High acuity nursing 6e global edition wagner 1

High-Acuity Nursing For these Global Editions, the editorial team at Pearson has collaborated with educators across the world to address a wide range of subjects and requirements, equipping students with the best possible learning tools This Global Edition preserves the cutting-edge approach and pedagogy of the original, but also features alterations, customization, and adaptation from the North American version Global edition Global edition Global edition H   igh-Acuity Nursing  S ixth edition Sixth edition K   athleen Dorman Wagner • Melanie G Hardin-Pierce Wagner • Hardin-Pierce This is a special edition of an established title widely used by colleges and universities throughout the world Pearson published this exclusive edition for the benefit of students outside the United States and Canada If you purchased this book within the United States or Canada you should be aware that it has been imported without the approval of the Publisher or Author Pearson Global Edition WAGNER_1292073403_mech.indd 12/08/14 2:08 pm Become PRACTICE-READY using your Pearson Resources Simplify your study time by using the resources included with this textbook at www.pearsonglobaleditions.com/wagner This book includes the following materials for you to use: • Learning Outcomes • NCLEXđ Review Questions ã Critical Thinking Activities ã Case Studies • Care Plans • Media Links A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM High-Acuity Nursing Sixth Edition Global Edition Kathleen Dorman Wagner, EdD, MSN, RN Faculty Emerita, University of Kentucky College of Nursing Lexington, Kentucky Melanie G Hardin-Pierce, DNP, RN, APRN, ACNP-BC University of Kentucky College of Nursing Central Baptist Hospital Lexington, Kentucky Boston Columbus Indianapolis New York San Francisco Hoboken Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM Publisher: Julie Levin Alexander Assistant to Publisher: Regina Bruno Executive Acquisitions Editor: Pamela Fuller Developmental Editors: Pamela Lappies and   Elizabeth Cosgrove Director of Marketing: David Gesell Senior Marketing Manager: Debi Doyle Marketing Coordinator: Michael Sirinides Project Management Lead: Patrick Walsh Production Project Manager: Cathy O’Connell Head, Learning Asset Acquisitions,   Global Edition: Laura Dent Acquisition Editor, Global Edition: Priyanka Ahuja Project Editor, Global Edition: Anuprova Dey Chowdhuri Procurement Supervisor: Vinnie Scelta Operations Specialist: Maura Zaldivar-Garcia Design Director: Andrea Nix Senior Art Director: Christopher Weigand Text Designer: Ilze Lemesis Cover Art: © StockLite/Shutterstock Lead Media Project Manager: Leslie Brado/Karen Bretz Media Project Coordinator: Tanika Henderson Full-Service Project Management: Integra Chicago Composition: Integra Printer/Binder: CPI Digital UK Cover Printer: CPI Digital UK Pearson Education Limited Edinburgh Gate Harlow Essex CM20 2JE England and Associated Companies throughout the world Visit us on the World Wide Web at: www.pearsonglobaleditions.com © Pearson Education Limited 2015 The rights of Kathleen Dorman Wagner and Melanie G Hardin-Pierce to be identified as the authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988 Authorized adaptation from the United States edition, entitled High-Acuity Nursing, 6th edition, ISBN 978-0-13-302692-4 by Kathleen Dorman Wagner and Melanie G Hardin-Pierce, published by Pearson Education © 2015 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means, electronic, mechanical, photocopying, recording or otherwise, withouteither the prior written permission of the publisher or a license permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS All trademarks used herein are the property of their respective owners.The use of any trademark in this text does not vest in the author or publisher any trademark ownership rights in such trademarks, nor does the use of such trademarks imply any affiliation with or endorsement of this book by such owners Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook appear on the appropriate page within text Notice: Care has been taken to confirm the accuracy of information presented in this book The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with current recommendations and practice at time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions This is particularly important when the recommended agent is a new and/or infrequently employed drug ISBN 10:    1-29-207340-3 ISBN 13: 978-1-29-207340-8 10 14 13 12 11 10 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Typeset in 10 MinionPro-Regular by Integra Printed and bound by CPI Digital UK The publisher’s policy is to use paper manufactured from sustainable forests A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM About the Authors Kathleen Wagner, EdD, MSN, RN, is now faculty emerita, ­having recently retired from the University of Kentucky College of Nursing after many years of teaching pathophysiology, pathopharmacology and high-acuity nursing to undergraduate nursing students She was also the educational consultant for the Undergraduate Nursing Program at the University of Kentucky She has a doctorate in instructional systems design and continues to work on a team developing Web-based clinical simulations for nursing students Melanie Hardin-Pierce, DNP, RN, APRN, ACNP-BC, is an associate professor in the University of Kentucky College of Nursing, where she teaches in the Doctor of Nursing Practice program and coordinates the Acute Care Nurse Practitioner Track She earned her Doctor of Nursing Practice degree at the University of Kentucky studying oral health in mechanically ventilated patients She is a board-certified acute-care nurse practitioner who practices as a critical care intensivist in Central Baptist Hospital, Lexington She is active in research of critically ill, mechanically ventilated patients, evidence-based practice, and interdisciplinary collaboration A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM Part ▸ Tissue Perfusion Thank You We extend a heartfelt thanks to our contributors and reviewers, who gave their time, effort, and expertise to the development and writing of this new edition of our book Contributors Arzouman, Jill, MS, RN, ACNS, BC, CMSRN University of Arizona Medical Center Tucson, AZ Chapter 1, High-Acuity Nursing Chapter 2, Holistic Care of the Patient and Family Bohnenkamp, Susan, RN, MS, ACNS-BC, CCM University of Arizona Medical Center Tucson, AZ Chapter 29, Alterations in White Blood Cell Function and Oncologic Emergencies Brenner, Zara R., MS, RN-BC, ACNS-BC College at Brockport, State University of New York Brockport, NY and Rochester General Hospital Rochester, NY Chapter 23, Alterations in Pancreas ­Function (with Maureen Krenzer) Cisney, Kathy Lea, MSN, APRN-BC, CWOCN, C Ped University of Kentucky Chandler Medical Center Lexington, KY Chapter 29, Complex Wound Management Dirkes, Susan, MSA, RN, CCRN Nursing Resource Consultants LLC Naples, FL Chapter 25, Alterations in Fluid and ­Electrolyte Balance Chapter 26, Acute Kidney Injury Ecklund, Margaret M., MS, RN, CCRN, ACNP-BC Rochester General Hospital Rochester, NY Chapter 6, Mechanical Ventilation Muzzy, Angela C., MSN, RN, CCRN University of Arizona Medical Center Tucson, AZ Chapter 8, Basic Cardiac Rhythm Monitoring Eksterowicz, Nancy R., MSN, RNBC University of Virginia Health System Charlottesville, VA Chapter 4, Acute Pain Management (with Donna Jarzyna) Nolde-Lopez, Grace, RN, MS, ANP-BC Craig Hospital Englewood, CO Chapter 19, Acute Spinal Cord Injury Jarzyna, Donna, MS, RN-BC, CNS-BC University of Arizona Medical Center Tucson, AZ Chapter 4, Acute Pain Management (with Nancy Eksterowicz) Priestley, Gail L., MSN, RN, ACNS-BC, CCRN University of Arizona Medical Center Tucson, AZ Chapter 11, Alterations in Pulmonary Function Kelso, Lynn A., MSN, APRN, ACNP-BC, FCCM, FAANP University of Kentucky Lexington, KY Chapter 22, Alterations in Liver Function Krenzer, Maureen, MS, RN, ANP, ACNS-BC Rochester General Hospital Rochester, NY Chapter 23, Alterations in Pancreas ­Function (with Zara Brenner) Lach, Helen W., PhD, RN, GCNS-BC Saint Louis University School of Nursing St Louis, MO Chapter 3, The Older Adult High-Acuity Patient (with Kristine L’Ecuyer) L’Ecuyer, Kristine M RN, MSN, CCNS, CNL Saint Louis University School of Nursing St Louis, MO Chapter 3, The Older Adult High-Acuity Patient (with Helen W Lach) Moore, Kathryn, DNP, RN, ACNP-BC, GNP-BC, CCRN, CEN Emory University Atlanta, GA Chapter 35, Acute Burn Injury Snyder, Kara A., MS, RN, CCRN, CCNS University of Arizona Medical Center Tucson, AZ Chapter 7, Basic Hemodynamic Monitoring Thacker, Diana, BSN, RN Kentucky Organ Donor Affiliates Lexington, KY Chapter 38, Solid Organ and ­Hematopoietic Stem Cell Transplantation (with Kathleen Wagner) Welsh, Darlene, PhD, RN University of Kentucky College of Nursing Lexington, KY Chapter 13, Alterations in Cardiac ­Function (with Kathleen Wagner) Chapter 14, Alterations in Myocardial ­Tissue Perfusion Accuracy Reviewer Rachel Kinder, PhD, RN Associate Professor Western Michigan University Bowling Green, KY A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM ▸ Reviewers Angie Koller, MSN, RN Ivy Tech Community College-Central Indiana Indianapolis, IN Deanna L Reising, PhD, RN, ACNS-BC, ANEF Indiana University School of Nursing Bloomington, IN Collin Bowman-Woodall, MS, RN Samuel Merritt University San Mateo, CA Jody Crossman, RN BSN  City College of San Francisco San Francisco, CA Sandra Wolfe Citty, PhD, ARNP-BC University of Florida Gainesville, Florida Antoinette France, MSNed, RN, CCRN Salt Lake Community College Salt Lake City, Utah Melissa A Bathish, PhD(c), RN, CPNP-PC University of Michigan School of Nursing Ann Arbor, MI Donna Molyneaux, PhD, RN Gwynedd-Mercy College Gwynedd Valley, Pa Judy Stauder, MSN, RN Stark State College North Canton, Ohio Elizabeth G Mencel, RN, MSN, CNE Montgomery County Community College,   Blue Bell, PA Laura B Sutton, PhD, ACNS-BC University of Florida College of Nursing Gainesville, FL Kristiann T Willliams, DNP, APRN, FNP-C Weber State University Ogden, Utah Sheri Tesseyman, RN, MS Westminster College School of Nursing and Health Sciences Salt Lake City, Utah Jennie M Wood, PhD, RN, CNE Youngstown State University Youngstown, OH Barbara Farris, MSN, RN Radford University School of Nursing Radford, VA A01_WAGN3408_06_GE_FM.indd 7 Phyllis D Wille, RN, MS, FNP-C, CNN Danville Area Community College Danville, Ilinois Diane Mulbrook, MA, RN Mount Mercy University Cedar Rapids, IA Sue Gosse, Ph.D., RN Eastern Illinois University Charleston, IL Thank You Michele Ochoa Oross, RN, BS, MPA City College of San Francisco San Francisco, CA Heather Kendall, RN, MSN, CCRN-CMC-CSC Missouri Western State University St Joseph, MO Karen Loving, MSN, RNC Gwynedd-Mercy College Gwynedd Valley, PA Deborah Barlock, MSN, RN Cleveland State University Cleveland, OH Becky Brown, MSN, BSN College of Southern Idaho Twin Falls, ID Joni Goldwasser, MSN, APRN, FNP-BC Radford University Waldron College School of Nursing Radford, Virginia Bonnie Kirkpatrick, RN, MS, CNS The Ohio State University Columbus, OH Karen Kulhanek, MA, BSN Kellogg Community College Battle Creek, MI Gail Nelson, MSN, BSN Westminster College School