Week 1 Power Point 65, 19, 9

Physical Manifestations EOL II •Physical Manifestations EOL, Table 9-2, p. 132 --Irregular breathing that gradually slows --Cheyne-Stokes respiration --Inability to cough or clear secretions --Hearing is usually last sense to disappear •Psychosocial EOL, Table 9-3, p. 132 •Culturally competent care

Decisional capacity refers to the ability to consent or refuse care. It means that the individual has an understanding and appreciation of the information that is shared and has the capacity to engage in the reasoning process.

Neuromuscular blocking agents (NMBAs) 1 Is Succinylcholine depolarizing or non depolarizing? 2 What is it used for? 3 May increase what element and cause what? 4 This element elevation is a higher risk in what patients? 5 is rocuronium and Vecuronium depolarizing or non depolarizing? 6 Rocuronium can be given as what? 7 Vecuronium can be given as IV bolus or what? And it less effect on What compared to pancuroniun or atracurium? 8 What is the sequence of paralysis, and the reverse?

1 Depolarizing: succinylcholine (Anectine) --Succinylcholine 2 ----Used to facilitate rapid intubation 3 ----May increase serum potassium and cause MH (Malignant hyperthermia) (rare effect-risk increased with use of inhaled general anesthetics) 4 ------Potassium elevation especially in patients with rhabdomyolsis, muscle damage, motor neuron disease, and trauma 5 Non-depolarizing: Rocuronium (Zemuron), Vecuronium (Norcuron), Cisatracurium (Nimbex), Pancuronium (Pavulon) 6 --Rocuronium (Zemuron) ----Given as an IV bolus or continuous infusion 7 --Vecuronium (Norcuron) ----Given as an IV bolus or continuous infusion ----Less histamine release than pancuroniun or atracurium (& less effect on HR & MAP) 8 Sequence of muscle paralysis after NMBA: Fine to gross motor impairment, beginning with eye muscles, > jaw> extremities> (neck to intercostals)> abdominal muscles> > diaphragm Sequence of recovery>> reverse order of paralysis

Issues Related to Caregivers 1 ICU visitation- AACN recommendations 2 What should the ICU nurse do to prepare the family for the visit and during the visit?

1 Limiting visitation does not protect the patient from adverse physiologic consequences. AACN strongly recommends less restrictive, individualized visiting policies. This is accomplished by assessing the patient's and caregiver's needs and preferences and incorporating these into the plan of care 2 The first time that caregivers visit it is important for you to prepare them for the experience. Briefly describe the patient's appearance and physical environment (e.g., equipment, noise).14 Join caregivers as they enter the room. Observe the responses of the patient and caregivers. Invite the caregivers to participate in the patient's care if they desire. In some ICUs, visitation includes animal-assisted therapy or pet visitation. The positive benefits of these interventions (e.g., decreases in BP and anxiety) far outweigh the risks (e.g., transmission of infection from animal to patient). They should be a part of the visitation policy.

Propofol side effects list 9

1 Propofol-Related Infusion Syndrome (PRIS) 2 Metabolic acidosis 3 Hypertriglyceridemia (monitor Lipids) 4 hypotension 5 bradycardia 6 AKI (acute kidney injury) 7 rhabdomyolysis 8 Apnea 9 dysrhythmias

Neuromuscular blocking agents (NMBAs) IV Peripheral Nerve Stimulator (PNS) 1 What do you give concurrently to patients that are paralyzed? 2 What is TOF? 3 What other reason to provide NMBA? 4 What is the care of an immobile paralyzed patient

1 Sedation & analgesia!!! It is essential to give IV sedation and analgesia concurrently when the patient is paralyzed. 2 TOF testing (2/4 twitches) Train of four --Ulnar or facial nerve. two out of four is normal, this is the right level of paralysis 3 --Airway/ Vent management- ventilator synchrony. The client cannot breath on their own. At times, the decision is made to paralyze the patient with a neuromuscular blocking agent (e.g., cisatracurium [Nimbex]) to provide more effective synchrony with the ventilator and improve oxygenation 4 Care of immobile, paralyzed patient. Provide these cares for immobile patients --Mechanical Eye lubrication (because they cannot blink) --DVT prophylaxis --Repositioning and ROM --Oral care --Urinary catheter --Routine vital signs and assessments

Issues Related to Caregivers •Identify the primary support person/spokesperson •Ensure you have the appropriate contact info •Include in the plan of care 1 What strategies are used when conducting a family assessment? P. 1157 2What are the main needs of families?

1 Strategies include active listening, reduction of anxiety, and support of those who become upset or angry. Recognize the caregivers' feelings, listen to them openly and without being judgmental, and acknowledge their decisions. Consult other team members (e.g., chaplains, psychologists, patient representatives) as necessary to help caregivers cope. 2 The main need of families: The major needs of caregivers of critically ill patients include information, reassurance, and access. Lack of information is a major source of anxiety for the caregivers.

