Patient & family

Family can sometimes be a burden for patients. Advocacy is a major role a nurse must face when caring for critical patients.

Sensory overload

Noise & sleep deprivation equal environmental factors when caring for patients.

Effects of noise

• Sleep disruption
• ↓O2 sats
• ↑BP
• Delayed wound healing

* Noise can also cause med errors due to distractions

* Use sedative music to help relax patient

Critical care: PTSD

Is common after critical care is given. Primary goal in nursing interventions is to increase safety, reduce sleep deprivation & minimize sensory overload.

* Give clustered care for ↑ rest periods

* DO NOT ASK "Do you know where you are?" Just reorient q2-4ºto maintain dignity of patient.

Relocation stress

Stress caused when transferring patient to another unit

______ ______ method is the best way to evaluate understanding of families & patients.

Teach back

Critical care: Elderly

They are at greater risk for negative outcomes. This is caused for many losses in life an elderly patient has suffered before hospitalization.

Structural assessment:

• Done upon admission
• Identify immediate family & decision makers
• Try to designate a primary spokesperson for the family

Developmental assessment

Information related to family's developmental stage, task & attachment

Functional assessment

Reveal how family members function and behave in relation to one another.

Cultural assessment questionaire

1. What are your specific religious & spiritual practices?
2. What are your beliefs about illness & death?
3. What is most important to you & your family at this time?

Most common needs for families

1. Receiving information
2. Receiving assurance
3. Remaining near patient
4. Comfort
5. Having support available

Family Bundle

• Evaluate
• Plan
• Involve
• Communicate
• Support

*Nurses can assist in promoting policy changes to affect open visitation policies when needed

Family observing invasive procedures

By doing so results in:

↑ knowledge of pts condition

↓ fear & anxiety

Promotes adaptation

Visual analog pain scale (VAS)

Used to help rate pain & anxiety

Behavioral pain scale

Each item is rated 1-4.

Facial expression- relaxed scores=1

Facial expression- grimacing = 4

Upper limbs- No movement= 1

Upper limbs- full bent w/finger flexion= 3

Upper limbs-Permanently retracted= 4

Compliance w/ventilation- tolerating movement= 1

Compliance w/ventilation- fighting ventilator= 3

Compliance w/ventilation- Unable to control ventilation= 4

Critical care pain observation tool

Facial expression:

Score rate from 0-2 (0=good)

Relaxed, no muscle tension= 0

Tense facial muscle= 1

Grimacing w/tense facial muscles= 2

Critical care pain observation tool

Nonventilator vocalization

0-2 (0=tolerating/good)

No sound = 0

Sighing, moaning = 1

Crying out, sobbing = 2

Richmond agitation sedation scale (RASS)

A 10 point scale, from 4- combative through 0- calm & alert, to -5 which is unarousable. The patient is asses for 30-60 seconds in the three steps, using discreet criteria.

* Useful in detecting changes in sedation status over consecutive days of critical care unit.

Ramsey sedation scale

Was developed for evaluation of postoperative patients emerging from general anesthesia.

This scale includes 3 levels of wakefulness & 3 levels of sedation.

Example:

Level:

1 = Pt. awake, anxious & agitated or restless

(Most awake)

3 = Pt. awake, responds to commands only

(least awake)

4 = Pt. asleep, brisk response to light tap or

loud auditory stimulus. (lightest sleep)

6 = Pt. asleep, no response to light tap or loud

auditory stimulus (complete sedation)

Sedation agitation scale

describes pt. behaviors seen in the continuum of sedation to agitation. Scores range from 1 (unarousable) to 7 (dangerously agitated).