of Nursing Salt Lake City, UT Raywattie Sooklall, PhD, MSN, BSN Palm Beach State College Lake Worth, FL 28/08/14 5:05 PM Preface When the first edition of High-Acuity Nursing was published in 1992, the term high-acuity was largely confined to leveling patient acuity for determining hospital staffing needs rather than being applied to a type of nursing care or education Since that time, the meaning of the term high-acuity nursing has been evolving to increasingly represent a distinct category of nursing that denotes care of complex patients outside of the critical care setting For the purposes of this textbook, we continue to define highacuity in a way that is consistent with our original intent–that it represents a level of patient problems beyond uncomplicated acute illness on a health–illness continuum The high-acuity nurse then, cares for complex patients with unpredictable outcomes across care settings (to include critical care) Today, high-acuity patients are found in many health care settings, from high-skill long-term facilities to critical-care units The patient population is older and faces an increased number of health issues upon entering the health-care system Hospitalized patients are being discharged earlier, often in a poorer state of health In the home-health setting, nurses provide care to patients with mechanical ventilators, central venous catheter lines, IV antibiotic therapy, and complicated injuries Whereas critical-care units are considered specialty areas within the hospital walls, much of the knowledge required to work within those specialties is generalist in nature It is this generalist knowledge base that is needed by all nurses who work with patients experiencing complex care problems to assure competent and safe nursing practice New to This Edition The sixth edition of the book has undergone a chapter reorganization based on feedback from faculty and students • All chapters have been updated and many have been reorganized and expanded • Bulleted chapter summaries are included on the Student Resources site • Answers to the Clinical Reasoning Checkpoint exercises are now available on the Student Resources site • Posttest items have been revised to reflect changes in content and are written using NCLEX style; answers and their rationales are located on the Student Resources website • Emerging Evidence boxes have been updated • Oncological emergencies, hypertensive crises, and acute ­aortic problems and crises have been added • A new chapter has been added focusing on metabolic responses to stress that complicate the patient’s illness and recovery, such as thyroid and adrenal gland issues • The Table of Contents is now annotated with chapter section titles for ease of checking chapter contents • The Related Pharmacotherapy boxes now include adult dosages Purpose of the Text The High-Acuity Nursing text delivers critical information focusing on the adult patient, using learner-focused, active learning principles, with concise language and a user-friendly format The book’s design breaks down complex information into small, discrete chunks for easy understanding Self-testing is provided throughout the text, using short section quizzes and Posttests All answers to the section review quizzes are provided to give learners immediate feedback on their command of section content before proceeding to the next chapter section The chapters in this book focus on the relationship between pathophysiology and the nursing process with the following goals in mind To revisit and translate critical pathophysiological concepts pertaining to the high-acuity adult patient in a clinically applicable manner To examine the interrelationships among physiological concepts To enhance clinical decision-making skills To provide immediate feedback to the learner regarding assimilation of concepts and principles To provide self-paced learning Ultimately, the goal is for the learner to be able to approach patient care conceptually, so that care is provided with a strong underlying understanding of its rationale This book is appropriate for use in multiple educational settings, including undergraduate nursing students, novice nurses, novice critical-care nurses, and home-health nurses It also serves as a review book for the experienced nurse wanting updated information about high-acuity nursing for continuing education purposes Hospital staff development departments will find it useful as supplemental or required reading for nursing staff, or high-acuity/critical-care classes Organization of the Text The book is divided into ten parts: Introduction to High-Acuity Nursing, Therapeutic Support of the High-Acuity Patient, Pulmonary, Cardiovascular, Neurological, Gastrointestinal, Fluid and Electrolytes, Hematologic, Nutrition and Metabolism, and Multisystem Dysfunction Part One: Introduction to High-Acuity Nursing is c­ omposed of three introductory chapters with topics that apply across ­high-acuity problems, including an introduction to h ­ igh-acuity nursing and the care of high-acuity patients, and important considerations when caring for the high-acuity older adult Part Two: Therapeutic Support of the High-Acuity Patient, is composed of six chapters that focus on supportive interventions, including pain management, nutrition ­ support, mechanical ventilation, hemodynamic monitoring, basic cardiac rhythm A01_WAGN3408_06_GE_FM.indd 28/08/14 5:05 PM ▸ monitoring, and complex wound management Parts Three through Ten cover topics that represent the more common complex health problems, assessments, and treatments associated with high-acuity adult patients All chapters contain Learning Outcomes, Section Review Questions, Clinical Reasoning Checkpoint, Chapter Summary and Posttest Each chapter is divided into small sections that cover one facet of the chapter’s topic (e.g., pathophysiology or nursing management), and each section ends with a short selfassessment review quiz Key words are bolded throughout the chapters to indicate glossary terms defined in the textbook’s Glossary Parts through 10 of the book are composed of two different types of chapters, including Determinants and Assessment chapters and Alterations chapters Determinants and Assessment Chapters Each part begins with an overview of normal concepts that provides a solid foundation for understanding the diseases being presented Normal anatomy and physiology are reviewed and relevant diagnostic tests and assessments are profiled The therapeutic support and disease-focused (Alterations) chapters draw heavily on the normal concepts, diagnostic tests, and assessments covered in their respective Determinants and Assessment chapters Alterations Chapters Following each Determinants and Assessment chapter is a series of organ- or concept-specific chapters that focus on a single topic area The majority of Alterations chapters are based on body systems (e.g., Chapter 10, Alterations in Pulmonary Function) and include the ­pathophysiology, assessments, diagnostic testing, and collaborative management of disorders commonly seen in high-acuity adult patients Several Alterations chapters focus on complications of high-acuity illness, such as multiple organ dysfunction syndrome and sensory motor complications of acute illness The pathophysiologic basis of disease is emphasized in this textbook with the belief A01_WAGN3408_06_GE_FM.indd Preface that strong foundational knowledge about the basis of disease ­improves learner understanding of the associated disease manifestations and rationales for treatment Summary This text focuses on major problems and therapies frequently encountered in high-acuity patients It is not designed as a comprehensive textbook of adult medical-surgical or critical-care nursing The book’s format reduces learner feelings of being overwhelmed by complex information Learners are more apt to feel in command of the concepts, giving them the confidence to proceed to the more complex concepts The sixth edition of High-Acuity Nursing has maintained the overall look and feel of the previous editions, with some valuable changes Although the sixth edition has been reorganized, we have not compromised our interactive approach The ultimate goal of this book continues to be to enhance the preparation of nurses for practice in today’s health care settings Kathleen Dorman Wagner Melanie G Hardin-Pierce Acknowledgments With any publication, there are several years of sweat and tears that go into its development To our Development Editors, Pam Lappies and Elizabeth Cosgrove, thank you both so much for your patience, diligence, sense of humor and work ethic—the book would have never made it to fruition without your hard work It has been a true pleasure to work with you! We would also like to warmly acknowledge the wonderful work of our Accuracy Reviewer, Dr Rachel Kinder, PhD, RN, whose meticulous scrutiny of the information in the book chapters made our work much easier and significantly enhanced the quality and accuracy of the book Finally, our warm thanks also to our Posttest item writer, Pamela Fowler, who significantly added to the value of the Posttests 28/08/14 5:05 PM www.freebookslides.com 85 CH A PTER ▸ Acute Pain Management a­ nesthesiologist Whenever local anesthetics are administered, it is important for the healthcare provider to monitor the patient for systemic anesthetic toxicity Signs and symptoms of this complication include a 25% drop in baseline heart rate, tinnitus, slurred speech or thick tongue, and mental confusion Table 4–4 provides a comparison of pharmacologic pain interventions Oral The oral route is most commonly used for opioids This route is also the most inexpensive and convenient For the high-acuity patient, however, the oral route may not be available because of a nothing-by-mouth status Although these patients are not able to take medications orally, they may have feeding tubes that act as an alternate medication route When oral or enteral routes are used in the high-acuity patient, the Table 4–4  Pharmacologic Interventions Type/Route of Analgesia Advantages Limitations Oral (alone) Effective for mild-to-moderate pain Relatively contraindicated in patients with renal disease, risk of or actual coagulopathy, and risk of or active GI irritation or bleeding May mask fever Oral (as an adjunct to opioid) Potentiating effect results in opioid sparing Cautions as above Parenteral (ketorolac) Effective for moderate to severe pain Useful where opioids are contraindicated, especially to avoid respiratory depression and sedation May advance to opioid Cautions as above Oral (PO) As effective as parenteral in appropriate doses Route of choice Noninvasive, inexpensive Use as soon as oral medication tolerated Oral route may not be available for high-acuity patients Slower onset of action Intramuscular Avoid when other routes available Injections painful and absorption unreliable May cause tissue trauma Subcutaneous Less painful and preferable to IM especially when slow infusion technique (1–3 ml/hr) utilized Can place a butterfly needle for continuous infusions Bolus injections painful and absorption unreliable Transdermal fentanyl patch Useful when oral route unavailable Noninvasive Difficult to titrate due to delay of effective blood fentanyl concentrations Rectal Does