3 Should families be allowed to visit or be present during a procedure? An emergency? 4 What would be the benefit of having family presence during these events?

3 and 4 being present helps caregivers to (1) overcome doubts about the patient's condition, (2) reduce their anxiety and fear, (3) meet their need to be together with and to support their loved one, and (4) begin the grief process if death occurs. AACN encourages critical care nurses to develop policies and procedures that provide for the option of family presence during invasive procedures and CPR.

During a conscious sedation procedure, a client is medicated with midazolam- 10 minutes later, the client's respiratory rate decreases to 8 bpm. What medication does the nurse prepare? A.Atropine B.Physiostigmine C.Flumazenil (Romazicon) D.Naloxone (Narcan) ANSWER: C

A client placed on dexmedetomidine begins to experience nausea, hypotension, and bradycardia. The nurse determines that the client is experiencing which of the following? A.Responding to the drug as expected B.Worsening of the underlying disease process C.Side effects of dexmedetomidine (Precedex) D.Requires a decrease in medication infusing rate ANSWER C

Common Problems of Critical care Patients Sleep

Arrange the environment to promote the patient's sleep-wake cycle. Strategies include scheduling rest periods, dimming lights at nighttime, providing eye masks/ear plugs, opening curtains during the daytime, getting physiologic measurements without disturbing the patient, limiting noise, and providing comfort measures (e.g., massage).7 If necessary, use benzodiazepines

Nurses in a Burn ICU unit are developing a poster presentation for a regional conference. In developing their poster, which level of evidence for their literature review is recognized as the strongest level of evidence? A.Well-designed controlled studies, both randomized and non-randomized B.Combination of theory- based framework and manufacturer's recommendations C.Meta-analysis of multiple controlled studies or metasynthesis of qualitative studies D.Peer-reviewed professional organizational standards, with support from clinical studies

C

Postmortem Care •After death is pronounced, the nurse prepares or delegates preparation of the body for immediate viewing, p. 139 --Close patient's eyes --Replace dentures --Wash and position body •Allow family privacy and as much time as they need with deceased person •Maintain respect for patient and family •Consideration cultural customs, state law, agency policy and procedure

Consideration must be given for: --Cultural customs --State law --Agency policy and procedure. •May be important to allow family to prepare or assist in preparing body in some cultures and some types of death •Remove tubes and dressings if appropriate. •Straighten the body, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face. •In the case of an unexpected or unanticipated death, preparation of the patient's body for viewing or release to a funeral home depends on state law and agency policies and procedures. •Never refer to the deceased person as "the body." •Care of and discussion related to the person should continue to be respectful even after death.

Common Problems of Critical care Patients Nutrition Contributing factors? •Hypermetabolic states •Malnourished •Adequate nutrition is essential •Nutrition consult within 24 hours •If the gut works, feed it.. •Why?

Contributing Factors Patients often arrive at ICUs with conditions that result in either hypermetabolic states (e.g., burns, sepsis) or catabolic states (e.g., acute kidney injury). Other times, patients are in severely malnourished states (e.g., chronic heart, pulmonary, or liver disease) If the gut works, Feed it Why? Enteral nutrition preserves the structure and function of the gut mucosa and stops the movement of gut bacteria across the intestinal wall and into the bloodstream. In addition, early enteral nutrition is associated with fewer complications and shorter hospital stays and is less expensive than parenteral nutrition.

Culturally Competent Care When approaching difficult conversations regarding death, what are good starting points?

Cultural perspectives on dying and death are complex. Telling some patients that they are dying as a way of letting them prepare for death may impose on the family's role. Others view a discussion about advance directives as a legal way to withhold, withdraw, or deny care. Customs surrounding dying and death vary. Caregiver requests may range from asking you to leave a window open so that the spirit of the deceased can leave, to providing the final bath for the deceased. Ask the caregivers about their cultural traditions when caring for the dying patient. Proceed cautiously when approaching patients facing death and their caregivers. Asking patients, "What do you want to know?" and "Who do you want with you when discussing options?" are good starting points.16 (Chapter 9 provides additional information about end-of-life care.)

Sedative/Hypnotics Dexmedetomidine 1 What are the properties of Dexmedetomidine? 2 patients sedated with Dexmedetomidine are more easily what? 3 how often should you titrate? 4 what are the onset and duration? 5 what is the major side effects and the three withdrawal effects? 6 Monitor patients for what?