Delirium: Assessment

* Goal- Keep patient safe

* Drug of choice- haloperidol

Delirium (acute brain dysfunction)

Characterized by an acutely changing or fluctuating mental status-

* I nattention

* Disorganized thinking

* Altered levels of consciousness

Delirium 3 clinical subtypes

1. Hypoactive: Quiet delirium, can go undiagnosed. Most prevalent, occurring in more than 60% of patients.

2. Hyperactive: Combative, agitated, disoriented. *hallucination, paranoia & delusions may be seen too** Extremely rare

3. Mixed: describes the fluctuating nature of delirium.

ABCDE Bundle for preventing Delirium:

• Awakening- Check neuro status at least once a shift, check breathing.
• Breathing coordination
• Choice of sedation- propofol (Nonbenzo sedative anesthetic), or versed (benzo, anxiety, sedation)- 6wk half life

Neuromuscular Blockade (NMB)

Use:

In operating room & critically ill pt.'s to facilitate endotracheal intubation and mechanical ventilation, to control increases in intracranial pressure & to facilitate procedures at the bedside (bronchoscopy, tracheostomy)

Neuromuscular Blockade (NMB):

Goal:

Complete chemical paralysis

Neuromuscular Blockade (NMB)

Atracurium (Tracrium)

Succinylcholine - short term use

agents do not possess any sedative or analgesic properties. Any patient receiving these agents must also be sedated!

Pt.s receiving effective NMB is not able to communicate or produce any voluntary muscle movements, including breathing.

Nursing care of a patient receiving NMB

• Perform train-of-four testing before initiation, 15mins after dosage change, then every 4hrs, to monitor the degree of pain
• Ensure appropriate sedation
• Lubricate eyes to prevent corneal abrasions
• Prophylaxis for DVT
• Reposition q 2hrs
• Monitor skin integrity
• Provide oral hygiene (swabs)
• Maintain mechanical ventilation
• Monitor breath sounds; suction airway as needed
• Provide passive ROM
• Monitor HR, respirations, BP & O2 sats
• Place indwelling urinary catheter to monitor urine output.
• Monitor bowel sounds; monitor for abdominal distention

Trains-of-four (TOF)

A peripheral nerve stimulator to assess the level or degree of paralysis.

Evaluates the level of NMB to ensure that the greatest amount of NMB is achieved with the LOWEST dose of NMB medication.

TOF how it works

The peripheral nerve stimulator delivers 4 low energy impulses and the number of muscular twitches is assessed.

* 4 twitches of the thumb or facial muscle indicate incomplete NMB.

* The absence of twitches indicates complete NMB. TOF goal is 2 out of 4 twitches

* The ulnar nerve & the facial nerve are the most frequently used sites for peripheral nerve stimulation. *

Common beliefs of the healthcare system

• Patients die of distinct illnesses, potentially curable
• Dying is often viewed as failure on the part of the system or providers
• The purpose of the healthcare system in the united States is to treat illness, disease, and injury & also to prevent illness & disease

Who speaks for the patient?

A. Surrogate decision making

B. Proxy

A. Healthcare surrogate- Appointed by pt. (POA)

• Designated by patient as part of advance directive
• Act as patient would have acted in similar situation

B. No family & cannot make decision themselves

• Legally designated decision maker
• State statute may designate order of succession

Advance directive

• Describe a patient's preference for treatment in terminal or vegetative state
• Legally recognized
• Presence of advance directive & end of life care distress should be shared w/significant others long before they are needed.

Dimensions of nursing care at end of life:

• Pain control- Alleviation of distressing symptoms (palliation)
• Communication & conflict resolution
• Withdrawing, limiting, or withholding of therapy
• Emotional & psychological care of the patient and family
• Caregiver organizational support (case manager- meals on wheels, hospice, caregivers, a case manager can handle all that)

Palliative care:

• Designed to relieve symptoms that negatively affect patient or family. * Nothing extraordinary- just make comfortable.

• Should be implemented w/ALL patients, not just the dying.

Common symptoms at end of life

• Pain * Diarrhea
• Anxiety * Nausea
• *Hunger or * Confusion
• Thirst * Agitation
• Dyspnea * Sleep disturbance

*Pt.'s when dying tend not to be hungry- GI slows down & doesn't process food, they feel full and don't want to eat.