not require functional IV May be appropriate in the patient unable to tolerate oral medications Absorption may be unpredictable, affected by defecation May not be acceptable to all patients Contraindicated in patients with painful anal conditions or who are at risk for infection (neutropenia) Intravenous (IV) Parenteral route of choice after major surgery or when oral route unavailable Suitable for titrated bolus or continuous infusion Requires intravenous access Requires monitoring, significant risk of respiratory depression with inappropriate dosing Patient-controlled analgesia (PCA) Can be used with intravenous, subcutaneous, or epidural routes Provides steady level of analgesia Provides patient control Avoids peaks and troughs Requires special infusion pumps and staff education Requires monitoring, significant risk of respiratory depression with inappropriate dosing Nonsteroidal anti-inflammatory drugs (NSAIDs) Opioids (continued) M04_WAGN3408_06_GE_C04.indd 85 30/08/14 12:13 PM www.freebookslides.com 86 Pa rt ▸ Therapeutic Support of the High-Acuity Patient Table 4–4  Continued Type/Route of Analgesia Advantages Limitations Epidural and intrathecal Provides good analgesia May be utilized for surgical or for cancer pain in specific circumstances May be used as a one-time injection (bolus) or as a continuous infusion Requires special infusion pumps and staff education Requires daily follow-up by experienced physician or pain team Requires monitoring, risk of respiratory depression higher with bolus dose than with continuous infusion Require daily follow up by experienced physician or pain team Local Anesthetics Epidural and intrathecal Effective regional analgesia Opioid sparing Addition of opioid to local will improve analgesia Usually used continuously Requires careful monitoring, special pumps and staff education Risk of hypotension, weakness, and numbness Peripheral nerve block Effective regional analgesia Used postoperatively or for trauma pain Opioid sparing May be one time injection or continuous infusion Requires careful monitoring, special pumps and staff education Data from Ballantyne (2002) and Ducharme (2011) clinician should monitor gastric function to assure absorption Patients may vomit medications before the analgesic has time to absorb Patients with diarrhea or rapid gastric emptying or dumping syndrome may not absorb pills effectively Intravenous The intravenous (IV) route can be used by the nurse or self-administered by the patient using IV PCA The most common method of PCA allows the patient to self-dose intravenously by pushing a button that is attached via a cord to an infusion device The infusion device can be programmed for the patient to self-administer doses of opioid without becoming overly sedated Other forms of PCA are through the subcutaneous and the epidural route When IV access is not possible, the rectal or sublingual routes should be considered in preference to the traditional use of subcutaneous (subcu) and intramuscular (IM) routes because these two routes can cause tissue trauma and pain In addition, the absorption of medications using subcu and IM routes is affected by individual patient factors such as heat, fever, and vasoconstriction that can either delay effectiveness or pose additional safety risks because peak effectiveness will be altered Intraspinal Intraspinal opioids can be administered in a variety of ways: • Single-dose epidural or intrathecal • Intermittent scheduled dose epidural or intrathecal • Intermittent patient-controlled epidural (PCEA) or intrathecal • Continuous infusion of opioid alone or in combination with local anesthetic epidural or intrathecal • Continuous infusion plus patient-controlled opioid alone or in combination with local anesthetic (American Pain Society, 2008) Epidural The goal of epidural analgesia is to instill analgesics into the epidural space to minimize discomfort and optimize M04_WAGN3408_06_GE_C04.indd 86 the patient’s recovery, while minimizing side effects The epidural route requires insertion of a small catheter into the area located just before the dura mater The analgesia is then available to cross the dura mater into cerebral spinal fluid An opioid, or a combination of opioid and local anesthetic, is delivered by injection or by using an infusion device The opioids diffuse across the dura mater and bind at opioid receptors The local anesthetic selectively blocks sensory nerve fibers that make up the spinal nerve roots, acting as a neural blockade The spinal nerve roots pass through the epidural space to the spinal cord, thus creating a convenient space to infuse drugs Combinations of opioid and local anesthetic agents are used to modulate the transmission of pain through different pathways This route requires low doses of analgesic, whether administered alone or in combination Side effects are minimized because lower concentrations are delivered directly to the site of action and little drug is available for systemic absorption Opioids are more potent in the epidural than IV because there is less protein binding (than in plasma); thus, more opioids are available at the receptors, resulting in less vascular uptake Neural blockade provides analgesia without the CNS effects of sedation, drowsiness, and respiratory depression that can occur when analgesics are given systemically (oral [PO], IV, or intramuscular [IM]) The benefits include: longer acting analgesia, avoidance of peaks and valleys in pain control, earlier ambulation in the postoperative patients, and lower doses Intrathecal The intrathecal route for analgesia requires the passage of a small needle or catheter directly into the cerebrospinal fluid (CSF) space Opioid flows through the CSF and rapidly binds to opioid receptors in the spinal cord Even smaller amounts of an intrathecally administered drug are required to achieve the same effects as epidural administration 30/08/14 12:13 PM www.freebookslides.com 87 CH A PTER ▸ Acute Pain Management This method places the spinal cord at some degree of risk, however, because of the potential for mechanical or chemical irritation or damage Because there is no added protection from the dura mater to prevent bacterial flow, there is a higher risk of infection through the direct intrathecal route Many ­ methods are available to deliver intrathecal medications, including ­percutaneous catheters, implanted ports, and implanted pumps Use of the epidural or intrathecal routes requires close communication between anesthesiology and nursing staff and careful monitoring of the patient Generally, this route is contraindicated in high-acuity patients who are septic or anticoagulated Peripheral Nerve Block A peripheral nerve block (PNB) is used to directly block pain transmission by bathing the nerve or surrounding area with local anesthetics PNBs are used for moderate to severe pain and can be administered either through a single injection or a continuous infusion The peripheral nerve path that is transmitting the pain is located largely by ultrasound or occasionally by a nerve stimulator The sites most frequently used for peripheral nerve blocks are the intercostal nerves medial to the insertion site of chest tubes, brachial plexus for rotator cuff repair, axillary for hand trauma or surgery, and lower extremities such as the femoral nerve prior to total knee arthroplasty (Eksterowicz et al., 2010) The duration of the analgesia depends on the half-life of the local anesthetic that has been injected A low concentration of local anesthetics can also be infused continuously Pleural Infusion The pleural infusion route primarily is used when multiple rib fractures are present A small catheter is placed into the pleural space (between the visceral and parietal pleura) and a local anesthetic is injected By administering a local anesthetic via this route, multiple intercostal nerves can be blocked at one time without repeated needle sticks to the skin Nonpharmacologic Interventions The National Institutes of Health (NIH), National Center for Complementary and Alternative Medicine or NCCAM (2009), defines complementary therapies as therapies used with conventional medicine Alternative therapies are generally used to replace conventional medicine, and integrative medicine refers to evidence-based pharmacologic and nonpharmacologic therapies that are used to promote wellness and healing, rather than to react treatment to illness or disease Nonpharmacologic therapies are often used concurrently with medications to manage pain The role of the clinician is to assist the patient in identifying the safety and ­effectiveness of therapies or interventions When appropriate, the c­linician identifies the risks and potential benefits of complementary ­ ­therapies All clinicians involved in the patient’s care have a role in providing the necessary support for utilization of these therapies as outlined in the care plan Guidelines for choice of nonpharmacologic interventions include pain p ­ roblem ­identification, effectiveness for a specific patient, and the skill of the clinician Nurses should seek additional education from qualified and licensed complementary and alternative m ­ edicine (CAM) practitioners (O’Conner-Von, Osterlund, Shin, & Simpson, 2010) Table 4–5 provides some simple guidelines for promoting relaxation and possibly reducing pain levels in high-acuity patients Table 4–5  Simple Guidelines Promoting Relaxation in High-Acuity Patients Technique Description Guided imagery Ask the patient to imagine a safe and peaceful scene that is restful and happy Instruct the patient to imagine the sounds and smells or the sensations such as warmth or cool Initially the patient may want to describe the scene or if the patient is unable to communicate you may want to guide them with suggestions Allow your voice to become rhythmic as you guide them through a special image Watch the patient’s eyelids for fluttering as this may be an indication that the patient is imagining the scene Focused breathing Instruct the person to breathe normally Do not require him or her to take deep breaths Coach the person to breathe in through the nose and out the mouth Repeat INHALE–EXHALE slowly and steadily Prolong the exhale When the person begins to maintain the rhythm, instruct the person to think about the air as it fills the nose, sensing the air as it moves through the throat and down into the lungs Picture the lungs opening to receive the fresh air Instruct the patient to think only of the air, exhaling all other thoughts away with each breath With closed eyes ask the person to visualize the air, softly moving throughout the body As the air passes through the body it caresses and calms flowing and ebbing Allow the person to continue for several minutes practicing the breathing Progressive muscle tension/relaxation Instruct the person to slowly tense then relax each muscle group Help the person to focus on the difference between muscle tension and relaxation, allowing the person to be more aware of physical sensations Instruct to start by tensing and relaxing the muscles in the toes and progressively working up to neck and head Have the person tense muscles for at least five seconds and then relax for 30 seconds, and repeat General Tips Unless your patient requests specific cognitive