Dexmedotomidine (Precedex) Selective α2- receptor agonist with sedative, analgesic/opioid sparing, and 1 sympatholytic properties, but with no anticonvulsant properties 2 Patients sedated with dexmedetomidine are more easily arousable and interactive, with minimal respiratory depression ICU Sedation: Loading Dose: 1mcg/kg over 10-20 minutes Maintenance 0.2- 0.7 mcg/kg/hour 3 Titrate dose every 30 minutes to reduce risk of hypotension 4 Onset of action: 5-10 minutes (IV) Duration: ~3 hours 5 Adverse Side Effects Leads to light sedation with minimal respiratory depression Withdrawal S/S Found in patients receiving up to 7 days of therapy Symptoms occur within 24-48 hours of discontinuation: Nausea Vomiting Agitation 6 Patients should be monitored for hypotension when started on dexmedetomidine as well as reflex tachycardia when medication is discontinued

Extrapyramidal symptoms (EPS)

Extrapyramidal symptoms (EPS), also known as extrapyramidal side effects (EPSE) if drug-induced, are movement disorders, which include acute and tardive[clarification needed] symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements).[1] Antipsychotics are often discontinued due to inefficacy and intolerable side effects such as extrapyramidal symptoms.[2]

Common Problems of Critical care Patients Anxiety •Discomfort with noise, unfamiliar sounds, equipment, and intense activity •Factors that influence anxiety? •What are some ways to reduce anxiety?

Factors that influence anxiety •Pain •Impaired communication •Reduced sleep/noise/alarms •Immobilization What are some ways to reduce anxiety? To help reduce anxiety, teach patients and caregivers to express concerns, ask questions, and state their needs. Include the patient and caregiver in all conversations and explain the purpose of equipment and procedures. Be sure to structure the patient's environment in a way that decreases anxiety. For example, encourage caregivers to bring in photographs and personal items. Appropriate use of antianxiety drugs (e.g., lorazepam [Ativan]) and relaxation techniques (e.g., music therapy) may reduce the stress response that can be triggered by anxiety.

Common Problems of Critical Care Patients. Nutrition

Feed the gut when it works because if you don't it will increase the risk of infection and the stomach acids cause erosion in the gut.

Common Problems of Critical care Patients Sensory Perceptual How to Limit sensory overload?

How to Limit sensory overload? Conversation is a particularly stressful noise, especially when the discussion concerns the patient and is held in the presence of, but without participation from, the patient. find suitable places for patient-related discussions. Whenever possible, include the patient and caregiver in the discussion. mute phones, set alarms based on the patient's condition, and reduce unnecessary alarms. For example, silence the BP alarm when handling invasive lines and then reset the alarm when done. Similarly, silence ventilator alarms when suctioning. Last, limit overhead paging and all unnecessary noise in patient care areas.

Side effects of antipsychotic drugs list 6

In addition to sedation, other side effects of antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects hypotension EPS Effects TD Athetosis muscle tone changes anticholinergic effects

The nurse observed that client has an acute onset of confusion. Which tool is the best choice to evaluation delirium in a critically ill client? A.Glasgow Coma Scale B.FACES assessment tool C.Richmond Agitation Sedation Scale D.Confusion Assessment Method (CAM-ICU) ANSWER: D

In the critical care environment, which factors can be altered or be adjusted to modify pain and anxiety? Select all that apply. A.Nursing care B.Procedural interventions C.Light and temperature D.Noise and monitoring E.Labs and diagnostics ANSWERS: ACDE

Behavioral Pain scale

Know 1 facial expression 2 Upper Limbs 3 Compliance with Ventilation

Mnemonic for Causes of Delirium D E L I R I U M

Mnemonic for Causes of Delirium: Dementia, dehydration Electrolyte imbalances, emotional stress Lung, liver, heart, kidney, brain Infection, intensive care unit Rx drugs Injury, immobility Untreated pain, unfamiliar environment Metabolic disorders

Intraoperative Care (Pain & Sedation) CHAPTER 18 (SEE Canvas Module 1 Lesson) p. 325-326 Table 18-6 and 18-7

Pain measurement tools can provide the nurse with both subjective and objective information. The pain measurement scale requires the patient to identify the level of pain on a 0 - 10 scale, with 0 being no pain and 10 being the worst possible pain. This scale often doesn't work in the critical-care setting when the patient is not able to communicate. The pain measurement tools for nonverbal patients vary. The behavioral pain scale is widely used in the ICU setting and was developed specifically to assess pain in the mechanically ventilated patient. The behavioral pain scale score includes facial expressions, limb movements, and compliance with ventilation. These scores can range from 3 to 12, and the nurse can initiate pain-relieving interventions as needed with this assessment. Another commonly used pain management tool is the critical-care pain observation tool, which may be more appropriate for patients not on mechanical ventilation. The scale includes the same aspects of the behavioral pain scale, but it has a replacement for the ventilation section if the patient is not intubated. The tool includes evaluation of the patient crying or moaning as pain indicators. The pain assessment tool used with the critically ill patient may vary in clinical settings as warranted by the specific patient population. Sedation scales and tools are also needed in the critical-care setting. Several of these assessment tools are currently utilized in clinical practice and include the Richmond Agitation-Sedation scale, the Ramsay Sedation scale, and the Sedation-Agitation scale. All of these scales are used to determine the appropriate level of sedation based on the patient's condition as it relates to the therapeutic or support interventions required to care for the patient.