Nursing interventions for Palliative care (in critical condition- not dying yet)

• Frequent repositioning
• Good hygiene
• Skin care
• Creation of a peaceful environment
• Pain relief

Palliation: Elements of Palliative care:

1. Early identification of end-of-life patients
2. Pain management as "fifth vital sign"
3. Pharmacological & nonpharmacological interventions to:

- Relieve pain (warm blanket is good)

- Control anxiety

- Control other distressing symptoms

Communication & conflict resolution

• Provide clear, ongoing, honest communication
• Allow time for family members to express themselves
• Agree on a treatment plan
• Emphasize that patient will not be abandoned
• Facilitate continuity of care

Withholding, Limiting, or Withdrawing treatment

• Does not constitute euthanasia or assisted suicide (illegal in most states)
• Shared decision-making model

Withdrawal of treatment

Discontinuation of life-sustaining therapies in a terminally ill or persistently vegetative patient.

Withholding of treatment

Failure to initiate life-sustaining therapies in a terminally ill or persistently vegetative patient.

Common withdrawal- Terminal weaning (intubation), start morphine IV drip & titrate for comfort- then remove tube.

Ventilator withdrawal

• Most common withdrawal intervention is called "terminal weaning"
• Titrate pain medications & sedation during this process

- Relieves tachypnea, dyspnea, and use of accessory muscles

Ethical principles related to withdrawal & withholding of treatment:

• Death is a product of the underlying disease

• Goal is to relieve suffering, not hasten death

• Withholding life-sustaining treatment is moral equivalent of withdrawing treatment

• Any treatment by be withheld or withdrawn with patient & family consent. *Even if no advance directive exists- Family can approve. *

• Any dose of analgesic or anxiolytic medication may reasonably be used to control pain & relieve suffering

• Life-sustaining treatment should not be withdrawn from patients on paralytic agents- this could cause them not to be able to breathe and that will be the cause of death.

• Cultural & religious perspective may affect patient & family decision making.

Other commonly withheld therapies:

1. Vasopressors
2. Antibiotics
3. Blood & blood products
4. Nutritional support
5. Possible deactivation of implanted devices (ICDs- internal cardioverter defibrillator & pacemakers and etc.,)

Other commonly withheld therapies: Vasopressors

• Epinephrine
• Noradrenaline hydrotartrate
• Phenylephrine ( Mesaton )
• Dobutamine
• Dopamine
• Ephedrine hydrochloride
• Midodrine

Also Glucocorticoids and mineralocorticoids

• Hydrocortisone
• Prednisone, Prednisolone
• Dexamethasone, Betamethasone
• Fludrocortisone

* Digoxin too!

Commonly withheld therapies: Antibiotics

Penicillin

Amoxicillin (Moxatag)

Amoxicillin/clavulanic acid

Azithromycin (Zithromax)

Ciprofloxacin (Cipro)

Commonly withheld therapies: Blood & blood products

* RBC

* WBC

* Fresh frozen platelets

* Cryoprecipitate:

Commonly withheld therapies: Nutritional support

• Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process of eating and digestion.
• The person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids and added vitamins and dietary minerals. It is called total parenteral nutrition (TPN) or total nutrient admixture (TNA) when no significant nutrition is obtained by other routes.
• It may be called peripheral parenteral nutrition (PPN) when administered through vein access in a limb, rather than through a central vein.
• Feeding tube
• NG tube

Nursing interventions during withdrawal or withholding of treatment:

• Provide anticipatory guidance to patient and family- Call chaplain before & if you know so they are on hand.
• Anticipate distressing symptoms & medicate to relieve symptoms
• Titrate therapy to relieve emotional & physical distress

Nursing interventions

• Ongoing assessment of response to therapy & comfort
• Pharmacological & nonpharmacological symptom management: - IV benzodiazepines for anxiety, -IV morphine for dyspnea & pain, - Medication titration to relieve symptoms often w/protocol

Benzodiazepines:

Diazepam (Valium)

Alprazolam (Xanax)

Clonazepam (Klonopin)

Lorazepam (Ativan)

Zolpidem (Ambien

Hospice

• Emphasizes comfort rather than cure
• Views dying as a normal process
• Philosophy of care, not a location
• Common in oncology
• Appropriate when aggressive interventions are withdrawn
• Quality end-of-life care

Comfort & sedation: Introduction

• Goal- Optimal level of comfort
• Pain leads to complications, such as sleep deprivation, agitation, and PTSD
• Pain is the 5th vital sign- Always be assessing for it
• Individualized management of pain & anxiety to targeted outcomes

