4833 W3

What are the four levels of sedation?

1. Light (minimal): alert & responsive to verbal commands (RASS -2, SAS+4) - pharmacologic relief of anxiety (anxiolysis) 2. Moderate (procedural): procedural sedation (RASS -3, SAS+3) - pharmacologic depression of patient consciousness - often the target level when tubes or lines are to be inserted 3. Deep: unable to maintain an open airway (RASS -4, SAS+2) 4.General anesthesia (RASS -5, SAS+1) - using multiple medications - administered by a physician anesthesiologist or a nurse anesthetist

Lorazepam (Ativan), Diazepam (Valium), and Chlordiazepoxide (Librium) are all examples of ___[1]___. They are typically used in the treatment of ___[2]___.

1. Long acting benzodiazepines 2. Delirium tremens/seizures and (sometimes) routine sedation.

How can delirium tremens by pharmacologically managed?

1. Long-acting benzodiazepines: - diazepam, lorazepam 2. Librium® (Chlordiazepoxide): - for acute AWS - Oral form only. 3. Thiamine (Vit. B1) multivitamins: - prevent confusion, reduced memory, sleep disturbances, encephalopathy, ataxia, muscle atrophy, death ((benzodiazepines can be used for DT, but should not be used for any other type of delirium))

What are the three categories of pain pharmacology?

1. Opioid agonists (first line) 2. Non-Opioids 3. Adjuvants (antidepressants, anticonvulsants, etc.)

What was discovered in the "Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment" (SUPPORT) regarding end of life care?

1. Poor communication - 50% of physicians knew pts' preferences for CPR 2. Aggressive treatment - >1/3 of pts died at least 10 days after being in ICU 3. Inadequate pain control - 50% of pts reported moderate to severe pain during hospital stay

How Can delirium in the ICU be prevented?

1. Spontaneous awakening trials 2. Daily delirium monitoring 3. Early mobilization - may also prevent muscle weakness that accompanies bed rest during critical illness and may reduce cognitive complications associated with prolonged illness. 4. Sleep protocols 5. clustering nursing care 6. uninterrupted rest periods

Sedation vacations (spontaneous awakening trial) involve these steps:

1. Turn off sedative infusions once daily 2. Stop analgesics 3. Assess by using RASS/SAS 4. Assess neurologic function 5. Restart sedation if agitation occurs ((One strategy to avoid the pitfalls of sedative dependence and withdrawal is a planned strategy to turn off the sedative infusions once each day.))

The first step in assessing the agitated patient is to rule out any sensations of pain. What are three pain scales used in critical care?

1. Verbal pain scale of 0-10 (NRS): - If the patient can communicate, the verbal pain scale is very useful. 2. The Behavioral Pain Scale (BPS) 3. Critical-Care Pain Observation Tool (CPOT): - If the patient is intubated and cannot vocalize, pain assessment becomes considerably more complex. BPS and the CPOT are the most reliable behavioral pain scales for monitoring pain in critically ill adults.

No more than _____ grams of acetaminophen should be given in 24hrs.

4 (Can cause liver dysfunction)

3. C fibers are small-diameter, unmyelinated fibers that transmit what type of pain? A. Aching B. Sharp C. Prickling D. Concentrated

A C fibers are implicated in the transmission of pain described as dull, diffuse, prolonged, and delayed. Alpha fibers conduct the rapid acute pain sensation described as prickling, sharp, and fast. These fibers are activated by mechanical and thermal stimuli and are carried by the neospinothalamic tract.

7. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which complications? A. Urinary retention, undue somnolence, itching, nausea, and vomiting B. Urinary incontinence, photophobia, headache, and skin rash C. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus D. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain

A Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence, itching, seizures, nausea, and vomiting.

6. Which combinations of drugs has been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids B. NSAIDs and antidepressants C. Opioid agonists and opioid antagonists D. Adjuvants and partial agonists

A The use of nonsteroidal antiinflammatory drugs (NSAIDs) in combination with opioids is indicated in patients with acute musculoskeletal and soft tissue inflammation.

How is naloxone prescribed and given?