Common Problems of Critical care Patients Sensory Perceptual Delirum

Patients with delirium can have a variety of manifestations ranging from hypoactivity and lethargy to hyperactivity, agitation, and hallucinations.

anticholinergic effects

Possible side effects include: confusion hallucinations memory problems dry mouth blurry vision constipation drowsiness sedation trouble urinating delirium decreased sweating decreased saliva

postmortem care

Postmortem Care. After the patient is pronounced dead, prepare or delegate preparation of the patient's body for immediate viewing by the family with consideration for cultural customs and in accord with state law and agency policies and procedures. In some cultures and in some types of death, it may be important to allow the family to prepare or assist in caring for the patient's body. In general, close the patient's eyes, replace dentures, wash the body as needed (placing pads under the perineum to absorb urine and feces), and remove tubes and dressings (if appropriate). The patient's body is straightened, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face. Allow the family privacy and as much time as they need with the deceased person. When the death is unexpected or unanticipated, preparation of the patient's body for viewing or release to a funeral home depends on state law and agency policies and procedures. Never refer to the deceased person as "the body." Care of and discussion related to the person should continue to be respectful even after death.

What is PRIS?

Propofol-related Infusion Syndrome (PRIS) is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of: metabolic acidosis rhabdomyolysis hyperlipidaemia enlarged or fatty liver

Common Problems of Critical care Patients

The patient admitted to the ICU is at risk for numerous complications and special problems. Critically ill patients are often intubated and mechanically ventilated, immobile, and at high risk for skin problems (see Chapter 23) and venous thromboembolism (see Chapter 37). The use of multiple, invasive devices predisposes the patient to health care-associated infections (HAIs). Sepsis and multiple organ dysfunction syndrome (MODS) may follow (see Chapter 66). Other special problems relate to anxiety, pain, impaired communication, sensory-perceptual problems, sleep, and nutrition.

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

Used for patients that are intubated

Sedative/Hypnotics What is the purpose? 1 What effects does it have and what affect does it not have? 2 What is the onset and duration? 3 What is recommeded periodically? 4 What are the 7 side effects 5 Turns urine what, and how often is the bottle and tubing changed? 6 What is the contraindication?

Purpose: Ideal for short outpatient procedures because of rapid onset of action, metabolic clearance. May be used for induction and maintenance of anesthesia. Propofol is used to put you to sleep and keep you asleep during general anesthesia for surgery or other medical procedures. It is used in adults as well as children 2 months and older. Propofol is also used to sedate a patient who is under critical care and needs a mechanical ventilator (breathing machine). 1 Has sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant properties, but no analgesic effects 2 Onset of action: 1-2 minutes (IV Bolus) Duration: 3-12 hours (dose/rate dependent) ICU sedation in intubated mechanically ventilated patient Initial: 5 mcg/kg/min; increase every 5 to 10 minutes to desired sedation Maintenance: 5-50 mcg/kg/min 3 Daily interruption with retitration is recommended Hepatic Elimination, Lipophilic 4 Adverse Drug Effects: Propofol-Related Infusion Syndrome (PRIS) Metabolic acidosis Hypertriglyceridemia (monitor Lipids) hypotension bradycardia AKI (acute kidney injury) rhabdomyolysis 5 12 hour bottle time and tubing change May turn urine green! 6 Contraindicated in egg or soybean allergy

Delirium (cont'd) •Prevention, early recognition, and treatment •Assess, prevent, & manage pain •Check medications/ alcohol and drug W/D •Metabolic factors •Delirium screening -- CAM-ICU, p. 1416 Table 59-18 (old) *Newer version* •ABCEDEF Protocol •Caregiver/ reorient/ mobility •Safety!

See chapter 59 p. 1414-1417 The ICU Liberation Bundle (formerly the ABCDEF Bundle) elements individually and collectively can help reduce delirium, improve pain management and reduce long-term consequences for adult intensive care unit (ICU) patients

Common Problems of Critical care Patients Sensory Perceptual Patients with delirium can have a variety of manifestations ranging from hypoactivity and lethargy to hyperactivity, agitation, and hallucinations. Delirium What can increase risk for delirium? Demographic Characteristics • Age 65 yr or older • Male gender Cognitive Status • Cognitive impairment • Dementia • Depression • History of delirium Environmental • Admission to ICU • Emotional stress • Pain (especially untreated) • Sleep deprivation • Use of physical restraints Functional Status • Functional dependence • History of falls • Immobility TURN CARD

Sensory • Sensory deprivation • Sensory overload • Visual or hearing impairment Decreased Oral Intake • Dehydration • Malnutrition Drugs • Alcohol or drug abuse or withdrawal • Aminoglycosides • Anticholinergics • Opioids • Sedative-hypnotics • Treatment with multiple drugs Coexisting Medical Conditions • Acute infection, sepsis, fever • Chronic kidney or liver disease • Electrolyte imbalances • Fracture or trauma • History of stroke • Neurologic disease • Severe acute illness • Terminal illness Surgery • Cardiac surgery • Noncardiac surgery • Orthopedic surgery • Prolonged cardiopulmonary bypass

Sedative/Hypnotics Propofol II What are the properties of propofol? Short term or long term procedures? What are the side effects of propofol (list 5)? How often is the sedation holiday? When is the tubing and change? What is the contraindication? What is the weird side effect of propofol?