therapies, normalize non-pharmacologic therapies Some patients may have preconceived ideas about the meaning of therapies such as hypnosis and relaxation therapies Always speak in a clear, slow, calm, and concise voice If the person is hard of hearing get close and speak loud and clear, but not yell Provide a quiet environment using soft music or rhythmic background noise Use these techniques for short periods and return frequently as the person requires practice M04_WAGN3408_06_GE_C04.indd 87 30/08/14 12:13 PM www.freebookslides.com 88 Pa rt ▸ Therapeutic Support of the High-Acuity Patient In general, especially with acute pain, nonpharmacologic interventions are useful in combination with analgesia and not take the place of analgesics Nonpharmacologic therapies can be initiated when pain is under reasonable control Assessment of the patient’s past experience with nonpharmacologic therapies is beneficial as patients may have experience with therapies that are compatible with their coping style and have been helpful in the past The provision of adequate support materials (written or audio) will increase the benefit of such interventions A patient who is fatigued, frightened, or in considerable pain will not be able to concentrate well enough to follow instructions or to perform time-consuming or complicated interventions Section Four Review The World Health Organization (WHO) Analgesic Ladder provides the clinician with what information? A General pain management choices based on level of pain B Nonpharmacologic interventions based on level of pain C Specific pain management choices based on severity of pain D Pharmacologic and nonpharmacologic pain management choices Which statement regarding nonopioid therapy is correct? A B C D Nonopioids have more severe side effects than opioids Nonopioids are harder to access than opioids Nonopioids can manage pain as effectively as opioids Combining opioids and nonopioids enhances analgesia effectiveness Emerging Evidence ■ In the emergency department (ED) setting, mandatory pain scoring using the ED computer ­information system during initial triaging resulted in significantly faster initiation of analgesia (Vazirani & Knott, 2012) ■ Pain is a major report of patients coming into the ED and seeking pain relief Nurses, however, report significant barriers to demonstrating proper care when dealing with pain in their ED patients Reported barriers included feelings of being overwhelmed by the fast pace and constant prioritizing and seeming lack of control; feelings of noncohesiveness among the ED staff, concerns about the complexity of pain, unrealistic patient expectations, and others (Bergman, 2012) ■ In hospitalized patients, pain management is an ­important factor in patient satisfaction and w ­ ell-being Nurses have the major responsibility to meet patient comfort needs A survey on nursing pharmacology knowledge and attitudes regarding pain was ­conducted Investigators found a negative correlation between the survey score and a nurse’s age and ­experience but a positive correlation between the score and a nurse’s educational level They concluded that nurses ­require ongoing education about pain management; h ­ owever, education alone is not sufficient to result in ­significant improvement in patients’ pain experiences (Lewthwaite et al., 2011) M04_WAGN3408_06_GE_C04.indd 88 What is the most common route used for PCA? A B C D Intramuscular Intravenous Subcutaneous Epidural The guidelines for choosing appropriate nonpharmacologic inter­ventions include which of the following? (Select all that apply.) A Skill of clinician B Effectiveness for patient C Pain problem identification D Type of opioid being used Answers: A, D, B, (A, B, C) Section Five: Issues in Inadequate Treatment of Acute Pain The undertreatment of pain has remained a persistent challenge for the medical and nursing professions despite advances in scientific knowledge regarding pain and its treatment (Strassels, McNicol, & Suleman, 2008) The undertreatment problem is multifactorial and involves complex social and healthcare system issues, as well as inadequate attention being given to pain education in many pharmacy, medicine, and nursing educational professional programs The authors conclude that, “Important clinical, human, and economic consequences of this shortcoming include altered immune system functioning, diminished ability to function, increased risk for chronic pain, needless suffering, and higher healthcare costs” (Strassels et al., 2008, p 276) This section provides a brief overview of some of the major pain-related misconceptions that often lead to undertreatment Definitions It is important to differentiate among tolerance, dependence, and addiction, terms that are misused and have potentially negative connotations The definitions of the following terms are as follows: • Tolerance A decrease in effectiveness or diminishing sideeffects for the same dose that had previously been effective or caused the side effects • Physical dependence When a drug is abruptly reduced or stopped, or an antagonist is given, symptoms of withdrawal occur Generally, the person will experience increased pain, nausea, malaise, chills, sweating, and confusion (American Society of Addiction Medicine [ASAM], 2011) 30/08/14 12:13 PM www.freebookslides.com CH A PTER ▸ Acute Pain Management • Addiction A chronic neurologic and biologic disease It is characterized by behaviors that include one or more of the following: impaired control of drug use, compulsive use despite harm to self or others, craving, and use of drug for purposes other than pain relief (Pasero, Polomano, Portenoy, & McCaffery, 2011) • Opioid pseudoaddiction A term applied to patients who develop behaviors that mimic those associated with addiction The individual may be labeled as drug craving or drug seeking Pseudoaddiction, however, results from inadequate pain management, not psychological dependence A variety of responses are noted in patients who experience unrelieved pain, from acceptable drug seeking to pathologic ­behaviors Unfortunately, it is often extremely difficult for nurses and physicians to discriminate between these two types of behaviors, particularly in situations in which patient–physician/ nurse contact is limited, such as in the emergency department Behaviors that suggest undertreatment of pain but are frequently misread as drug seeking rather than pain relief seeking include demands for different or more pain medications that escalates, clock watching, preoccupation with obtaining pain medications, and anger (ASAM, 2011) Pseudoaddiction results in a patient’s distrust and suspicion of staff and avoidance of the patient by staff Pseudoaddiction is distinguishable from actual addiction by resolution of ­aberrant behaviors when pain is relieved (ASAM, 2011) Reasons for Opioid Undertreatment of Pain The practice of treating pain with minimal drug use is known as oligoanalgesia Physicians underprescribe opioids by two methods: prescribing subtherapeutic doses and prescribing time intervals for drug doses that are shorter than the pharmacologic duration of action Nurses undertreat pain by administering less than the prescribed dose for the patient and ­administering opioids at longer intervals than prescribed Patients often c­ ontribute to their own undertreatment of pain by not requesting as needed (PRN) pain medications, taking medication at longerthan-ordered intervals, taking less than the amount prescribed, or refusing to take the drug at all (Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011) Inadequate treatment of pain is a complex problem based on misconceptions widely held by physicians, nurses, and patients There are four common misconceptions regarding opioid use that contribute to inadequate treatment: fear of addiction, physical dependence, tolerance, and respiratory depression Fear of Addiction (Psychological Dependence) Fear of addiction is probably the major cause of undertreatment of pain The term opiophobia has been used to describe the ­ irrational fear of prescribing (or consuming) adequate amounts of opiates for therapeutic results In fact, very few ­hospitalized patients who receive opioids become addicted; as the pain subsides, so does the use of the opioids The term ­addiction should be used with extreme caution The indiscriminate labeling of a person who uses drugs as being an addict M04_WAGN3408_06_GE_C04.indd 89 89 carries a strong social stigma that may negatively label an individual (Pasero & McCaffery, 2011) Fear of Physical Dependence Some of the fear associated with physical dependence is generated from the belief that opioid withdrawal is life-threatening, the symptoms associated with physical dependence are difficult to control, and the presence of symptoms of physical dependence prevent decreases in opioid doses as the pain decreases In addition, many people believe that addiction is the natural progression of physical dependence It is true that any patient who receives repeated doses of opioids is at risk for some degree of withdrawal symptoms if the opioid is suddenly stopped These symptoms, however, can be effectively managed by gradual reduction in opioid dosage as the patient’s pain subsides (Pasero, Quinn et al., 2011) Fear of Tolerance Fear of tolerance is usually seen in ­ atients with long-term pain associated with either a disease p process or painful treatments (e.g., patients with burns, cancer, or life-threatening illnesses) Patients, physicians, and nurses have expressed fear that opioids lose their effectiveness over time and may not work when really needed A part of this fear is the belief in an imaginary dose ceiling, beyond which the drugs cannot be taken In fact, this feared dose ceiling does not seem to exist As tolerance to an opioid develops, so does the patient’s tolerance to the side effects of sedation and respiratory depression Tolerance is treated by decreasing the dose interval or increasing the dose Nursing management should focus on patient education about the concept of tolerance, and monitoring for the therapeutic and nontherapeutic effects of the adjusted dosage (Pasero, Quinn et al., 2011) Fear of Respiratory Depression Physicians and nurses are particularly sensitive to the fear of respiratory ­depression All opioids have the capability of causing ­respiratory depression, yet it need not be a life-threatening problem and should not prevent therapeutic opioid use In the majority of hospitalized patients, respiratory depression has not been shown to be a significant problem Nursing assessment should focus on close observation of the patient’s response to opioids Sedation develops before respiratory depression; therefore, the nurse should observe and document whether the patient becomes oversedated following the administration of opioids Respiratory depression is dose related, and low doses are generally considered safe Monitoring for oversedation is the only way to determine what dose of an opioid will cause respiratory depression in any given patient It is important to watch the individual’s response, especially to the first dose Use of a standard assessment for opioid oversedation is considered best practice In the high-acuity patient the most commonly used scales to assess and document