- 0.4mg IVP slowly (2min) - repeat 30min after 1st dose if needed

How does PCA bolus dosing work?

- Bolus injection or Continuous infusion w/ Bolus injection - Bolus lockout interval (1-4 hour limit)

Why might nonopiods be combined with opioids in critical care pts?

- Can reduce opioid requirements - increase analgesic effects

Delirium in the ICU can be assessed using these tools:

- Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) - Intensive Care Delirium Screening Checklist (ICDSC) ((Both instruments are used in tandem with the RASS to exclude patients in coma and identify delirium. ))

What are the side effects of fentanyl?

- Hemodynamic & Resp. responses (similar to morphine) - Bradycardia & chest wall muscle rigidity if a high dose is given rapidly

How does intraspinal pain control work and what types are there?

- Interfering the transmission of pain to CNS by binding opiate receptors TYPES: Intrathecal (subarachnoid) analgesia: - intraoperative use - placed directly into the cerebral spinal fluid - Quick, risk of serious infections Epidural analgesia: - penetrates the dura - Commonly used in ICU after major surgeries - hydrophilic or lipophilic - longer lasting

What are the two scales to assess sedation/agitation?

- Riker Sedation-Agitation Scale (SAS) - Richmond Agitation-Sedation Scale (RASS) ((Because individuals do not metabolize sedative medications at the same rate, the use of a standardized scale will ensure that continuous infusions of sedatives such as propofol or dexmedetomidine are titrated to a specific goal))

What does "equianalgesia" mean?

- To provide equal analgesic effects with new agents - Morphine is the standard for the conversion of opioids

Describe the nonopioid KETAMINE and its uses?

- a dissociative anesthetic agent w/ analgesic properties. - spares the respiratory drive - SE: release of catecholamines and delirium. - not recommended for routine therapy in critically ill patients.

What is Propofol (Diprivan) and what is it used for?

- a powerful sedative and respiratory depressant used for sedation in mechanically ventilated pts in critical care - In the CCU, propofol is prescribed as a continuous infusion at lower doses to induce a state of deep sedation. - used when a pt needs to be quickly awakened for a spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT), or to assess neurologic status. ((It is important to add an opiate to ensure adequate pain control and amnesia. Propofol is not a reliable amnesic, and patients sedated with only propofol can have vivid recollections of their experiences.))

Describe the nonopioid LIDOCAINE and its uses?

- anesthetic used for procedural/neuropathic/nonneuropathic pain - used with caution in patients with hepatic dysfunction

What are the complications associated with propofol?

- bacterial growth - Rhabdomyolysis - Release of intracellular toxic contents - disruption of fatty acid metabolism

What assessments would you expect in a patient with respiratory depression?

- decreased RR (<8 breaths/minute) - decreased Spo2 - decreased LOC - elevated ETco2

Why might NSAIDs be combined with opioids in critical care pts?

- indicated in the pt with acute musculoskeletal and soft tissue inflammation - KETOROLAC most commonly used in CCU (increases risk for kidney failure)

Propofol is lipid soluble, which means that. . .

- it quickly crosses cell membranes, including the blood-brain barrier. - rapid onset of sedation (~ 30 seconds), with immediate LOC - very short half-life (2-4 minutes) - rapidly eliminated (30-60 minutes) - does not have metabolites.

Describe the opioid methadone (Dolophine, Methadose) and its uses?

- morphine-like properties w/ less sedation - chronic pain, treat addiction to opioids - It is longer acting (4-8hr duration, 15-55hr half-life) than morphine - does not accumulate in patients with kidney failure. - Can prolong the QT interval (torsades de pointes)

Prolonged oversedation can lead to. . .

- pressure ulcers - thromboembolism - gastric ileus - ventilator-associated pneumonia - delayed weaning from mechanical ventilation - ↑ Delirium - ↓ Cognitive outcomes

Describe codeine (opioid analgesic) and its uses?

- rarely used in the CCU - for mild to moderate pain. - usually compounded with a nonopioid - metabolized in the liver - available only through PO, IM, and SQ (no IV use)

What is the major disadvantage of using bolus administration for pain meds?

- rise and fall of the serum opioid levels - periods of pain control with periods of breakthrough pain.