Table 18-6, p. 325 Stuff about Propofol: •IV general anesthetic; sedative & hypnotic- no analgesic properties •Short-term- procedures, IV sedation for intubated patients •Apnea, bradycardia, dysrhythmias, ↓↓ BP , hyperglyceridemia •Daily sedation vacation/ holiday •12- hour bottle and tubing change •Contraindicated in egg or soybean allergy •May turn urine green!

Sedative/Hypnotics Dexmedetomidine II What are the properties of Dexmedetomidine? More easily ____ with minimal _____ ______? Can be used in what kind of patients? _____ ______ synergistic effect? Side effects? Withdrawal s/s?

Table 18-8, p. 326 Stuff about Dexmedetomidine: •Potent anesthetic- alpha-2 agonist for short-term use as a sedative (< 24 h) •More easily arousable with minimal respiratory depression •can be used in non-intubated patients •opioid sparing-synergistic effect •Hypotension, bradycardia, respiratory depression, and reflex tachycardia •Withdrawal S/S: nausea, vomiting, agitation

Sedative/HypnoticsBenzodiazepines What are some examples of benzos? What affects does it have? Increases the risk for what? What are the side effects? Benzos can increase the risk for what? What is the antidote?

Table 18-8, p. 326 •IV midazolam, lorazepam, and diazepam •Reduce anxiety and induce amnesia •Synergistic effect with opioids ↑ risk for respiratory depression •hypotension, tachycardia, prolonged sedation or confusion •↑ risk for delirium •Reversal for serious benzo-induced respiratory depression--Flumazenil

Neuromuscular blocking agents (NMBAs) II how does it work? What is the main drug for depolarizing? Used to facilitate what? Increases what? so monitor for what disorder? What are the 4 side effects What are the nondepolarizing NMBA?

Table 18-8, p. 326 •Interrupt nerve impulses- paralysis •Depolarizing: succinylcholine (Anectine) •Used to facilitate rapid intubation •May increase serum K & cause MH (Malignant Hyperthermia) •Potassium elevation in rhabdomyolsis, muscle damage, motor neuron disease, and trauma -need to know K+ level •Nondepolarizing: Rocuronium Vecuronium, Cisatracurium, Pancuronium

Opioids What is the purpose of opiods? What are the effects of opiods? What drug is often combined with opiods? For what procedures? name three opioids What are the side effects? 6 side effects What is the antidote for opiods?

Table 18-8, p. 326 •Pain management postoperatively •Produce sedation and analgesia •Often combined with benzodiazepines for procedures and ventilator management Opioids: --Morphine sulfate --Hydromorphone (Dilaudid) --Fentanyl (Sublimaze) Side Effects •Respiratory depression, hypotension, vomiting, bradycardia, peripheral vasodilation, pruritis •Naloxone (Narcan)-- Analgesic effects are also reversed

Common Problems of Critical care Patients Impaired communication •What are some of reasons for this? •How can we communicate in these situations? •What if the patient and/or family do not speak English? •Non-verbal communication/ Touch?

What are some of reasons for this? Inability to communicate is distressing for patients who cannot speak because of the use of sedative and paralyzing drugs or an endotracheal tube. As part of every procedure, explain what will happen or is happening to the patient. How can we communicate in these situations? When the patient cannot speak, explore other methods of communication, such as picture boards, notepads, magic slates, or computer keyboards. When speaking with the patient, look directly at the patient and use hand gestures when appropriate. What if the patient and/or family do not speak English? For patients and caregivers who do not speak English, an approved interpreter or interpreter phone service must be provided (see Chapter 2). Non-verbal communication/ Touch Nonverbal communication is important. High levels of procedure-related touch and lower levels of comfort-related touch often characterize the ICU environment.

Common Problems of Critical care Patients Delirium Drug Therapy •Used when non-pharm measures fail •Many have psychoactive properties- worsen delirium What is used for sedation? What Antipsychotic/neuroleptics are used? Which anipsychotic is not IV? What other drug is used but may worsen delirium?

What is used for sedation? Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation What Antipsychotic/neuroleptics are used? •*haloperidal- IM/PO (not IV) •risperidone, olanzapine, & quetiapine Which antipsychotic is not IV? haloperidal What other drug is used but may worsen delirium? Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects. However, these drugs may worsen delirium caused by other factors and must be used cautiously.