Pain & Anxiety:

• Difficult to differentiate pain & anxiety
• Relationship is cyclical; one may exacerbate the other

- Patient feelings of powerlessness

- Suffering

- Mental status changes: Agitation, Delirium, ICU psychosis

Pain:

Pain:

1. Unpleasant sensory & emotional experience associated w/actual or potential tissue damage. ** triggers autonomic response (fight or flight)**
2. Pain is what the patient says it is

Anxiety:

Anxiety:

1. Prolonged state of apprehension in response to fear
2. Marked by apprehension, agitation, and autonomic arousal (sense of doom)

Predisposing factors of pain:

• Disease, procedures, monitoring devices, nursing care, trauma- all can cause/increase pain.
• Many factors influence pain perception:

- Expectation

- Previous pain experiences

- Emotional state

- Cognitive status

Predisposing factors of anxiety

• Inability to communicate (noise, lights, excess stimulation)

Examples:

- Endotracheal tube- pt. gagging or coughing, needs adjustment- it's better for the tube to be placed on either side of the mouth. If needs adjustments call respiratory.

- Monitor alarms

- Lack of mobility

- Unfamiliar surroundings

- Sleep deprivation

Physiology of pain: Nociceptors

• Nociceptors most abundant receptors

- Mechanical stimuli= surgery or wound, pinching or crushing

- Chemical stimuli= Burn, chili pepper in the eyes, acid burns

- Thermal stimuli- Heat and cold stimulation

• Have very little adaptation to pain
• Initiation of the inflammatory response to tissue injury

Physiology of Anxiety

• Anxiety is confined within the brain
• Purely psychogenic disorder; no actual tissue damage
• Linked to reward & punishment center

Positive effects of pain/anxiety:

1. Increase performance levels
2. Removes one from potential harm
3. Fight-or-flight response

Negative effects of pain/anxiety

1. Raises catecholamine's- (tachycardia & hypertension)
2. Interference w/healing
3. Increased oxygen consumption - *end-organ ischemia
4. Increased respiratory effort & hyperventilation

Five-Step assessment of pain: American pain society guidelines

• Assess & treat pain promptly; document
• Engage patient in management plan
• Provide preemptive treatment
• Reassess & treat to meet patient's needs
• Institute quality improvement plan related to practice & outcomes

Subjective assessment tools: Characteristics of pain

This is what you would ask patient regarding their pain, during your assessment.

1. precipitating cause
2. Severity
3. Location & radiation
4. Duration
5. Alleviating or aggravating factors

Subjective PQRST

P= provocation or position

Q= quality (sharp, dull, aching)

R= radiation (does is travel to other parts of the body)

S= severity or associated symptoms

T= timing or triggers

Subjective Assessment tools:

• Pain score, 0-10 rating scale
• Faces scale
• VAS

Faces scale

Series of faces from happy to distressed- you can have them point

Visual analog scale (VAS)

- Patient points to a level of pain severity on a 10cm line

- Can also be done w/pencil to mark severity

Objective assessment tools:

For patient who cannot communicate, no objective tool completely reflects patients' pain level

• Behavioral pain scale
• Critical-care pain observation tool
• Checklist of nonverbal pain indicators

Behavioral pain scale: Scored items

There are 3:

1. Facial expressions
2. Upper limbs
3. Compliance with ventilation

Each item is graded 1-4;

1= Relaxed, no movement or Tolerating movement

4= Grimacing, Permanently retracted or unable to control ventilation.

Critical-care pain observation tool: Scored indicatiors

There are 5 scored categories & each are graded from 0-2, add each category for a total overall score.

0= Absence of or tolerating well, 2= Grimacing, fighting or restlessness

1. Facial expression
2. Body movements
3. Muscle Tension
4. Compliance w/the ventilator
5. Nonventilator, vocalization

Neuromuscular Blockade:

* Must be sedated- can cause mental trauma

Indications:

• Facilitate treatment or procedures, including emergency or difficult intubation
• Improve tolerance of mechanical ventilation, espcecially nontraditional modes
• Manage elevate ICP

* No sedative or analgesic properties- Must provide sedation!!!