Clonidine (Catapres) is a ___[1]___ and is used for ___[2]___.

1) Central alpha-adrenergic agonist - ((alpha 2 agonist)) 2) Alcohol withdrawal syndrome (in patch form)

Dexmedetomidine (Precedex®) is a ___[1]___ and is used for ___[2]___. Complications for this medication include: ___[3]___.

1) Central alpha-adrenergic agonist - ((alpha 2 agonist)) 2) short-term sedation (<24 hours) in mechanically ventilated 3) bradycardia and hypotension.

Delirium in the ICU can also be called _____[1]_____ or ____[2]_____. Over ____[3]____ of mechanically ventilated patients experience this.

1) post icu syndrome 2) icu psychosis 3) half

Midazolam (Versed) is a _____[1]_____. When used for longer than 24hrs with continuous infusion, ______[2]______.

1) short acting benzodiazepine 2) the sedative effect is prolonged by its active metabolites.

How can alcohol dependence be screened? (what tools)

1. Alcohol Use Disorders Identification Test (AUDIT) - assess alcohol dependency 2. Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) - can assess the severity of alcohol withdrawal

What are the three types of sedation medications?

1. Benzodiazepines 2. Sedative-hypnotic agents - i.e. propofol - recommended 3. Central alpha-adrenergic receptor agonists - i.e. dexmedetomidine - recommended

What are the six barriers to pain assessment?

1. Communication 2. Altered level of consciousness (ALOC) 3. Older patients: Cognitive deficits or delirium 4. Cultural influences 5. Lack of knowledge: i.e. fear of addiction 6. Health professional's attitudes about pain/pain management

The antidote to reverse benzodiazepine overdose is ___[1]___. It should be used with caution because ___[2]___.

1. Flumanzenil (Romazicon) 2. patients with benzodiazepine dependence can have rapid withdrawal which can induce seizures and other adverse side effects.

4. Which assessment findings might indicate respiratory depression after opioid administration? A. Flushed, diaphoretic skin B. Shallow respirations with a rate of 24 breaths/min C. Tense, rigid posture D. Change in level of consciousness

D

Which phrase best describes the concept of pain? A. An uncomfortable experience only felt by patients with an intact nervous system B. An unpleasant experience accompanied by moaning, crying, and tachycardia C. Activation of the sympathetic nervous system from an injury D. Whatever the patient says it is, occurs when that patient says it does

D Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does.

How is delirium in the ICU treated pharmacologically? What should be monitored?

Delirium can be treated with: HALOPERIDOL - S/E: Prolonged Q-Tc interval, Vent. Dysrhythmias (MONITOR WITH ECG) - Contraindication: prolonged QTI, Torsades de pointes ATYPICAL ANTIPSYCHOTICS: - Risperidone (Risperdal®) - Quetiapine (Seroquel®) - Clozapine (Clozaril®) - etc. ((There is no prophylactic use of meds for delirium))

What is a common complaint of families of critically ill patients?

Dissatisfied with communication and decision-making - Insufficient physician communication -Unmet communication needs from aggressive care to end-of-life care

20. Which statements are true regarding pain assessment and management? (Select all that apply.) A. The single most important assessment tool available to the nurse is the patient's self-report. B. The only way to assess pain in patients unable to verbalize because of mechanical ventilation is through observation of behavioral indicators. C. The concept of equianalgesia uses morphine as a basis for dosage comparison for other medications. D. Transcutaneous electrical nerve stimulation and application of heat or cold therapy stimulate the nonpain sensory fibers. E. Meperidine, a synthetic form of morphine, is much stronger and is given at lower doses at less frequent intervals.

A, C, D

Morphine's water solubility allows it to have a slower onset of action ranging from __[A]__ minutes and a total duration of __[B]__ hours.

A. 5-10 B. 3-5

What are the four processes of nociception?

Transduction: noxious stimuli (Spinal cord) - refers to mechanical, thermal, or chemical stimuli that damage tissues. Stimuli are sources of pain that trigger the liberation of neurotransmitters. Transmission: CNS - As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach the brain. - muscle rigidity can appear because of a reflex activity. Perception: Interpretation - The pain message is transmitted by the spinothalamic pathways to centers in the brain, where it is perceived. Modulation: inhibit or enhance pain - process by which painful messages that travel from the nociceptive receptors to the CNS may be enhanced or inhibited.

