Exam #1: Chapter 9- sedation, agitation, delirium management

What are the recommended scales used to standardize assessments of agitation in a critically ill adult?

-The richmond agitation-sedation scale (RASS) -The sedation-agitation scale (SAS)

What does the score of 1 Represent on the SAS scale?

-Unarousable -Minimal or no response to noxious stimuli; does not communicate or follow commands

What does the score of -5 resemble on the RASS scale?

-Unresponsive -No response to voice or physical stimulation

What is the importance of the use of target sedation?

-Use of a target sedation number lowers the risk of unintentional oversedation (RASS −4 or −5; SAS 1 or 2)

What does the score of 2 Represent on the SAS scale?

-Very sedated -Arouses to physical stimuli but does not communicate or follow commands; may move spontaneously

What is light sedation?

(minimal sedation) -refers to pharmacological relief of anxiety (anxiolysis) so that the pt. is alert and can respond to verbal commands -RASS -1 -SAS 3

What does the score of 5 Represent on the SAS scale?

-Agitated -Anxious or mildly agitated, attempts to sit up, calms down to verbal instructions

What is daily sedation interruption?

-At a scheduled time, all continuously infusing sedatives are stopped. -The pt is allowed to regain consciousness for clinical assessment using a standardized instrument such as RASS or SAS -The patient is carefully monitored, and when awareness is attained, an assessment of LOC and neurologic function is performed. -If the patient becomes agitated, it is essential that a protocol be in place for the nurse to restart the sedatives.

What does the score of 4 Represent on the SAS scale?

-Calm and cooperative -Calm, awakens easily, follows commands

What does the score of 7 Represent on the SAS scale?

-Dangerously agitated -Pulls at ETT, tries to remove catheters, climbs over bed rail, strikes at staff, thrashes side to side

What does the score of -4 resemble on the RASS scale?

-Deep sedation -No response to voice, but movement or eye opening to physical stimulation

What does the score of -1 resemble on the RASS scale?

-Drowsy -Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 s)

What does the score of -2 resemble on the RASS scale?

-Light sedation -Briefly awakens with eye contact to voice (<10 s)

What does the score of -3 resemble on the RASS scale?

-Moderate sedation -Movement or eye opening to voice (but no eye contact)

s/s of benzodiazepine withdrawal

-Neurologic: Agitation, anxiety, delirium, tremors, myoclonus, headache, seizures, fatigue, paresthesias, sleep disturbances -Sensory: Increased sensitivity to light/sound, sweating -Musculoskeletal: Muscle cramps -Gastrointestinal: Nausea, diarrhea -Respiratory: tachypnea

s/s of opioid withdrawal?

-Neurologic: Delirium, tremors, seizures -Sensory: Dilation of pupils, teary eyes, irritability, increased sensitivity to pain, sweating, yawning -Musculoskeletal: Cramps, muscle aches -Gastrointestinal: Vomiting, diarrhea -Respiratory: Tachypnea

Use of sedative hypnotic agents in the critical care unit

-Propofol is a powerful sedative and respiratory depressant used for sedation in mechanically ventilated patients in critical care. -white milky appearance -At high doses propofol is intended to produce a state of general anesthesia in the OR. -In the critical care unit, propofol is prescribed as a continuous infusion at lower doses to induce sedation in critically ill patients -Propofol is clinically effective and cost-effective because it can be titrated, or turned off, when a patient is mechanically ventilated and may decrease time to extubation

What would a pt score on a RASS or SAS assessment when the target is to achieve deep sedation?

-RASS -4 -SAS 1 to 2 -These target values describe a mechanically ventilated patient who is not responsive to a spoken voice and who does not respond purposefully to physical stimulation.

What does the score of 3 Represent on the SAS scale?

-Sedated -Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again; follows simple commands

What are the recommended pain scales for pain assessments in critically ill adults?

-The behavioral pain scale (BPS) -The critical-care pain observation scale (CPOT)

What is delirium?