• Monitor level with train-of-four (TOF)

Train-of-four:

Peripheral nerve stimulator

• Evaluates the level of neuromuscular blockade (NMB)
• To ensure that the greatest amount of neuromuscular blockade is achieved w/the lowest dose of NMB medication
• The ulnar and facial nerve are most commonly used
• Delivers 4 low-energy impulses, and the number of muscular twitches is assessed.

* 4 twitches of the thumb or facial muscle = incomplete NMB

* The absence of twitches indicates complete NMB

* TOF Goal is 2 out of 4 twitches.

Nursing care NMB

1. TOF testing
2. Sedation
3. Care of immobile, paralyzed patient

- Mechanical ventilation & airway management

- Eye lubrication

- DVT prophylaxis

- Repositioning and range of motion

- Oral care

- Urinary catheter

- Routine vital signs & assessments

management of pain and anxiety: Nonpharmacological management

• Environmental manipulation- Fan to make more comfortable

• Guided imagery- meditate or "down by the pond, relaxing"

Management - Opioids

• Administration: IV bolus, IV infusions, PCA, patch- (fentanyl)
• Rapid onset, ease of titration, lack of accumulation, low cost

- Fentanyl= Fastest onset- available in patch too

- Morphine= Longer duration

- Hydromorphone- Dilaudid

Management -Opioids: Concerns

* Respiratory depression- monitor breathing & O2 sats

* Hypotension- sit up slowly, fall risk, dizziness

Management NSAIDS

• May decrease need of opioid- non-inflammatory & inflammation causes pain.
• Risk of GI bleeding & renal (ibuprofen) or liver (APAP) insufficiency

* Check platelet level, if low hold ASA- Ask doctor

Management -Sedatives

• Pharmacological treatment for anxiety

- Benzodiazepines

- propofol- knocks you out!

- Dexmedetomidine (Precedex)- sedative for procedures!

Patient- Controlled Analgesia

• Can be effective, pt. must be able to manage pump
• Best suited for patients with:

* Elective surgery

* Large surgical or traumatic wounds

* Normal cognitive function

* Normal motor skills

* So obviously someone who is in a coma, or delirious would not be a good candidate for a PCA.

Management challenges:

• Invasive procedures- procedural or conscious sedation
• Substance abuse

- May have higher than normal threshold to pain meds- it's not the pain itself

- Alcohol withdrawal syndrome (AWS)- higher tolerance for pain meds as well

• Restraining devices- Complications for immobility

Versed (midazolam):

• Benzodiazepine
• It makes you forget what happened!

Management challenges: Elderly

- Comorbidities- multiple health issues

- Multiple medications- for the multiple health issues!

- Physical frailty

- Cognitive or sensory deficits- Cannot hear, get confused, or cannot see very well.

Nutritional support:

All critically ill patients are assumed to be at ____________ risk.

nutritional

Utilizations of nutrients: Cell require-

1. Carbohydrates
2. proteins
3. fats
4. water
5. electrolytes
6. vitamins
7. trace elements

Ingested nutrients:

• nutrients are ingested orally
• mouth first breaks down food w/saliva
• Stomach stores and mixes food w/gastric secretions:

- Secretes intrinsic factor for vitamin B12

- Secretes fluids high in Na+ and K+

Duodenum:

-pancreas & liver empty here

-Absorbs minerals

Jejunum

Glucose & water-soluble vitamins absorbed

Ileum

- protein broken down & absorbed

- Absorbs fat-soluble vitamins

Colon

• Absorbs Na+ & K+
• Vitamin K formed
• Water reabsorbed
• Absorption of short-chain fatty acids

Pancreas

Secretes digestive enzymes

Gallbladder

Assists in emulsifying fats

Nutritional assessment

• Provide baseline subjective and objective data regarding nutritional status
• Determines nutritional risk factors
• identifies nutritional deficits
• Establishes nutritional needs
• Identifies medical, psychosocial, and socioeconomic fctors

Albumin

decreased level you will edema

Daily weights

Most accurate measurement for weight

Nutritional therapy goal: Any pt who cannot meet needs orally for __ or more days requires nutritional support

3 days

Nutritional therapy goal:

Obvious damage or trauma

nutritional support within 24hrs

Nutrition care plan

Determine:

- Pt.'s calorie, protein, and fluid needs

- Intake targets

- Route of administration

Set measurable short & long term goals

- Weight gain

- Stable laboratory values * with propofol must look at triglycerides labs- it's lipid based!