Common Problems of Critical care Patients Pain •Pain is very common- up to 70% of patients report moderate to severe unrelieved pain •Untreated pain is linked with anxiety •Which 4 patients are at a higher risk of pain? •How to assess patients on IV pain and sedation meds?

Which patients are at a higher risk for pain? ICU patients at high risk for pain include those who (1) have medical conditions that include ischemic, infectious, or inflammatory processes; (2) are immobilized; (3) have invasive monitoring devices, including endotracheal tubes; and (4) require invasive or noninvasive procedures. Many patients on IV pain and sedation meds However, patients getting deep sedation are often unresponsive. This prevents you and other HCPs from fully assessing the patient's neurologic status. To address this issue, guidelines should include a daily, scheduled interruption of sedation, or "sedation holiday" for select patients. These daily interruptions allow you to awaken the patient to conduct a neurologic examination

Know RASS and the CAM ICU is for SEE Canvas Module 1: Topic 2 •Sedation medication is given to reduce symptoms; dose is adjusted based on tools or scales •Richmond Agitation-Sedation Scale (RASS) • Used in conjunction with the CAM-ICU

goes with the CAM ICU, used for assessing sedation RASS-Sedation CAM ICU-delirium

Resuscitation A chemical code involves the use of drugs for resuscitation without the use of CPR. A "no code," or a DNR order, allows the person to die with comfort measures only and without the interference of technology. Some states have implemented a form called out-of-hospital DNR for use by terminally ill patients who wish to have no heroic measures used to prolong life after they leave an acute care facility

• Common health care practice --Right to decide whether CPR will be used --CPR is given for respiratory or cardiac arrest unless otherwise ordered by a physician. •Physician's orders should specify --Full Code --Chemical Code •No Code - DNR or AND •Imperative that status is known in critical care areas

Neuromuscular Blocking Agents Depolarizing agent: succinylcholine (Anectine) Facilitate endotracheal intubation, promote skeletal muscle relaxation (paralysis) to enhance access to surgical sites.

• If intubated, monitor return of muscle strength, level of consciousness, and ventilation. • Maintain patent airway. Monitor respiratory rate and rhythm until patient able to cough and return to previous levels of muscle strength. Ensure availability of nondepolarizing reversal agents (e.g., neostigmine [Prostigmin]) and emergency respiratory support equipment. • Monitor temperature and levels of muscle strength with temperature changes.

Neuromuscular Blocking Agents Nondepolarizing agents: pancuronium rocuronium atracurium cisatracurium (Nimbex) Effects of nondepolarizing agents are usually reversed toward end of surgery by administration of anticholinesterase agents (e.g., neostigmine, pyridostigmine).

• If intubated, monitor return of muscle strength, level of consciousness, and ventilation. • Maintain patent airway. Monitor respiratory rate and rhythm until patient able to cough and return to previous levels of muscle strength. Ensure availability of nondepolarizing reversal agents (e.g., neostigmine [Prostigmin]) and emergency respiratory support equipment. • Monitor temperature and levels of muscle strength with temperature changes.

Organ and Tissue Donation what body part can be donated? Organ donation decision is made by who?

•Any body part or the entire body may be donated, p. 135 •Provide information- outcomes are based on wishes and values --Organ donation can be made by --legally competent persons --immediate family following death --on donor cards or, in some states, on DLs --Handled by various agencies that differ by state and community ----Life Alliance, UOM (ex) •Follow legal guidelines for organ or tissue donation •Some tissues must be used within hours after death so require immediate physician notification

Legal and Ethical Issues

•Basic ethical principles -Autonomy, Beneficence, Nonmaleficence, Justice, Veracity, Fidelity, Confidentiality •Legal issues: Informed consent, capacity, torts (slander, libel, defamation, assault, battery)

Special Needs of Nurses •Caring for dying patients is Intense and emotionally charged •Recognize your values, attitudes and feelings about death --Express feelings of sorrow, guilt, and frustration --Be aware of what you can and cannot control --Realize it is OK to cry with the patient or family --Be aware of your own physical and emotional stress --Get involved in hobbies or other interests (me time) --Maintain a support system in /and out of work •Many nurses who care for dying patients are passionate about providing quality EOL care. •A bond or connection may develop between you and the patient and/or family.

•Be aware of how grief personally affects you. •When dealing with death and the dying you are not immune to feelings of loss, helplessness, and powerlessness. --Express feelings of sorrow, guilt, and frustration. --Recognize your own values, attitudes, and feelings about death. --Be aware of what you can and cannot control. --Realize it is OK to cry with the patient or family. --Focus on interventions to decrease your own physical and emotional stress. --Get involved in hobbies or other interests. --Schedule time for yourself. --Maintain a peer support system. --Develop a support system beyond the workplace. •Hospice agencies can provide care of their team with professionally assisted groups, informal discussion sessions, and flexible time schedules.