sedation are the Pasero Opioid-Induced Sedation Scale (POSS), the Richmond Agitation and Sedation Scale (RASS) and the Aldret (a scale commonly used to assess readiness for discharge from the postoperative care unit) The POSS is the only scale designed to assess sedation from opioids and then select the appropriate course of action (Pasero, Quinn et al., 2011) A study comparing the effectiveness of selected scales in evaluating sedation, 30/08/14 12:13 PM www.freebookslides.com 90 Pa rt ▸ Therapeutic Support of the High-Acuity Patient including RASS and POSS, concluded that the POSS was superior to the other scales in measuring sedation in patients receiving opioids (Nisbet & Mooney-Cotter, 2009) The POSS is a simple scale comprised of descriptive criteria, including S (sleep, easy to arouse), (awake and alert), (slightly drowsy, easily aroused), (frequently drowsy, arousable, drifts off to sleep during conversation), and (somnolent, minimal or no response to verbal and physical stimulation) Criteria and are considered an unacceptable level of opioid sedation (Nisbet & Mooney-Cotter, 2009) doses to regularly scheduled analgesics, primarily when a certain known activity causes pain (e.g., ambulation, sitting up in a chair, coughing, and deep breathing) It is recommended that the nurse as a patient advocate be alert to the patient’s comfort status and be proactive in consulting with the physician regarding changing the PRN order to ATC if a more effective analgesia schedule is required The nurse also has an important role in educating the patient and family regarding effective analgesia scheduling Nursing Approach in Acute Pain Management a­ djusting and individualizing therapy based on the effects the drug is having on the patient rather than the milligrams being administered The goal is to gain the desired level of pain relief with minimum side effects When using this approach, the ­clinician should consider the following: The way in which an analgesic is administered is probably more important than which drug is administered (Pasero, Quinn et al., 2011) In the acute care setting, the nurse maintains significant control over how analgesics are administered Nursing activities that have an impact on therapeutic pain management include the following: • Selecting an appropriate opioid or nonopioid from the analgesics ordered • Evaluating when to administer the analgesic • Evaluating how much analgesic to administer • Obtaining a change in prescription when required Effective pain management requires objective assessment skills and specific knowledge of opioids and nonopioids In addition, the nurse must individualize the care plan to best meet the patient’s individual comfort needs There are two major approaches to effective pain management: the preventive and the titration approaches Preventive Approach Using the preventive approach, analgesics are administered before the patient complains of pain For example, when pain is occurring consistently over a 24-hour period, administering analgesics on a regular a­ round-the-clock (ATC) schedule is more effective than administering them PRN This method helps to maintain a consistent therapeutic level of analgesic in the bloodstream and diminishes the likelihood of undertreatment of pain Administering pain medication on a PRN basis can cause prolonged delays in treating the patient’s pain If PRN analgesia is to be used, it is i­mportant for the clinician to know the halflife and effectiveness of the medication being administered in order to predict when the patient is likely to need another dose Maintaining awareness of pain by offering pain medication on a routine b ­ asis is more effective for pain control than requiring the patient to ask for medication (PRN) The patient may wait for the pain to ­become severe before requesting ­analgesia, or the clinician may be delayed in getting the drug to the patient Either situation makes adequate pain relief more difficult to obtain There are times when PRN administration is an ­acceptable option, for example, changing to PRN late in the p ­ ostoperative course to help decrease side effects; or when the pain is ­incidental, intermittent, or unpredictable (Pasero, Quinn et al., 2011) In addition, PRN analgesics may be used as supplemental M04_WAGN3408_06_GE_C04.indd 90 Titration Approach The titration approach calls for • Dose Analgesic potency helps provide a rational basis for choosing the appropriate starting dose • Interval between doses Assess the patient regarding the amount of time it takes for the pain to increase For example, if the nurse is administering an analgesic every four hours and the patient notices that the pain increases quickly after three hours, the interval should be changed to three hours • Route of administration Use a conversion chart for equal analgesic dosing when switching from one route to another (see Table 4–6) In general, the oral dose is the preferred route unless oral administration is no longer possible, making it necessary to switch to the IV route The most common reason for switching from IV to oral is when the pain is subsiding Equianalgesic conversion should be done without loss of pain control • Choice of drug In general effective analgesia with opioids is dose related and rarely requires a switch to another opioid Unrelieved pain is not considered a reason for ­ switching from one opioid to another The most common reason for switching from one class of opioids to another is for the management of side effects When switching from one opioid to another, it is important to monitor the patient for a heightened risk of incomplete tolerance The patient who is already tolerant to the original opioid may not be tolerant to the new opioid In such cases, it is recommended to reduce the starting doses by 25–50% (Pasero, Quinn et al., 2011) Opioids are classified as full (pure) opioid agonists, partial agonists, or mixed agonist–antagonists Full ­agonists are more ­potent than partial agonists Agonist–­ antagonists activate one type of opioid receptor and at the same time block another type Withdrawal-like symptoms can ­occur when switching a ­patient from a pure agonist to an agonist–antagonist Regardless of the approach chosen to treat pain, undertreatment can still occur Improved education for all healthcare professionals about pain and its treatment is a crucial first step in reversing this problem Further, the high-acuity nurse must act as the patient’s advocate through open communication with the other interdisciplinary team members when there is perceived undertreatment of pain 30/08/14 12:13 PM www.freebookslides.com 91 CH A PTER ▸ Acute Pain Management Table 4–6  Equianalgesic Doses of Selected Opioids Drug Trade Name Routes Equianalgesic Dose (MG) Morphine Generic IM/IV 10 4-6 (IM) PO/R 30 4-7 IM/IV 1.5 4-5 (IM) PO/R 7.5 4-6 IM/IV 130 4-6 (IM) PO 200a 4-6 Hydromorphone Codeine Generic; Dilaudid Generic; APAP; Tylenol 3, etc Duration (Hours) Oxycodone Generic; w/APAP; Percocet w/ASA; Percodan PO 20 3–5 Fentanyl Generic; Sublimaze; Duragesic IM/IV 0.1 1–2 IM 4-6 R 10 4-6 IM/IV 75 4-5 (IM) PO 300 4-6 Topical Oxymorphone Meperidineb Numorphan Generic; Demerol (not recommended) a The dose of codeine may be lowered when administered as a combination product containing aspirin or acetaminophen, which work synergistically Meperidine has very limited use, as the toxic metabolite, normeperidine, builds to unacceptable levels in the CNS b Section Five Review A common physiologic consequence of chronic opioid use that results in a person’s requiring an increasing dose of opioids to maintain the same level of analgesia defines which term? A B C D Pseudoaddiction Tolerance Psychological dependence Physical dependence Which statement is correct regarding opioid use and ­respiratory depression? A B C D Respiratory depression precedes the onset of sedation Respiratory depression worsens as tolerance develops Sedation occurs before respiratory depression Respiratory depression is a common problem in hospitalized patients 3 PRN analgesics are appropriately used in which situations? (Select all that apply.) A B C D When pain is intermittent When pain is consistent When pain is unpredictable When used as a supplement to scheduled doses When the titration approach to pain management is used, the emphasis is on what? A The patient’s analgesic response B Total milligrams per day C Physical dependance D Psychological dependance Answers: B, C, (A, C, D), A Section Six: Monitoring for Opioid-Induced Respiratory Depression reversal is not necessary Naloxone is presented in detail later in this section Respiratory depression is a feared but essentially preventable complication of opioid analgesia The relationship between an opioid analgesic dose and the effects on analgesia and ­respiratory depression varies based upon genetic, gender, age, comorbidities, concurrent sedating medications and the route of administration (Overdyk, 2009) Pharmacologic interventions using an opioid antagonist such as naloxone (Narcan®) reverses opioid effects (referred to as “rescue dosing”); h ­ owever, rapid reversal is not without risks Therefore, it is to the patient’s advantage when the nurse is able to anticipate and prevent respiratory depression, best assuring that rapid opioid There are a variety of factors (variables) that increase the likelihood of respiratory depression in patients receiving opioids These factors can be divided into patient and iatrogenic variables (see Box 4–2) Clinically significant respiratory depression is defined by more than respiratory rate It encompasses rate and quality of respirations Respirations should be assessed for 60 seconds and compared to the patient’s baseline, allowing time for the nurse to evaluate trends in ventilation The duration of the assessment provides an opportunity to evaluate quality of respirations, which includes depth, regularity and snoring that may be associated with airway obstruction Assessment during sleep M04_WAGN3408_06_GE_C04.indd 91 Assessment 30/08/14 12:13 PM www.freebookslides.com 92 Pa rt ▸ Therapeutic Support of the High-Acuity Patient Box 4–2  P  atient and Therapy Related Variables for Opioid-Induced Respiratory Depression Patient Variables Age Pulmonary disease or compromise History of obstructive sleep apnea (OSA) (History of snoring or witnessed apnea during sleep) Body mass index (BMI) of greater than 30 kg/m2 Neck circumference of greater than 17.5 inches Impaired renal or hepatic function Neurologic disorder resulting in muscle weakness Iatrogenic (Therapy) Variables Modality and Level Risk: ■ Lowest Risk: Continuous epidural infusion ■ Moderate to High Risk: Basal or continuous intravenous ­infusion First 24 hours postoperatively Hospital Environment Variables ■ Night shift ■ Patients admitted to units where nurses are unfamiliar with their care; a poor environment of care, such as poor ­nursing/ management or nursing/physician communication; or poor staffing and less education of nursing staff providing care Data from George et al (2010), Needleman et al (2011), Ramachandran et al (2011), Schmid-Mazzaccoli, Hoffman, Wolf, Happ, & DeVita (2008) is best accomplished before waking or stimulating the patient as arousal stimulates respiration and prevents an accurate evaluation of the