Enteral Nutrition:

• Delivery of nutrients to GI tract
• Preferred method

- Lower risk of infection

- Less expensive

• Small-versus large-bore tubes for delivery
• Gastric versus small bowel feeding
• Long-term nutrition: PEG (stomach) or jejunostomy (J-tube)

*After placement of PEG tube, button is tight to prevent/stop bleeding; loosen after a while to prevent skin breakdown.

Enteral formulas:

• Standard 1 calorie/ml
• Contain protein, fats, carbs, vitamins & trace elements
• Specialized formula examples:

- Elemental

- High protein

- Fiber enriched

- Wound healing

• Immune-enhancing formulas

Guidelines for Enteral feeding:

Short-term enteral feeding

1. Nasogastric route
2. Nasoduodenal route
3. Nasojejunal
4. Orogastric route- intubated & remove when extubated.

Guidelines for Enteral feeding:

Long-term enteral feeding

- Gastrostomy tube

- Jejunostomy tube

Feeding schedule

- intermittent: gastric

- Continuous: small bowel feedings- acute care settings.

Assess gastric residuals

- How? How often?- With an irrigation syringe and every 4hrs

What is significant? - Residual, too much means pt. is not tolerating feeding. Hold per policy if 200mL or more & put it back.

- Differences between gastric & small bowel locations- vomit & aspirate

Flush feeding tube with ____ of water

30mLs

Tolerance of Enteral nutrition (EN)

1. Presence of bowel sounds in 4 quadrants, as determined by auscultation
2. Presence of bowel mobility or bowel movements
3. Palpation of soft abdomen

Signs of intolerance to EN

1. Nausea / Vomiting
2. Absent bowel sounds
3. Abdominal distention
4. Cramping

Guidelines for Parenteral nutrition

Feeding delivered into bloodstream

- Central line (TPN)= hypertonic

- Peripheral line (PPN)= isotonic

TPN

Central line= hypertonic fluids

PPN

Peripheral line= isotonic fluids

The nurse would suggest oral or enteral feedings for which patient?

• A patient who is severely malnourished
• A patient who has been NPO for 36hrs

Parental Nutrition: Indications

Used for patients who are unable to tolerate enteral feeding

- GI obstruction

- Intractable vomiting or diarrhea

- NPO for an extended period of time (>1wk)

Patients who are admitted very malnourished

- start immediately, if unable to tolerate enteral feeding.

Unable to meet nutritional demands with EN

Parenteral nutrition: complications

Monitor for complications

- Infection (sepsis)

- Electrolyte imbalances

- Fluid imbalances

- Hyperglycemia (TPN contains insulin)

Hold enteral feeding when giving _____ because it will cause a reaction.

Dilantin

Nursing Care for enteral & parental feedings

• Assess pt.'s ability to obtain or nutrients
• If infection, look for malnutrition as cause
• Be alert for food-nutrient-drug interactions
• Assess for recent changes in health status
• Weigh daily
• Assess protein-energy malnutrition in the elderly
• interpret laboratory finding cautiously ( albumin is the lab to check for malnourishment, normal range 3.4--5.4g/dL)

EN & PN complications

• Risk for refeeding syndrome
• Risk for diabetes or glucose intolerance
• Monitor liver function for parenteral support

Preventing complications: EN & TPN

• Enteral tube obstruction
• Aspiration & improper tube placement
• Diarrhea- consider clostridium difficile
• Dumping syndrome
• Hyperglycemia
• Electrolyte imbalances

EN/TPN- Monitoring & evaluating

• Assess progress in meeting objective

- Begin at the initiation of therapy

- Stable patient assessed every week

- Critically ill patient assessed more often

• Documentation
• Review changes in medications