What is visceral pain?

Visceral: organs (heart, stomach, liver)

16. The nurse is caring for a patient with a patient-controlled analgesia (PCA). The patient's spouse asks about the advantages of using this type of pain management therapy. What should the nurse say to the spouse? A. "The method allows the patient to act preemptively by administering a bolus of medication when pain begins." B. "This method allows the patient to choose between an opioid and a nonopioid medication to control pain." C. "This method decreases the risk of respiratory depression and other side effects." D. "This method allows for the rise and fall of the blood level of the opioid."

ANS: A The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient's pain does not respond within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects.

9. Which statement accurately describes the duration of acute pain? A. Acute pain is associated with the injury to the joints and lasts about 9 months. B. Acute pain is associated with the healing process and should not exceed 6 months. C. Acute pain is persistent pain of more than 6 months after the healing process. D. Acute pain is associated with damage to the nervous system and is of infinite duration.

ANS: B Acute pain has a short duration, and it usually corresponds to the healing process (30 days) but should not exceed 6 months. It implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response and lead to permanent damage to the patient's nervous system. In such instances, acute pain can become chronic.

13. Which patient is MOST likely to be experiencing a life-threatening opioid side effect? A. Patient with respiratory rate of 10 breaths/min who is breathing deeply B. Patient with a respiratory rate of 8 breaths/min who is difficult to arouse C. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min D. Patient with a temperature of 100.5°F who is asleep but easily roused

ANS: B Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate (fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient's level of consciousness or snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely.

14. The nurse is caring for a patient with moderate pain. What is the maximum dose of acetaminophen the patient should receive in 24 hours? A. 1 g B. 2 g C. 4 g D. 500 mg

ANS: B Special care must be taken for patients with liver dysfunction, malnutrition, or a history of excess alcohol consumption, and their acetaminophen total dose should not exceed 2 g/day.

15. A patient has been taking Demerol 50 mg tablets three times a day for the past 5 years for chronic back pain; however, the patient complains that the medication is not providing the same level of pain relief as it once did. Based on this statement, the nurse suspects that the patient has developed what problem? A. Addiction B. Tolerance C. Physical dependence D. Physical withdrawal

ANS: B The patient has developed a tolerance to the medication. Tolerance is defined as a diminution of opioid effects over time. Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief. Physical dependence to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped.

17. Relaxation, guided imagery, and music therapy are all examples what type of pain management? A. Physical techniques B. Cognitive-behavioral techniques C. Nonopioid analgesia D. Equianalgesia

ANS: B Using the cortical interpretation of pain as the foundation, several interventions can reduce the patient's pain report. These modalities include cognitive techniques such as relaxation, distraction, guided imagery, and music therapy.

18. The patient has received ketamine for its analgesic effects. The patient suddenly states, "I feel like I am floating and can see everything you are doing. I am not in control." What is this response called? A. Hallucination state B. Guided imagery C. Dissociative state D. Adverse event

ANS: C Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (eg, midazolam) can reduce the incidence of this unpleasant effect.

11. Why use a specific pain intensity scale in the critical care unit? A. It eliminates the subjective component from the assessment. B. It focuses on the objective component of the assessment. C. It provides consistency of assessment and management. D. It provides a way to interpret physiologic indicators.

ANS: C Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management, and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient's pain. However, the patient's tool preference should be considered.

10. A patient complains of pain at his incision site. The nurse is aware that four processes are involved in nociception. In what order do the processes occur? A. Transmission, perception, modulation, and transduction B. Perception, modulation, transduction, and transmission C. Modulation, transduction, transmission, and perception D. Transduction, transmission, perception, and modulation

ANS: D Four processes are involved in nociception: transduction, transmission, perception, and modulation.

8. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to closely monitoring the patient for side effects and complications, which intervention might enhance the patient's pain control? A. Maintain the patient flat in bed during the infusion. B. Position the patient on the right side to encourage flow of the medication across the dura. C. Limit visitors and remove any distractions such as television and music. D. Consider administration of adjunct medication such as a nonsteroidal anti-inflammatory agent.

ANS: D Positioning will not affect medication administration, distractions such as visitors and soothing music can often enhance the effects of pharmacologic pain control, adjuvant medications can help decrease anxiety, and nonopioid analgesics can provide greater pain relief at the peripheral and central levels. Instruct and guide patient through nonpharmacologic measures (eg, relaxation therapy, guided imagery, and biofeedback) to enhance pharmacologic effectiveness. The epidural space is filled with fatty tissue and is external to the dura mater. The fatty tissue interferes with uptake, and the dura acts as a barrier todiffusion, making diffusion rate difficult to predict.

12. The patient is sedated and breathing with the use of mechanical ventilation. The patient is unable to communicate any aspects of his pain to the nurse. What tool should the nurse use to assess the patient's pain? A. FLACC B. Wong-Baker FACES C. BIS D. BPS

ANS: D The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the critical care unit.

What does it mean when a pt has a high APACHE score?

Acute Physiology and Chronic Health Evaluation (APACHE): - acute physiology score + age points + chronic health points - Minimum score = 0; maximum score = 71. - High score: more severe disease & increased risk of death.

19. A nurse is administering naloxone to a patient experiencing respiratory depression. Which action should the nurse take while administering this medication? A. Give it rapidly via IV bolus at a rate of 0.5 mL over 15 seconds. B. Discontinue it as soon as the patient is responsive and able to take deep breaths. C. Repeat it as early as 5 minutes after the first dose if warranted. D. Mix 0.4 mg of naloxone with 5 mL normal saline.

B Naloxone is normally given intravenously very slowly (0.5 mL over 2 minutes) while the patient is carefully monitored for reversal of the respiratory signs. Naloxone administration can be discontinued as soon as the patient is responsive to physical stimulation and able to take deep breaths. However, the medication should be kept nearby. Because the duration of naloxone is shorter than most opioids, another dose of naloxone may be needed as early as 30 minutes after the first dose. The benefits of reversing respiratory depression with naloxone must be carefully weighed against the risk of a sudden onset of pain and the difficulty achieving pain relief. To prevent this from occurring, it is important to provide a nonopioid medication for pain relief. Moreover, the use of naloxone is not recommended after prolonged analgesia because it can induce withdrawal and may cause nausea and cardiovascular complications (eg, dysrhythmias).

2. What are the neural processes of encoding and processing noxious stimuli associated with pain called? A. Perception B. Nociception C. Transduction D. Transmission

B Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction refers to mechanical (eg, surgical incision), thermal (eg, burn), or chemical (eg, toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the nervous system (NS) pathway reaches the thalamus, and the pain sensation transmitted by the parasympathetic nervous system (PS) pathway reaches brainstem, hypothalamus, and thalamus. These parts of the central nervous system (CNS) contribute to the initial perception of pain.

Why are benzodiazepines not typically used for the sedation of mechanically ventilated adults?

Benzodiazepine-based sedative regimens are associated with: - worse patient outcomes - longer duration of mechanical ventilation - delirium.

How would a nonverbal, mechanically ventilated pt rate their pain?

By using the BEHAVIOR PAIN SCALE: - assigns numerical scores to a patient's facial expressions and body positions. The authors of the BPS determined a cutoff score >5 for the presence of pain.

How would a critically ill patient (verbal or not) rate their pain?

By using the CRITICAL CARE PAIN OBSERVATION TOOL: - assigns numerical values to patient facial expressions, body movements, compliance with the ventilator or vocalization in nonintubated patients, and muscle tension. A cutoff score >2 was established in postoperative adults in ICU.

5. The patient is admitted to the critical care unit with hemodynamic instability and an allergy to morphine. The nurse anticipates that the practitioner will order which medication for severe pain? A. Hydromorphone B. Codeine C. Fentanyl D. Methadone

C Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent than morphine. Hydromorphone produces an inactive metabolite (ie, hydromorphone-3-glucuronide), making it the opioid of choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid. Methadone is a synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This makes it difficult to titrate in the critical care patient.