patient’s respiratory status during sleep It should be noted again that the night shift is a more frequent time for unanticipated respiratory depression Sedation Assessment The nurse’s recognition of advanc­ ing sedation is a sensitive indicator of impending respiratory depression (Pasero & McCaffery, 2011) Opioid analgesia depresses both respiratory effort and rate, relaxes pharyngeal tone and depresses the response to hypoxia and hypercarbia Sedative effects of opioids generally precede respiratory depression The use of a valid and reliable tool in sedation assessment is key to monitoring sedation Two tools which have been tested in the arena of opioid analgesia are the POSS (Box 4–3) and the RASS, both of which are valid and reliable The advantage of the POSS is that it includes recommended nursing actions for each level of sedation, providing direction for intervention for oversedation Use of Technology in Assessment Technological monitoring adds complexity and time to the nursing assessment; however, this is offset by early recognition of ventilatory changes Continuous monitoring of oxygen saturation by pulse oximetry (SpO2) and end tidal carbon dioxide (EtCO2) levels, allows trending of critical parameters for earlier recognition of impending respiratory depression Pulse Oximetry Pulse oximetry measures oxygen ­saturation in arterial blood and pulse rate Continuous monitoring of oxygen saturation has been recommended when initiating ­ opioid analgesia for patients at high risk for opioid induced M04_WAGN3408_06_GE_C04.indd 92 Box 4–3  P  asero Opioid-Induced Sedation Scale (POSS) S = Sleep, easy to arouse Acceptable: No action necessary; supplemental opioid may be given if needed = Awake and alert Acceptable: No action necessary; supplemental opioid may be given if needed = Slightly drowsy, easily aroused Acceptable: No action necessary; supplemental opioid may be given if needed = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable: Decrease opioid dose by 25–50% Administer acetaminophen or an NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely until sedation level is less than = Somnolent, minimal or no response to physical stimulation Unacceptable: Stop opioid Notify anesthesia provider; very slowly administer dilute IV naloxone (0.4 mg ­naloxone in 10 mL saline; 0.5 mL over 2-minute period); administer acetaminophen or an NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely until sedation level is less than Pasero Opioid-Induced Sedation Scale (POSS) by Chris Pasero from Pain Assessment in the Patient Unable to Self-Report: Position Statement with Clinical Practice Recommendations Reproduced by permission of Chris Pasero respiratory depression in order to facilitate the identification of trends One study found that pulse oximetry monitoring did not affect the rate of patient transfer to the intensive care unit, but did decrease the ICU length of stay and cost, potentially due to early intervention (Taenzer, Pyke, McGrath, & Bilke, 2010) Capnography Opioids suppress ventilation; therefore, monitoring of EtCO2 and respiratory rate, as well as oxygenation, is appropriate EtCO2 monitoring has been shown to detect changes in ventilation (the exchange of air between the lungs and the atmosphere) earlier than pulse oximetry which simply measures the oxygen saturation of hemoglobin (Kopka, Wallace, Reilly, & Binning, 2007) Normal EtCO2 levels are 35–45 mm Hg Decreased respiratory rate (hypoventilation) increases EtCO2 levels, and patients with pulmonary disease may have elevations in baseline EtCO2 levels due to chronic ventilation problems Assessment and documentation of the patient’s baseline EtCO2 as a comparison to current levels allows for trending of ventilatory status The nurse should report an upward trend of EtCO2 levels from normal or from the patient’s baseline In summary, pulse oximetry only measures oxygenation, and EtCO2 only measures ventilation; therefore, to adequately reflect patient status, monitoring of both is necessary The combination of technological monitoring, careful monitoring of respiratory rate and quality, and monitoring of the patient’s sedation level with a valid and reliable tool provides a more comprehensive overview of the patient status Nursing Interventions Assessment of the patient’s risk factors (individual and ­iatrogenic) must be documented in a manner that allows the 30/08/14 12:13 PM www.freebookslides.com CH A PTER ▸ Acute Pain Management information to be accessible across the continuum of care to all providers The plan of care for patients at a higher risk for respiratory depression should include a greater frequency and intensity of monitoring (e.g., the use of continuous technological monitoring during opioid analgesia) Continuation of higher level of monitoring should be based upon the patient’s response to opioid therapy as evidenced by level of sedation, respiratory rate and quality, oxygenation saturation, and EtCO2 levels The patient’s risk and the plan of care should be communicated at care transitions during hand off communication Once oversedation and a downward trend in respiratory rate and quality have been identified, monitoring frequency and intensity must be increased Rapid opioid dose reductions may be considered when pain levels allow Opioidsparing therapies, such as the use of nonsedating analgesics (e.g NSAIDs or acetaminophen) may decrease this downward trend Working collaboratively with the prescribing healthcare provider to consider the omission of or dosage decrease of other sedating agents may also be effective in reducing the risk of advancing sedation and respiratory depression For example, a nonsedating antiemetic such as Ondansetron can replace a sedating agent such as Phenergan Stimulation of the patient may be adequate to prevent hypoventilation until the analgesic effect decreases This approach requires individual nursing attention or transfer to a higher level of care Opioid Reversal Agent Naloxone (Narcan), may be required if the patient develops severe respiratory depression (respiratory rate below eight breaths per minute or increasing sedation with minimal patient response to physical stimulation, an oxygen saturation below 90% and/or ongoing upward trend of EtCO2) (Pasero & McCaffery, 2011) The half-life of naloxone is 30–81 minutes (Pasero & McCaffery, 2011), which can result in an extended time during which the patient may be in extreme pain Use of naloxone can also result in opioid withdrawal symptoms and other potentially major complications (see Box 4–4) The naloxone dose should be administered slowly to avoid the sudden onset of pain or opioid withdrawal, in order to avoid precipitation of a sympathetic crisis The exact PCA ­opioid reversal protocol will be specified by the prescribing healthcare provider or agency policy Increased frequency and intensity of monitoring should continue until the analgesic 93 Box 4–4  P  otential Negative Effects of Rapid Reversal of Opioids ■ ■ ■ ■ ■ Rapid onset of opioid withdrawal symptoms Severe pain Sympathetic Nervous System Crisis (tachycardia, tachypnea, and hypertension) Myocardial ischemia, myocardial infarction, pulmonary edema Reduced effectiveness of opioid therapy if resumed following reversal Data from Arnstein (2011) and Pasero & McCaffery (2011) dose has been metabolized as naloxone has a relatively short duration of action, allowing symptoms to return (American Pain Society [APS], 2008; Pasero & MacCaffery, 2011) Additional information on naloxone is provided in the box Related Pharmacotherapy: Opiate Reversal Agent Note that pain experts recommend a dilute solution of naloxone to avoid the creation of complications related to unrelieved pain and to prevent creation of a stress response One ampule of naloxone, 0.4 mg, can be diluted in 10 milliliters (mL) of saline and can be administered at 0.5 mL by IV push every 2–3 minutes until the patient is responsive Titration of naloxone is discontinued as soon as the patient becomes responsive and respirations become normal (Arnstein, 2011; Pasero & McCaffery, 2011) Sedatives and analgesics in large doses are frequently administered in the ICU and contribute to delirium, which is subsequently associated with a longer hospital stay and decreased quality of life after discharge from the ICU Delirium is also associated with increased mortality Skrobik et al., (2010) ­measured outcomes after implementing a protocol to ­manage analgesia, sedation, and delirium for 604 patients The ­education protocol included nonpharmacologic management of symptoms and individualized titration of sedation, analgesia, and delirium therapies The use of coanalgesics such as acetaminophen and NSAIDs was encouraged The protocol was associated with better outcomes in terms of superior analgesia, lower mean doses of opioids, shorter duration of mechanical ventilation and shorter ICU and hospital length of stay Decreasing the mean doses of opioids and sedative use was accomplished by individualizing the care of each patient Section Six Review What statement about opioid-induced respiratory depression is accurate? a It is not of concern, since it can be immediately reversed with an opioid antagonist such as naloxone b It prevents tachypnea in the anxious patient with pain c Prevention is best for the patient in order to decrease risk and side effects or complications of reversal d It occurs more frequently during the first 24 hours postoperatively 2 What is the safest modality for opioid analgesia? a b c d Patient controlled analgesia IV bolus Oral Epidural M04_WAGN3408_06_GE_C04.indd 93 Use of continuous SpO2 and EtCO2 monitoring for early recognition of impending respiratory depression has which major advantage? a b c d They monitor oxygenation status They monitor oxygenation and ventilation status They monitor ventilation status They monitor sedation and ventilation status 4 What statements about evaluating patient risk for opioid-induced respiratory depression are accurate? (Select all that apply.) a b c d It is necessary during the admission process It only is important in opioid-naïve patients It is the responsibility of the physician It provides essential information to communicate at ­transitions in care Answers: C, D, B, (A, D) 30/08/14 12:13 PM www.freebookslides.com 94 Pa rt ▸ Therapeutic Support of the High-Acuity Patient Related Pharmacotherapy: Opiate Reversal Agent* Opioid Antagonist Major Side/Adverse Effects naloxone hydrochloride (Narcan) "" Actions and Uses Short-acting narcotic antagonist Used for rapid reversal of narcotic overdose Rapidly reverses sedation, respiratory depression, and hypotension associated with overdose Naloxone replaces the opioid at the Mu receptor sites; therefore, once reversal ­occurs, the opioid analgesic effects will rapidly cease Dosages (Adults) Bolus Administration: Opiate overdose: 0.4 – mg IV and repeat every 2–3 up to 10 mg if needed; administer over 10–15 seconds minimally Postoperative opiate depression: 0.1 – 0.2 mg IV and repeat every 2–3 up to doses if needed; administer over 10–15 seconds minimally IV infusion administration: Dilution required (2 mg in 500 mL NS or D5W) to make concentration of mcg/mL Section Seven: Pain Management in Special Patient Populations Several important patient-focused factors influence