Indications for Sedation/Analgesia

•Cardiac cath lab •Cardioversion •Endoscopy procedures •General surgical interventions •Eye/ oral surgical interventions •Some orthopedic procedures •Biopsies (CT-guided, bronchoscopy, etc.) •Interventional radiology •Gynecologic/ urologic procedures • Support physiological rest • Substance abuse withdrawal TIP: Prepare for emergency complications from any sedation procedure- crash cart, BVM (bag-valve-mask device), oxygen equipment, reversal agents, and suction ready!

Resuscitation II •CPR is given for respiratory or cardiac arrest unless otherwise ordered by a physician. •However, whether and to what extent CPR is used is no longer the sole decision of the physician. •The ANA supports patient's right to self-determination, and a primary role of nurses is supporting patient and family decisions. •Full code refers to use of complete and total heroic measures including CPR, drugs, and mechanical ventilation. •Chemical code involves use of drugs without CPR. Turn Card

•DNR indicates comfort measures only without interference of technology. •Some states have out-of-hospital DNR for patients being cared for out of acute care facilities. •Term being used to replace DNR is AND - Allow Natural Death: --More accurately conveys what actually happens. --Also referred to as "comfort measures only" status. --Comfort measures include pain control and symptom management. --Natural progression to death is not delayed or interrupted. --Care is not withheld. Care is supportive, providing comfort and dignity, while allowing nature to take its course.

Ethical Principles Related to Withdrawal and Withholding of Treatment Terminal weaning is a clinical intervention for withdrawing mechanical ventilatory support when such support is an unacceptable outcome for a patient. Withdrawal of life support must be done in a humane manner for the patient, the family, and the patient's care providers

•Death is a product of the underlying disease •Goal: relieve suffering, not hasten death •Withholding is the moral equivalent of withdrawing • Patient and family consent • Rarely limits to analgesic or anxiolytics • Patients on paralytic agents cannot be removed from life support •Cultural and religious perspectives may affect patient and family decision making

Medical Futility II

•The identification of the dying patient is often subjective and based on the health care providers' opinions and interpretations of patient response and results. This makes the determination of the appropriate intensity of care for patients near the end of life extremely difficult. •There is mounting evidence that high-intensity or aggressive care near the end of life is associated with a decreased quality of life and little to no improvement in duration of life.

Assessment: End of Life II Nursing care of terminally ill and dying patients is holistic and encompasses all psychosocial and physical needs. •Although there is no cure for the person's disease, the treatment plan still consists of assessment, planning, implementation, and evaluation. The main difference is that the focus of care is on the management of the symptoms of the disease, not necessarily the disease itself. •Physical assessments are abbreviated and focused on changes that accompany terminal illness. •Assessment may occur weekly for patients cared for in their homes by hospice programs. •In the final hours of life, physical assessment may be limited to essential data. •Key elements of social assessment include: --family relationships --communication patterns --differences in expectations --interpersonal conflicts that may result in family disruptions during the dying process and after death --patient and family goals. TURN CARD

•Multiple systems often fail during the EOL period. •Neurologic assessment is especially important: --LOC, presence of reflexes, pupil responses. •Evaluate changes in circulation: --Vital signs, skin color, temperature. •Monitor and describe respiratory status: --Character and pattern of respirations and breath sounds. •Monitor I and O: --Nutrition and fluid intake, urinary output, bowel function for renal and GI functioning. •Ongoing condition of fragile skin that can easily break down. •See Table 9-8 for more information. •Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. •Skin integrity is difficult to maintain at the end of life because of immobility, urinary and bowel incontinence, dry skin, nutritional deficits, anemia, friction, and shearing forces. •If possible, it is important to discuss with the patient and family the goals of care before treatment begins. An advanced directive should be completed so that the patient and family wishes are followed.

AACN- EBP •Implement practice based on evidence •Evaluate research •Hierarchy of evidence

•Nurses are encouraged to implement care that is evidence based and to challenge practices that have "always been done" but are not supported by clinical evidence. •Research studies are graded by the quality of evidence, with many different schemes used. •Meta-analysis and systematic reviews are considered the highest level of evidence. This book uses AACN's grading scheme.

Neuromuscular blocking agents (NMBAs) III Observe for what? What are the indications? It does not have What properties? so you must provide what? How do you monitor NMBA?

