morphine (Duramorph, MS Contin, Roxanol)

opioid analgesic: causes direct vasodilation

fentanyl (Sublimaze, Duragesic)

opioid analgesic: has a rapid onset of action for patients in acute distress

fentanyl (Sublimaze, Duragesic)

opioid analgesic: 100x the potency of Morphine (1/100 dose of Morphine)

1. fentanyl (Sublimaze, Duragesic)

2. hydromorphone (Dilaudid)

opioid analgesics: lacks active metabolites, good for patients with renal insufficiency (2)

hydromorphone (Dilaudid)

opioid analgesic: longer duration of analgesia, lasts longer than Morphine and Fentanyl

meperidine (Demerol)

opioid analgesic: a CNS stimulant, causing tremors, agitation, psychosis, and seizures

meperidine (Demerol)

opioid analgesic: not commonly prescribed, research recommends against the use of it

1. PCA pump (morphine/hydromorphone)

2. epidural (fentanyl/bupivacaine)

3. on-Q ball

alternate pain control methods (3)

1. ketorolac (Toradol)

2. acetaminophen (Ofirmev)

non-narcotic analgesics (2)

ketorolac (Toradol)

non-narcotic analgesic: 350x stronger than Aspirin

ketorolac (Toradol)

non-narcotic analgesic: opioid sparing (can be used in combination with lower amounts of opioids to help patients experience similar pain relief)

ketorolac (Toradol)

non-narcotic analgesic: change dose r/t renal function and age, use caution in older adults and patients with renal insufficiency

ketorolac (Toradol)

non-narcotic analgesic: should NOT be taken for longer than 5 days due to an increase in bleeding risk and an increase in renal indices

acetaminophen (Ofirmev)

non-narcotic analgesic: IV drip (1000 mg/100 mL)

1. mild to moderate pain in adults and pediatrics > age 2

2. moderate to severe pain with an opioid in adults and pediatrics > age 2

3. reduction of fever in adults and pediatrics

indications for acetaminophen (Ofirmev) (3)

1. nalbuphine (Nubain)

2. buprenorphine (Buprenex)

3. butorphanol (Stadol)

agonist-antagonist analgesics (3)

agonist-antagonist analgesics (Nubain, Buprenex, Stadol)

analgesic class: may precipitate withdrawal in chronic opioid users, use caution

1. morphine (MS Contin)

2. fentanyl (Sublimaze)

3. hydromorphone (Dilaudid)

according to the SCCM clinical practice guidelines on pain management, if IV analgesia is required, _____ are recommended agents (3)

fentanyl (Sublimaze, Duragesic)

according to the SCCM clinical practice guidelines on pain management, _____ is preferred for rapid onset of analgesia in acutely distressed patients

1. fentanyl (Sublimaze, Duragesic)

2. hydromorphone (Dilaudid)

according to the SCCM clinical practice guidelines on pain management, _____ is best for hemodynamic instability or renal insufficiency (2)

1. morphine (Duramorph, MS Contin, Roxanol)

2. hydromorphone (Dilaudid)

according to the SCCM clinical practice guidelines on pain management, _____ are preferred for intermittent therapy because of their longer duration of action

equianalgesia

refers to the doses of various analgesics that are estimated to provide the same amount of pain relief

oligoanalgesia

the practice of treating pain with minimal drug use

1. fear of addiction

2. fear of physical dependence

3. fear of tolerance

4. fear of respiratory depression

common misconceptions regarding opiate use that contributes to inadequate treatment of pain (4)

to have a calm patient that can be easily aroused with the maintenance of a normal sleep schedule

what is the goal of sedation?

1. rule out other causes for the behaviors (e.g., hypoxia, hypoglycemia, sensory overload, drug interactions, sleep deprivation, pain, fear)

2. once other causes are ruled out, move to medications with a plan

3. most desirable to have PRN orders for sedation

Society of Critical Care Medicine (SCCM) recommendations for sedation (3)

1. sedation-agitation scale

2. motor activity assessment scale

sedation scales (2)

1. midazolam (Versed)

2. diazepam (Valium)

3. lorazepam (Ativan)

benzodiazepines for sedation (3)

midazolam (Versed)

benzodiazepine for sedation: very short-acting, commonly used for cardioversion

lorazepam (Ativan)

benzodiazepine for sedation: recommended for long-term sedation

1. propofol (Diprivan)

2. dexmedetomidine (Precedex)

non-benzodiazepines for sedation (2)

propofol (Diprivan)

non-benzodiazepine for sedation: induces a state of deep sedation in low doses

propofol (Diprivan)

non-benzodiazepine for sedation: has a short half-life, the patient can be fully conscious within 30 min after stopping the drip

propofol (Diprivan)

non-benzodiazepine for sedation: slows cerebral metabolism and decreases ICP

propofol (Diprivan)

non-benzodiazepine for sedation: not a reliable amnesic

propofol (Diprivan)

non-benzodiazepine for sedation: has a high lipid content, delivers 1.1 kcal/mL as fat

propofol (Diprivan)

non-benzodiazepine for sedation: all tubing and solution must be changed q 12 hr

propofol (Diprivan)

non-benzodiazepine for sedation: patient must be intubated

allergy to eggs, egg products, and soy

contraindication of propofol (Diprivan)

propofol-related infusion syndrome (PRIS)

rare, generally associated with high doses and prolonged use of propofol (Diprivan)

