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Description : Check out this medical PowerPoint presentation titled "Comfort and Sedation".

This medical PowerPoint presentation talks about Comfort and Sedation. Comfort and sedation are related concepts, but they are not exactly the same thing. Comfort refers to a state of physical and emotional well-being, free from pain, discomfort, and distress. Sedation, on the other hand, refers to a state of reduced consciousness or awareness, often induced by medication.

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Published on : Mar 16, 2023 | Views : 769 | Downloads : 1

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Slide 1-

Chapter 5 Comfort and Sedation Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Introduction Pain occurs from a variety of causes Goal—optimal level of comfort Pain leads to complications, such as sleep deprivation, agitation, and PTSD Pain is the fifth vital sign Individualize management of pain and anxiety to targeted outcomes
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Pain and Anxiety Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain 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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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Pain and Anxiety(continued) Difficult to differentiate pain and anxiety Relationship is cyclical; one may exacerbate the other Figure 5-1. The anxiety-pain cycle. (From Cullen L, Greiner J, Titler MG. Pain management in the culture of critical care. Critical Care Nursing Clinics of North America. 2001;13[2]:151-166.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Predisposing Factors of Pain Disease, procedures, monitoring devices, nursing care, trauma Many factors influence pain perception Expectation Previous pain experiences Emotional state Cognitive status
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Predisposing Factors of Anxiety Inability to communicate, noise, light, excess stimulation Examples Endotracheal tube Monitor alarms Lack of mobility Unfamiliar surroundings Sleep deprivation
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Physiology of Pain Pain travels nervous system to the brain Acute pain activates sympathetic nervous system Chronic pain, less activation Acute pain travels via A-delta fibers Chronic pain travels via C fibers
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Physiology of Pain(continued) Nociceptors most abundant receptors Mechanical stimuli Chemical stimuli Thermal stimuli Very little adaptation to pain Initiation of the inflammatory response to tissue injury
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Transmission of Pain Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Figure 5-2. Transmission of pain signals into the brainstem, thalamus, and cerebral cortex by way of the “fast” pain pathway and “slow” pain pathway. (From Guyton A, Hall J. Textbook of Medical Physiology. 12th ed. Philadelphia: Saunders; 2011.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Physiology of Anxiety Anxiety is confined within the brain Purely psychogenic disorder; no actual tissue damage Linked to reward and punishment center
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Positive Effects of Pain/Anxiety Increases performance levels Removes one from potential harm Fight-or-flight response
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Negative Effects of Pain/Anxiety Raises catecholamines Tachycardia and hypertension Interference with healing Increased oxygen consumption End-organ ischemia Increased respiratory effort and hyperventilation
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Five-Step Assessment of Pain American Pain Society Guidelines Assess and treat promptly; document 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
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Critical Thinking Challenge Why is pain assessment more challenging in critically ill patients?
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Subjective Assessment Tools Characteristics of pain Precipitating cause Severity Location and radiation Duration Alleviating or aggravating factors
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 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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Quick Quiz! The nurse asks a patient with chest pain if it travels to the neck or shoulders. This is an assessment of: Position Quality Radiation Severity Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Subjective Assessment Tools Pain score, 0 to 10 rating scale 0 = No pain 10 = Worst pain imaginable FACES scale, series of faces from happy to distressed 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
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Critical Thinking Challenge Which pain scales do you believe would work best in critically ill patients?
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Objective Assessment Tools For patients who cannot communicate, no objective tool completely reflects patients’ pain level Examples Behavioral Pain Scale (Table 5-2) Critical-Care Pain Observation Tool (Table 5-3) Checklist of Nonverbal Pain Indicators
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Behavioral Pain Scale Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21
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Critical-Care Pain Observation Tool Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Critical Thinking Challenge Compare and contrast observations of pain using the Behavioral Pain Scale (see Table 5-2) and Critical-Care Pain Observation Tool (see Table 5-3).
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Sedation Assessment—Tools Sedation medication is given to reduce symptoms; dose is adjusted based on tools or scales Richmond Agitation-Sedation Scale (RASS) Ramsey Sedation Scale (Ramsey) Sedation-Agitation Scale (SAS; Riker) Interobserver agreement in assessment using various scales is important
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Critical Thinking Challenge Compare and contrast sedation scales: Richmond Agitation-Sedation Scale (see Table 5-4). Ramsay Sedation Scale (see Table 5-5). Sedation-Agitation Scale (see Table 5-6).
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Continuous Monitoring of Sedation Assess brain activity Electroencephalogram (EEG) 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
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Bispectral Index Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Figure 5-5. The Bispectral Index (BIS) monitor and electrode. (Image used by permission of Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Delirium Acutely changing mental status Key word: inattention Types Hyperactive—agitated, combative, disoriented Hypoactive—quiet delirium Mixed—fluctuating between the two Many risks (Box 5-3)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Delirium Assessment Confusion Assessment Method for the ICU (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC) Goal—keep the patient safe Drug of choice—haloperidol
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ABCDE Bundle for Preventing Delirium Awakening Breathing Coordination Choice of Sedation Delirium monitoring Early mobility and exercise Resource: www.icudelirium.org Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Neuromuscular Blockade Indications Facilitate treatment or procedures, including emergency or difficult intubation Improve tolerance of mechanical ventilation, especially non-traditional modes Manage elevated ICP No sedative or analgesic properties Must provide sedation! Monitor level with train-of-four (TOF) Peripheral nerve stimulator
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Nursing Care Neuromuscular Blockade 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
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Quick Quiz! To assess patients for delirium, which term is most helpful in initial assessment? Combative Inattention Paranoid Wild Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33
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Peripheral Nerve Stimulator Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Figure 5-6. A train-of-four peripheral nerve stimulator. (Courtesy Fisher & Paykel Healthcare, Auckland, New Zealand.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Management of Pain and Anxiety
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Nonpharmacological Management Environmental manipulation Guided imagery Music therapy Critical Thinking Challenge Discuss how these strategies can be implemented in the critical care setting.
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37 Preventing Pain Is More Effective Than Treating Pain
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38 Management—Opioids Rapid onset, ease of titration, lack of accumulation, low cost Fentanyl—fastest onset Morphine—longer duration Hydromorphone Concerns Respiratory depression Hypotension Administration: IV bolus, IV infusions, PCA, patch (fentanyl)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 39 Management—Epidural Opioid or local anesthetic Facilitates mobility and pulmonary hygiene
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 40 Management—NSAIDs NSAIDs may decrease need of opioid Risks of GI bleeding and renal (ibuprofen) or liver (acetaminophen) insufficiency
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 41 Management—Sedatives Pharmacological treatment for anxiety Benzodiazepines Propofol Dexmedetomidine Titrate to an end point (sedation scales or tools)
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Quick Quiz! The nurse is concerned about administering opioid medication to a patient in pain since the patient is weaning from mechanical ventilation. The nurse consults with the clinical pharmacist who suggests trying a/an: Neuromuscular blockade PCA pump with fentanyl Sedative such as lorazepam (Ativan) Intravenous nonsteroidal agent Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 42
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Patient-Controlled Analgesia 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 Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 43
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 44 Management Challenges Invasive procedures Procedural or conscious sedation Review Figure 5-11 Substance abuse May have higher than normal threshold Alcohol withdrawal syndrome (AWS) Restraining devices Complications from immobility
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 45 Management Challenges(continued) Elderly patients Comorbidities Multiple medications Physical frailty Cognitive or sensory deficits
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 46 Algorithm for Sedation Management Figure 5-8. Sample algorithm of sedation guidelines. (Courtesy Cleveland Clinic, Cleveland, Ohio.)