•Observe airway patency and adequacy of respiratory muscle movement Indications •Facilitate treatment or procedures, emergency or difficult intubation •Improve tolerance of mechanical ventilation •Manage elevated ICP •No sedative or analgesic properties •Must provide sedation! P. 1619 •Monitor level with train-of-four (TOF) peripheral nerve stimulator (PNS)

Death

•Occurs when all vital organs and body systems cease to function, p. 131 •Irreversible cessation of cardiovascular, respiratory, and brain function •Brain Death is --Irreversible loss of all brain functions including the brainstem --Occurs when the cerebral cortex stops functioning or is destroyed --Exact definition of death can be controversial

Legal and Ethical Issues Patients and families struggle with many decisions during the terminal illness and dying experience. Many people decide that the outcomes related to their care should be based on their own wishes and values. It is important to provide information to assist patients with these decisions. The decisions may involve the choice for

•Organ and tissue donations •Advance directives General term used to describe documents that give instructions about future medical care and treatments and who should make the decisions in the event the person is unable to communicate •Resuscitation The patient or family has the right to decide whether CPR will be used. It is no longer the sole decision of the physician Do not resuscitate (DNR) Must indicate any specific measures to be used or withheld. Must be signed by a physician to be valid •Mechanical ventilation •Tube feeding placement (1) organ and tissue donations, (2) advance directives (e.g., medical power of attorney, living wills), (3) resuscitation, (4) mechanical ventilation, and (5) feeding tube placement.

Many decisions during the terminal illness and dying experience

•Organ and tissue donations •Advance directives •Resuscitation •Mechanical ventilation •Tube feeding placement

Nursing: Withdrawal and Withholding of Treatment

•Provide anticipatory guidance to patient and family •Anticipate distressing symptoms and medicate to relieve symptoms •Titrate therapy to relieve emotional and physical distress

Organ and Tissue Donation II Who can decide organ donation? List 3

•Provide information so that care outcomes are based on wishes and values. •Organ donation --Can be made by legally competent persons --Can be made by immediate family following death --Can be specified on donor cards or, in some states, on drivers' licenses --Handled by various agencies that differ by state and community (organ bank, organ-sharing network, organ-sharing alliance) --Follow specific legal guidelines for organ or tissue donation. --Some tissues must be used within hours after death so require immediate physician notification.

Physical Manifestations EOL

•Respiratory changes are common at the end of life. •Respirations may be rapid or slow, shallow, and irregular. •Breath sounds may become wet and noisy, both audibly and on auscultation. Noisy, wet-sounding respirations, termed the death rattle or terminal secretions, are caused by mouth breathing and accumulation of mucus in the airways. •Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. •The physical manifestations of approaching death are listed in Table 9-2. TABLE IS NOT IMPORTANT

Medical Futility

•Situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient's health condition, or a lack of attainable goals of care •Legal and organizational definitions may vary, and much controversy exists •Consider situations when care and treatment may be considered futile

Death II

•Technological developments in life support have led to questions about when death actually occurs: --When the whole brain (cortex and brainstem) ceases activity --Or when function of the cortex alone stops. •The American Academy of Neurology developed the diagnostic criteria that must be validated by a physician: --Coma or unresponsiveness --Absence of brainstem reflexes --Apnea-(no questions on apnea test) •Currently legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected. •In some states and under specific circumstances, registered nurses are legally permitted to pronounce death. •Diagnosis of brain death is of particular importance when organ donation is an option.

Withdrawing and Withholding Treatment II

•Terminal weaning can be titration of ventilator to minimal levels; removal of the ventilator but not the airway or endotracheal tube. •Each facility has policies and procedures to consult. •AACN Web site has guidelines available for end-of-life (EOL) care and ventilator withdrawal.

Withdrawing and Withholding Treatment Withholding or withdrawing treatments must be included in an advance directive. The directive must clearly state what is to be done and what is not to be done. The ANA position statement states that the decision to withhold artificial nutrition and hydration should be made by the patient or surrogate together with the interprofessional team.21 For patients who are no longer receiving artificial nutrition and hydration, it is important to continue to provide expert nursing care.

•Ventilator withdrawal: most common intervention --Called "terminal weaning". Allow the client to die •Titrate pain medications and sedation during this process --Relieves tachypnea, dyspnea, and use of accessory muscles •Vasopressors •Antibiotics •Blood and blood products •Nutritional supportterm-49 •Possible deactivation of implanted devices (ICDs)

Critical Care Patient High risk for actual or potential life-threatening problems. Patients may be clustered by disease or acuity (stable/unstable). •What are the 3 reasons why a patient might need to be an ICU? •What type of patient would not be admitted to an ICU?

•What are the 3 reasons why a patient might need to be an ICU? A patient is generally admitted to the ICU for one of three reasons. First, the patient may be physiologically unstable, requiring advanced clinical judgments by you and the HCP. Second, the patient may be at risk for serious complications and need frequent assessments and often invasive interventions. Third, the patient may need intensive and complicated nursing support related to the use of IV polypharmacy (e.g., sedation, thrombolytics, drugs requiring titration [e.g., vasopressors]) and advanced technology (e.g., mechanical ventilation, intracranial pressure monitoring, continuous renal replacement therapy, hemodynamic monitoring). •What type of patient would not be admitted to an ICU? The patient who is not expected to recover from an illness is usually not admitted to an ICU. For example, the ICU is not used to manage the patient in a persistent, vegetative state or to prolong the natural process of death.