1. acute refractory bradycardia

2. severe metabolic acidosis

3. cardiovascular collapse

4. rhabdomyolysis

5. hyperlipidemia

6. renal failure

7. hepatomegaly

clinical manifestations of propofol-related infusion syndrome (PRIS) (7)

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: centrally acting selective alpha-2 receptor agonist

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: a short-term sedative for mechanically ventilated patients (max 24 hours)

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: decreases norepinephrine levels

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: reduces brain noradrenergic activity

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: decreases blood pressure and heart rate

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: reduces the need for add-on Morphine

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: provides little amnesic effects

dexmedetomidine (Precedex)

non-benzodiazepine for sedation: use caution in diabetic patients r/t more pronounced hypotension and decreased sympathetic response (bradycardia)

1. light sedation (i.e., anxiolytic)

2. moderate sedation (i.e., conscious sedation, procedural sedation)

3. deep sedation and analgesia

4. general anesthesia

levels of sedation (4)

light sedation

level of sedation: minimal sedation, anxiolysis

light sedation

level of sedation: patient follows commands

moderate sedation (i.e., conscious sedation, procedural sedation)

level of sedation: depression of consciousness during which patients respond purposefully to verbal commands

deep sedation and analgesia

level of sedation: depression of consciousness during which patient cannot be easily aroused but may respond purposefully after repeated painful stimulation

general anesthesia

level of sedation: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation

general anesthesia

level of sedation: positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function

general anesthesia

level of sedation: cardiovascular function may be impaired

oversedation

a state of unintended patient unresponsiveness in which the patient resides in a state of suspended animation that resembles general anesthesia

moderate sedation (i.e., conscious sedation, procedural sedation)

level of sedation: goal is to minimize discomfort while reducing undesirable autonomic responses to painful stimuli, or to help a patient through a procedure that requires that they remain still for an extended period

I, II, or III

adult patients classified as ASA Status _____ are appropriate for administration of mild to moderate sedation by a qualified RN

I or II

pediatric patients classified as ASA Status _____ are appropriate for administration of mild to moderate sedation by a qualified RN

IV or V

adult patients classified as ASA Status _____ are NOT appropriate for administration of mild to moderate sedation by an RN and should have an anesthesia provider responsible for care

III, IV, or V

pediatric patients classified as ASA Status _____ are NOT appropriate for administration of mild to moderate sedation by an RN and should have an anesthesia provider responsible for care

status I

ASA physical status: a normal healthy patient

status II

ASA physical status: a patient with mild systemic disease

status III

ASA physical status: a patient with severe systemic disease

status IV

ASA physical status: a patient with severe systemic disease that is a constant threat to life

status V

ASA physical status: a moribund patient who is not expected to survive without the operation

status VI

ASA physical status: a declared brain-dead patient whose organs are being removed for donor purposes

ASA classification system

the purpose of the _____ is simply to assess the degree of a patient's sickness or physical state prior to selecting the anesthetic or prior to performing surgery

naloxone (Narcan)

reverses opioid agonists

1-3 min

onset of action for IV doses of naloxone (Narcan)

10-15 min

onset of action for IM doses of naloxone (Narcan)

1. rebound sedation may occur

2. if used in patients with chronic opioid use, will precipitate acute withdrawal and abrupt sympathetic discharge possibly leading to acute pulmonary edema

nursing considerations for naloxone (Narcan) (3)

flumazenil (Romazicon)

reverses benzodiazepines

1. rebound sedation may occur

2. if used in patients with chronic benzodiazepine use, will precipitate acute withdrawal

3. may precipitate seizures unresponsive to benzodiazepines

nursing considerations for flumazenil (Romazicon) (3)

delirium

occurs in up to 87% of mechanically ventilated patients in the ICU. associated with increased mortality, ICU stay, and healthcare costs

1. reduced awareness of the environment

2. poor thinking skills (cognitive impairment)

3. behavior changes

clinical manifestations of delirium (3)

1. correct cause if identified

2. haloperidol (Haldol)

3. olanzapine (Zyprexa)

treatment of delirium (3)

1. extrapyramidal symptoms (EPS)

2. neuroleptic malignant syndrome

3. prolongs the QT interval

adverse effects of haloperidol (Haldol) (3)

Parkinson's

the use of haloperidol (Haldol) should be avoided in patient's with _____

haloperidol (Haldol)

treatment of delirium: avoid use in patients with Parkinson's

haloperidol (Haldol)

treatment of delirium: prolongs the QT interval