-a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions, abnormal thought processes, and inappropriate behavior. -it is difficult to diagnose in a critically ill patient and represents acute brain dysfunction caused by sepsis, critical illness, or dysfunction of other vital organs -to assess delirium in mechanically ventilated critical care patients you can use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC)

What is the standard in critical care r/t amount of sedation for comfort for a pt.?

-achievement of the lightest possible sedation to provide comfort for an alert pt. is now considered the standard in critical care

What does the score of +2 resemble on the RASS scale?

-agitated -Frequent nonpurposeful movement; fights ventilator

What does the score of 0 resemble on the RASS scale?

-alert and calm

How are types and amount of sedatives to give a pt. determined?

-all sedatives are to be administered to a specific target level identified by a RASS or SAS level appropriate to the pt.s clinical condition -A target level is specified every day and reevaluated whenever there is a change in sedation dosage or patient condition

What does the score of +4 resemble on the RASS scale?

-combative -Overtly combative, violent, immediate danger to staff

What is the second step of an assessment of an agitated pt.?

-determine the minimum level of sedation required for an individual pt.

What are the most frequently used benzodiazepines in critical care?

-diazepam (Valium) -midazolam (Versed) -lorazepam (Ativan)

What is the antidote for benzodiazepine-related overdose?

-flumazenil (Romazicon)

Use of Benzodiazepines in the critical care unit

-have powerful amnesic properties that inhibit reception of new sensory information - they do not confer analgesia. -no longer recommended for sedation of mechanically ventilated critically ill adults -they are associated with worse patient outcomes, including longer duration of mechanical ventilation and delirium. -Short-acting benzodiazepines are still helpful for the treatment of acute short-term agitation -s/e= respiratory depression & hypotension

What is agitation?

-hyperactive patient movements that range in intensity from slight restless hand and body movements to pulling out lines and tubes or physical aggression and self-harm -frequently encountered causes of agitation include pain, anxiety, delirium, hypoxia, ventilator dyssynchrony, neurologic injury, uncomfortable position, full bladder, sleep deprivation, alcohol withdrawal, sepsis, medication reaction, and organ failure. -benzodiazepines have been shown to induce delirium -Haloperidol, an antipsychotic medication, can be administered for management of acute agitation. - can be assessed using scales SAS and RASS -goal is to treat the cause of the agitation rather than to overmedicate

How can you prevent delirium in mechanically ventilated pts?

-in mechanically ventilated patients, the interventions include spontaneous awakening trials, daily delirium monitoring, and early mobility

What is the result of prolonged oversedation?

-is associated with negative sequelae, including pressure ulcers, thromboemboli, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation -also been linked to an increase in delirium and worse long-term cognitive outcomes

What is the lowest and highest score on the Richmond agitation-sedation scale (RASS)?

-lowest= -5 (unresponsive) -highest= +4 (combative)

What is the lowest and highest score on the Sedation-agitation scale (SAS)?

-lowest= 1 (unarousable) -highest= 7 (dangerously agitated)

What are s/s of propofol-related infusion syndrome?

-metabolic acidosis -muscular weakness -rhabdomyolysis -myoglobinuria -acute kidney injury -cardiovascular dysrhythmias -Metabolic acidosis is the most common sign

What is deep sedation?

-pharmacologic depression of pt. consciousness to where the pt. cannot maintain an open airway

What is moderate sedation?

-pharmacological depression of pt. consciousness -also known as "procedural sedation" -*this is often target level when tubes or lines are inserted*

What is general anesthesia?

-pharmacological depression of pt. consciousness using multiple medications, administered by a physician anesthesiologist or a nurse anesthetist

What does the score of +1 resemble on the RASS scale?

-restless -Anxious but movements not aggressive or vigorous

What is the first step in assessing an agitated pt.?

-to rule out any sensations of pain

What does the score of 6 Represent on the SAS scale?

-very agitated -Does not calm despite frequent verbal reminding of limits, requires physical restraints, bites ETT

What does the score of +3 resemble on the RASS scale?

-very agitated -Pulls or removes tube(s) or catheter(s); aggressive