acute pain management These factors include age, concurrent medical disorders, and history of substance abuse A basic understanding of these factors helps to facilitate effective pain management Pharmacology and Aging Elderly patients are more sensitive to analgesic agents and often require less medication to provide effective analgesia In addition, the effects of the analgesic agents may last longer The use of naloxone to reverse opioid-induced respiratory depression is rare but more prevalent in older patients, who are receiving CNS depressants or who have developed other conditions such as pneumonia and renal failure Therefore all drugs should be administered with caution Chronologic age does not have a direct relationship with ­deterioration of organ function; thus aging individuals vary greatly in their capacity to absorb, metabolize, and excrete drugs It can be stated, however, that as a group, older adults are at higher risk for drug toxicity than younger adults for a variety of reasons (see Chapter 3, Fig 3–2) Drug reactions may be dose-related or the result of the drug’s interaction at the cellular level Older adults tend to take more drugs, including analgesics, on a long-term basis often related to the ­presence of chronic illnesses that require drug therapy These medications may interact with analgesics, ­producing symptoms Older adults tend to have less body water and increased body fat Less body water causes high blood ­levels of water-soluble drugs because of decreased ­ distribution volume Increased body fat causes prolonged effects of ­ M04_WAGN3408_06_GE_C04.indd 94 Rapid loss of analgesia Rapid opiate withdrawal (if dependence exists) "" Nausea and vomiting "" Hyperventilation "" Tremors "" Nursing Implications Cautious use when used with suspected or known narcotic dependence "" For administering undiluted bolus—minimum delivery rate = over 10–15 seconds "" Monitor closely for manifestations of opioid withdrawal "" Data from Wilson, Shannon, & Shields (2011) *Nurses who work with patients receiving PCA therapy need to be knowledgeable about the agency’s opioid reversal protocol fat-soluble drugs because of increased distribution volume in fat tissue (Strassels, McNicol, & Suleman, 2008) Other complicating factors that increase the risk of adverse reactions or s­ubtherapeutic ­dosing include the fact that short-term memory impairment may cause a person to take incorrect dosages, miss doses, or take multiple doses Impaired vision may lead to under or overdosage Impaired agility in opening containers may encourage a patient to miss a dose Financial factors as well as limited transportation may keep the patient from filling prescriptions Often these complicating factors are missed when taking a pain history Opioid use in the older adult has a wider distribution in the body with little difference in pharmacokinetics The difference in pharmacokinetics may be associated with increased brain sensitivity (Halaszynski, Saidi, & Lopez, 2010) This increases the risk for respiratory depression and increased cognitive impairment; thus opioids should be ­initiated with caution until sensitivity is determined Studies have shown that opioids are underutilized in older patients who could significantly benefit from their use; however, there is no reason for underutilization if opioids are administered according to an appropriate pain management plan (Katzung, 2009) In obtaining a medication history, the nurse should reconcile the patient’s prescription and over-the-counter (OTC) preparations, OTC supplements, alcohol, caffeine and tobacco use, and home remedies The nurse should be aware that ­ certain drugs often prescribed for older adults, such as ­diuretics, ­anticholinergics, and sedatives, have a great ­number of ­undesirable side effects in this patient population In a­ ssessing the older adult, symptoms suggesting drug toxicity ­incontinence, rather than the more commonly seen nausea, vomiting, diarrhea, and rash 30/08/14 12:13 PM www.freebookslides.com CH A PTER ▸ Acute Pain Management Patients with Concurrent Medical Disorders While opioids remain first line therapy, high-acuity patients frequently have more than one organ with decreased function at any single time Impaired function of the liver and kidneys has serious implications for analgesic therapy Analgesics are primarily metabolized in the liver, with a small percentage being excreted unchanged The kidneys have the major responsibility for opioid excretion When either of these organs has decreased functioning, serum drug levels increase, placing the patient at increasing risk for the development of adverse effects Certain opioids (e.g., morphine) are converted into polar glucuronidated metabolites (M6 Glucuronate) in the liver and then excreted through the kidneys The glucuronidated metabolites maintain analgesic capabilities that may be stronger than the actual opioid If kidney function is significantly impaired, these metabolites may accumulate in the blood, resulting in prolonged and deeper analgesia This can compromise the patient by precipitating severe respiratory depression, deep sedation, or intractable nausea Meperidine is a synthetic opioid, poorly absorbed through the oral route With repeated use of meperidine, normeperidine, a toxic metabolite of meperidine, can accumulate in the presence of renal insufficiency or high drug doses, resulting in CNS stimulation, which can precipitate tachycardia and seizure activity When kidney or liver impairment is present, doses of most opioids must be reduced and the patient monitored closely for the development of accumulative effects Many healthcare facilities have removed meperidine from their drug formularies as a choice for pain treatment due to the risk of CNS toxicity with repeated dosing, and because there are other more acceptable alternatives now available Management of the Tolerant Patient with Superimposed Acute Pain Patients who have been receiving long-term opioid therapy for chronic pain are at risk for undertreatment of acute pain as a result of opioid drug tolerance In such cases, the opioid dose requirements may be significantly higher than what is ­usually recommended to reach a satisfactory level of analgesia A thorough pain history provides valuable information regarding the potentially altered dose requirements of this patient population It is recommended that the patient’s home routine opioid dose be considered as a baseline, increasing the baseline by 50%, to which additional opioids are titrated to manage the incidence of acute pain (Mitra & Sinatra, 2011; Gordon, 2008; and Mehta & Langford, 2006) When the patient is able to take oral medications, this can easily be accomplished by continuation of the patient’s home opioid dose in a long acting oral form and titration of either short-acting oral opioid or PCA for acute pain coverage As healing occurs and pain diminishes, shortacting opioids should be weaned accordingly A patient restricted to IV therapy requires conversion from the home oral opioid dose to an hourly IV dose PCA can then be delivered, starting with a conservative continuous PCA dose with additional opioid delivered in the patient incremental M04_WAGN3408_06_GE_C04.indd 95 95 format The continuous dose and the incremental dose can be slowly titrated upward to control pain while monitoring for oversedation or respiratory depression Interpatient variability requires individual dose titration Chronic opioid use can complicate the treatment of a patient in severe acute pain Hyperalgesia Both the use of high dose opioids over a prolonged time and the effects of chronic pain on the CNS can produce a condition known as hyperalgesia Hyperalgesia is not the same as tolerance Unlike tolerance, exposure to a drug induces changes that cause decreased response to the drug’s ­effects over time; hyperalgesia is characterized by increasing pain despite repeated upward titration of opioids In general, the pain will be reported as diffuse and extend beyond the original area of the pain Increasing opioids only makes the pain worse (Davis, Shaiova, & Angst, 2007) Hyperalgesia should be suspected when the opioid becomes less effective in absence of disease progression, especially if it is in conjunction with unexplained pain reports Treatment for hyperalgesia requires careful and appropriate detoxification when appropriate Use of nonopiates such as NSAIDS, lidocaine IV infusion, heat and/ or ice, the addition of muscle relaxants, the use of anticonvulsants such as gabapentin (Neurontin) or pregabalin (Lyrica), SSRIs (i.e., venlafaxine [Effexor] or duloxetine [Cymbalta]), and tricyclic antidepressants can help decrease sensitization of the CNS The use of acupuncture or TENSs units along with relaxation therapy has been demonstrated to decrease hyperalgesia (Heinl, Drdla-Schutting, Xanthos, & Sandkëhler, 2011) Furthermore, switching from morphine or hydromorphone to methadone or buprenorphine is considered an effective treatment but requires experienced clinicians to transition the patient’s therapy The Known Active or Recovering Substance Abuser as Patient Nurses caring for high-acuity patients are likely to encounter a patient with active substance abuse prior to admission High-risk behavior coincides with traumatic injuries involving alcohol and drug use Patients with chemical dependencies have increased morbidity Pain management of the high-acuity patient who is either an active or recovering substance abuser has important nursing implications Recognizing the distinction between drug abuse or misuse and chemical dependency is important when considering analgesic therapy The nurse ­caring for patients with chemical dependency must recognize the importance of treating pain despite the challenges This ­discussion presents a brief overview of some of the issues and nursing implications related to controlling pain when caring for the patient with substance abuse An Ethical Code The American Society of Pain Manage­ ment Nurses views addiction as a treatable disease that is chronic and relapsing (ASPMN, 2002) It is characterized by ­uncontrolled, compulsive use and overconsumption of substances despite known harmful effects Treating pain in this population poses a dilemma that is largely attributable to the medical maxim, “do no harm.” Can and should pain in addicted patients be treated using substances that are in themselves 30/08/14 12:13 PM www.freebookslides.com 96 Pa rt ▸ Therapeutic Support of the High-Acuity Patient addicting, thereby potentially contributing to the addiction? Experts in the fields of pain and addiction answer “yes” to this question All people, regardless of whether they are substance abusers or not, have the right to have their pain relieved; thus relief of pain temporarily overrides the problem of addiction (Reinisch, 2008; ASPMN, 2002) Assessing Opioid Misuse or Abuse It can be extremely difficult to evaluate whether a person’s behavior stems from drug seeking related to addiction or from relief seeking related to undertreated pain This is true particularly in healthcare settings, where there is often limited assessment and evaluation time involved However, persons with or without active substance abuse can exhibit pain-relief–seeking behaviors when pain is not adequately controlled