Benzodiazepines should only be used to treat agitation if the patient displays ___________.

EXTREME agitation (SAS 7+, RASS +4) ((In the past when a patient was agitated, a benzodiazepine sedative (lorazepam or midazolam) was quickly administered to reduce the patient's mental awareness. However, because benzodiazepines have been shown to induce delirium, these medications are no longer recommended.))

_______ can be administered to manage acute agitation in sedated patients.

Haloperidol

Hydromorphone (Dilaudid) has a similar onset/duration as morphine. How do the two drugs differ?

Hydromorphone is 4-5x more potent.

What are the side effects of Morphine?

Hypotension Respiratory depression Cardiac instability Allergies Constipation

advance directive (living will)

Instructions by a resident about what steps to take or not to take to extend life as the resident approaches death.

Fentanyl has a rapid onset/duration because _______.

It is lipid soluble. Onset: immediate Duration: .5-1 hrs

What is the weakest opioid and why is it used?

MEPERIDINE (DEMEROL): - Short duration (1-2hr) - Used for shivering in PACU (Should not be given long term because it has CNS-toxic metabolites)

What is the most commonly prescribed opioid in the CCU?

MORPHINE

What are some causes of agitation in sedated patients?

Pain, anxiety, delirium, hypoxia, ventilator dyssynchrony, neurologic injury, uncomfortable position, full bladder, sleep deprivation, alcohol withdrawal, sepsis, medication reaction, organ failure

What is a POLST?

Physician orders for life-sustaining treatment (POLST): - Signed by a pt and their physician - Medical orders that are honored across all treatment settings - legal in California

What is somatic pain?

Somatic: superficial tissues (skin, muscles, joints, bones)

What are some adverse effects of chronic/acute pain?

Tachycardia/bradycardia Hypertension/hypotension Desaturation Bradypnea

Why are vital signs not considered the primary indicators for pain?

The American Society for Pain Management Nursing (ASPMN) recommendations emphasize that vital signs should not be considered as primary indicators of pain because they can be attributed to other distress conditions, homeostatic changes, and medications.

What is nociception?

The neural process of encoding and processing noxious stimuli

10. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue? A. Delirium B. Hypoxemia C. Hypocalcemia D. Sedation withdrawal

a. Delirium Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior. There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal.

14. What are the risk factors for delirium? A. Hypertension, alcohol abuse, and benzodiazepine administration B. Coma, hypoxemia, and trauma C. Dementia, hypertension, and pneumonia D. Coma, alcohol abuse, and hyperglycemia

a. Hypertension, alcohol abuse, and benzodiazepine administration Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine administration.

5. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse's actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator. Which medication would be appropriate to sedate the patient this time? A. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm Correct B. Haloperidol 5 mg IVP stat C. Propofol 5 mcg/kg/min by IV infusion D. Fentanyl 25 mcg IVP over a 15-minute period

a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia. Fentanyl is a narcotic and is not appropriate for use as a sedative.

18. Which complications can result from prolonged deep sedation? (Select all that apply.) A. Pressure ulcers B. Thromboembolism C. Diarrhea D. Nosocomial pneumonia E. Delayed weaning from mechanical ventilation F. Hypertension

a. Pressure ulcers b. Thromboembolism d. Nosocomial pneumonia e. Delayed weaning from mechanical ventilation Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility, including pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.

6. When administering propofol over an extended period, what laboratory value should the nurse routinely monitor? A. Serum triglyceride level B. Sodium and potassium levels C. Platelet count D. Acid-base balance

a. Serum triglyceride level Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content.

What is neuropathic pain?

arises from a lesion or disease affecting the somatosensory system

3. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. What action should be the nurse take first? A. Administer midazolam 5 mg by intravenous push immediately. B. Assess the patient to see if a physiologic reason exists for his agitation. C. Obtain an arterial blood gas level to ensure the patient is not hypoxemic. D. Apply soft wrist restraints to keep him from pulling out the endotracheal tube.

b. Assess the patient to see if a physiologic reason exists for his agitation. The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem.

4. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure alarm. What action should the nurse take next? A. Administer midazolam 5 mg by intravenous push immediately. B. Eliminate noise and other stimuli in the room and speak softly and reassuringly to the patient. C. Obtain an arterial blood gas to ensure the patient is not becoming more hypoxemic. D. Call the respiratory care practitioner to replace the malfunctioning ventilator.

b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to the patient. Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic means to decrease anxiety.

17. What are the causes of delirium in critically ill patients? (Select all that apply.) A. Hyperglycemia B. Meningitis C. Cardiomegaly D. Pulmonary embolism E. Alcohol withdrawal syndrome F. Hyperthyroidism

b. Meningitis e. Alcohol withdrawal syndrome f. Hyperthyroidism The causes of delirium in critically ill patients include metabolic causes (acid-base disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).

11. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is haloperidol? A. Sedation level B. QTc-interval C. Oxygen saturation level D. Brain waves

b. QTc-interval Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce dose-dependent QTc-interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use.

7. What is a major side effect of benzodiazepines? A. Hypertension B. Respiratory depression C. Renal failure D. Phlebitis

b. Respiratory depression The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related.

2. A patient has been taking benzodiazepines and suddenly develops respiratory depression and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse's next action? A. Decrease benzodiazepines to half the prescribed dose. B. Increase IV fluids to 500 cc/hr for 2 hours. C. Administer flumazenil (Romazicon). D. Discontinue benzodiazepine and start propofol.

c. Administer flumazenil (Romazicon). The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients.

16. Which intervention is an effective nursing strategy to decrease the incidence of delirium? A. Restriction of visitors B. Early nutritional support C. Clustering of nursing care activities D. Bed rest

c. Clustering of nursing care activities As lack of sleep is a major contributor to the development of delirium, interventions to promote sleep should help decrease the incidence of delirium. Some critical care units have initiated sleep protocols to increase the opportunity for patients to sleep at night, dimming lights at night, ensuring there are periods of time when tubes are not manipulated, and clustering nursing care interventions to provide some uninterrupted rest periods. Early ambulation is also appropriate.

15. What are the two scales that are recommended for assessment of agitation and sedation in adult critically ill patients? A. Ramsay Scale and Riker Sedation-Agitation Scale (SAS) B. Ramsay Scale and Motor Activity Assessment Scale (MAAS) C. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS) D. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS)

c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS) The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS.

8. What is the major advantage of using propofol as opposed to another sedative for short-term sedation? A. Fewer side effects B. Slower to cross the blood-brain barrier C. Shorter half-life and rapid elimination rate D. Better amnesiac properties

c. Shorter half-life and rapid elimination rate Propofol is an effective short-term anesthetic agent, useful for rapid "wake-up" of patients for assessment; if continuous infusion is used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of sedation, and length of time sedated.

What is nociceptive pain?

comes from sensory receptors for painful stimuli

9. Which medication is used for sedation in patients experiencing withdrawal syndrome? A. Dexmedetomidine B. Hydromorphone C. Diazepam D. Clonidine

d. Clonidine Clonidine (often prescribed as a Catapres patch) is a central -agonist and is recommended for sedation during withdrawal syndrome.

1. To achieve ventilator synchrony in a mechanically ventilated patient with acute respiratory distress syndrome (ARDS), which level of sedation might be most effective? A. Light B. Moderate C. Conscious D. Deep

d. Deep Deep sedation is used when the patient must be unresponsive to deliver necessary care safely.

13. Which medication has a greater advantage for treatment of alcohol withdrawal syndrome (AWS) because of its longer half-life and high lipid solubility? A. Lorazepam B. Midazolam C. Propofol D. Diazepam

d. Diazepam Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility. Lipid-soluble medications quickly cross the blood-brain barrier and enter the central nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because of rapid withdrawal. Propofol is indicated for sedation use.

12. What is the most common contributing factor to the development of delirium in critically ill patients? A. Sensory overload B. Hypoxemia C. Electrolyte disturbances D. Sleep deprivation

d. Sleep deprivation Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium.

Fentanyl is preferred for patients with ________.

hemodynamic instability or morphine allergy