Comfort and Sedation

CHAPTER 5
CAROL DIANE EPSTEIN, PHD, RN, FCCM

Introduction
Pain occurs from a variety of

causes
Goaloptimal 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

Slide 2

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 with

actual 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

Slide 3

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
Slide 4

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 tissue

injury

Slide 5

Physiology
Anxiety is confined within the brain
Purely psychogenic disorder; no actual tissue

damage
Linked to reward and punishment center
Increase performance levels
Removes one from potential harm
Fight-or-flight response

Slide 6

Negative Effects of Pain/Anxiety

Raises catecholamines (NE causes

tachychardia and HTN)

Tachycardia and hypertension
Interference with healing
wound healing and general
recovery is slowed down.
Increased oxygen consumption
End-organ ischemia, tissues
robbed of needed oxygen.
Increased respiratory effort and
hyperventilation ACID BASE
ISSUES, look them up.

Slide 7

5-Step Assessment of Pain ***

American Pain Society Guidelines, cant skip

any of these steps.

Assess and treat promptly; document
Engage patient in management plan
Provide preemptive treatment, aka
treatment of pain before it starts. want to
bring 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
Slideoutcomes
8

Critical Thinking Challenge

Why is pain assessment more challenging

in critically ill patients? Because they cant

tell you they are in pain due to tubes and
drains etc. Patients are often heavily
sedated and disoriented.
What issues have been identified with
nursing assessment and management of
pain in critically ill patients?

Slide 9

Subjective Assessment Tools

Characteristic of

pain
Precipitating cause
Severity
Location and
radiation
Duration
Alleviating or
aggravating factors
Slide
10

Subjective PQRST ****

Chest pain characteristics
P
Q
R
S
T

= provocation or position
= quality
= radiation
= severity or associated symptoms
= timing or triggers

Slide
11

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 GIVING

MEDICATION ETC.
Slide
12

Objective Assessment Tools

For patients who cannot communicate, no objective tool

completely reflects patients pain level

1. Behavioral Pain Scale (Table 5-2): validated only in MV
patients: in sedated & nonverbal
3 categories
2. 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.
Slide
13

Sedation AssessmentTools
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)

Inter-observer agreement in assessment

using various scales is important

No tool is considered the gold standard
Goal is calm, easily aroused patient
Slide
14

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 <60

Slide
15

Goal is to get 40-60 percent on this.

Slide
16

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
Slide
17

Risks (See Table 5-15)

Slide
18

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

Elsevier items and derived items 2009, 2005, 2001
by Saunders, an imprint of Elsevier Inc.

Neuromuscular Blockade: Therapeutic Paralysis

Indications: skeletal muscle paralysis (cannot breathe,

needs to be mechanically ventilated)

Facilitate treatment or procedures, including emergency
or difficult intubation
Improve tolerance of mechanical ventilation, especially
non-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)
Slide
Peripheral
ulnar or facial
Elsevier
items
and derived items 2009,nerve
2005, 2001 stimulator
19
by Saunders, an imprint of Elsevier Inc.

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 of
germs and bacteria in them.
Urinary catheter
Slide
Elsevier items and derived items 2009, 2005, 2001
20

Routine
vital
signs
and
assessments
by Saunders, an imprint of Elsevier Inc.

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 venous
pressure.(CHECK THIS)

AdministrationIV bolus, IV infusions,

PCA, patch (fentanyl)

Epidural: Opioid or local anesthetic

Slide
Facilitates mobility and pulmonary
hygiene

21

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. Just
treat them and make sure to manage the pain
adequately.

Restraining devices
Complications from immobility
Algorithms for Sedation Management:

Review Figure 5-8

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22