Healthcare providers should be aware of behaviors and evidence that suggest active addiction Box 4–5 lists some of the more common behaviors and evidence of active substance abuse The problem of differentiating between pseudoaddiction and addiction-driven behaviors may become even more difficult if the person has previously experienced inadequate pain relief Previous negative pain-relief–seeking experiences tend to foster maladaptive behaviors that can be misconstrued by the healthcare team as drug seeking and perpetuate suspicion and distrust, which encourages the practice of oligoanalgesia One way to identify addictive behaviors is to initiate treatment and observe the behaviors: Pseudoaddiction behaviors cease when Box 4–5  Evidence Suspicious of Active Substance Abuse Behavioral Evidence ■ Frequent occurrences of significant impairment in ­communication or physical abilities ■ Swings in mood and changes in personality ■ Drug hoarding ■ Withdrawal or alienation from family or friends ■ Heavy alcohol use in social settings ■ Obtaining drugs from others ■ Use of multiple pharmacies ■ Forging prescriptions ■ Change in appetite, unexplained weight change ■ Changes in speech pattern (e.g., slurred, rapid) ■ Fatigue or drowsiness (depressants); restlessness, irritability (stimulants) ■ Impaired memory ■ Altered appearance and hygiene Physical Evidence ■ Inappropriately dilated or constricted pupils ■ Red or watery eyes ■ Hand tremors, stumbling gait ■ Altered sleep patterns ■ Persistent inflammation of nostrils, runny nose ■ Deteriorating health ■ Altered vital signs (elevated [stimulants]; decreased [depressants]) ■ Evidence of substance abuse (e.g., needle marks) M04_WAGN3408_06_GE_C04.indd 96 pain relief is achieved, whereas addiction behaviors continue when the primary motivation is something other than pain relief It is crucial to closely observe and document changes in behavior prior to and during pain relief interventions The probability of opioid abuse has been linked to c­ ertain risk factors This has led to the development of screening tools to help determine which patients may be at the highest risk for opioid abuse in order to determine the appropriate level of monitoring necessary during pain control interventions Two such tools are the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain (SOAPP) The authors of both tools emphasize that all patients deserve t­ reatment for pain despite the level of risk or the presence of aberrant behaviors These tools are proposed to be used solely to determine the level of monitoring required (Webster & Webster, 2005) Major Considerations in Pain Management Clinicians often confuse physical dependence with the addiction when managing pain in the active or the recovering addict The use of opioids may renew physical dependence, but that does not predict whether the person will relapse into addiction Undertreatment of acute pain is more likely to reactivate the behaviors associated with addiction Stress is also known to increase substance craving and inadequate pain relief often increases stress, which may result in an escalation of substance use in the acute abuser or relapse in the recovering abuser Although managing pain in this population may be difficult, it is not impossible Employing recommendations of experts, such as those developed by the ASPMN, can be useful in guiding medical and nursing pain interventions in this population Clinical Management Considerations The National Cancer Institute (NCI, 2011) offers guidelines that can be applied to pain treatment of the high-acuity patient with a history of substance abuse: • Involve a multidisciplinary team Substance abuse is complex and requires interdisciplinary care, such as pain expert physicians, nurses, social workers and, if available, an addiction medicine expert • Set realistic goals for therapy The risk of relapse increases with the heightened stress associated with life-threatening disease Prevention of ­relapse may be impossible, requiring altered goal setting for management to include structured therapy, support, and limit setting • Evaluate and treat comorbid psychiatric disorders The substance abuser is at extreme risk for anxiety, personality disorders, and depression Presence of these disorders may require treatment during acute disease states • Prevent or minimize withdrawal symptoms Obtain a complete drug history, keeping in mind that many patients abuse multiple drugs Laboratory drug screening tests can provide a baseline of currently abused substances Healthcare professionals should be familiar with the manifestations of commonly abused substances (see Table 4–7) 30/08/14 12:13 PM www.freebookslides.com 97 CH A PTER ▸ Acute Pain Management Table 4–7  Commonly Abused Substances and Withdrawal Manifestations Substance Common examples Common Street Names Withdrawal Onset and Manifestations Opiates (CNS depressant) Codeine, hydromorphone (Dilaudid), morphine, oxycodone (Percodan), others Heroin, opium Morphine: morph, M Dilaudid: little D, dillies, lords Percodan: percs Heroin: horse, smack, H Opium: hop, tar Onset: 4–6 hours following last dose Manifestations: Mild initially and becoming more severe; dilated pupils, runny nose, diarrhea, abdominal pain, chills, gooseflesh, insomnia, aching joints and muscles, nausea and vomiting, muscle twitching and tremors (may become severe), mental depression Alcohol (CNS depressant) Beer, wine, whiskey, many others Liquor, beer, booze, wine Onset: 12–48 hours Manifestations: Headache, anxiety, depression, nervousness, shakiness, irritability, fatigue, clouded thinking, emotionally labile; GI: nausea, vomiting, anorexia; CV: heart palpitations; EENT: enlarged, dilated pupils; skin: clammy, pale, sweaty palms; musculoskeletal: tremors, abnormal movements Severe (complicated) withdrawal: Rapid muscle tremors, seizures, tachycardia, cardiac dysrhythmias, profuse sweating, hallucinations, others Barbiturates (CNS depressant) Phenobarbital, pentobarbital Barbs, red devils, goof balls, yellow jackets, downers Onset: 12–20 hours following last dose Manifestations: Similar to alcohol withdrawal in the absence of alcohol; other mental changes: blank facial expression, slurred speech, flat affect; severe withdrawal can result in respiratory and heart failure, seizures, and death Cocaine (CNS stimulant) None Coke, blow, snow, nose candy Onset: 4–8 hours Manifestations: Few physical withdrawal symptoms; strong psychological symptoms, including rapid onset of depression, fatigue/ sleepiness, strong craving for more cocaine, loss of pleasure; may also experience paranoia, agitation Amphetamines (CNS stimulant) Methylphenidate (Ritalin), pemoline (Cylert) Speed, uppers, dexies, crank, meth, ice, crystal Onset: 4–8 hours Manifestations: Depression, severe craving, mental confusion, insomnia, restlessness, paranoia, possible psychosis Ecstasy (3, 4-methylene­ None dioxymethamphetamine [MDMA]) XTC, Adam, roll, E Onset: Rapid Manifestations: Depression, anxiety, panic attacks, sleeplessness, depersonalization, paranoid delusions, drug craving Anabolic-androgenic steroids Roids, juice, Arnolds, stackers, gym candy Onset: Not fully documented Manifestations: Mood swings, fatigue, restlessness, anorexia, insomnia, reduced sex drive, the desire for more steroids Depo-Testosterone, clomiphene citrate (Clomid), stanozolol • Consider the impact of tolerance Patients with a known his- tory of recent opioid abuse may require one-and-a-half times or more opioids to provide analgesia to achieve pain relief • Apply appropriate pharmacologic principles to treat chronic pain Analgesic dose individualization is an important principle; focusing on dose size rather than pain relief achievement may result in pain undertreatment and subsequent development of pseudoaddiction behaviors M04_WAGN3408_06_GE_C04.indd 97 • Use a multimodal approach to treatment when benefits outweigh risks Recognize specific drug abuse behaviors (see Table 4–7) • Use nondrug approaches concurrently with analgesics as appropriate These may include further patient education, relaxation and coping techniques, and complementary pain relieving interventions 30/08/14 12:13 PM www.freebookslides.com 98 Pa rt ▸ Therapeutic Support of the High-Acuity Patient Other clinical pain management suggestions include the following: • Avoid (if possible) analgesics that have the same pharmacologic basis as the abused drug • Choose extended-release and long-acting analgesics (e.g., fentanyl and methadone) rather than short-acting ones, and restrict short-acting opiates for breakthrough pain • Avoid naloxone (Narcan) unless life-threatening toxic effects are present because use of naloxone will precipitate immediate opiate withdrawal • Administer analgesics orally rather than intravenously when possible Section Seven Review Older patients have fewer endogenous receptors and ­neurotransmitters than younger patients What is the primary clinical significance of this statement? A Larger doses of opioids are required to achieve pain relief B Pain relief using opioids is more unpredictable C Smaller doses of opioids are required to achieve pain relief D Pain relief using opioids is less effective 2 Accumulation of morphine metabolites in the blood because of renal dysfunction can cause what condition? A B C D Severe respiratory depression Seizures Tachycardia CNS stimulation Section Eight: Moderate Sedation/Analgesia It is important that the high-acuity nurse have a clear understanding of the different stages of consciousness to effectively communicate with members of the health care team Clarification of terms leads to increased patient safety Conscious sedation is an outdated term, traditionally used for moderate sedation and is classified as a “sedation level two” on the American Society of Anesthesiologists’ (ASA) sedation-analgesia continuum Most often it is used to induce relaxation with minimal variation in vital signs when patient cooperation is needed for a procedure This is very different from the intent to provide analgesia (pain relief with minimal side effects) In the Core Curriculum for Pain Management, Simpson (2011) describes moderate sedation/analgesia as “the purposeful intent to produce an altered mental status by administering pharmacological agents, primarily through the ­intravenous route producing an altered level of consciousness while ­maintaining a patent airway and responding to verbal and environmental stimuli” (p 320) The Ramsay Sedation Scale was developed in 1974 to assess sedation in the intensive care unit Recently this scale was modified to correlate with sedation definitions that have been outlined by the Joint Commission A comparison of these definitions is summarized in Table 4–8 Purpose of Moderate Sedation/Analgesia A high-acuity patient who is moderately sedated can tolerate uncomfortable procedures such as diagnostic colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), M04_WAGN3408_06_GE_C04.indd 98 Accumulation of the metabolite of meperidine (normeperidine) in the blood can result in what condition? A B C D Severe sedation Bradycardia Severe respiratory depression Seizures Which statement is accurate about the known substance abuser who is hospitalized? A The patient should receive no opioids B The patient may require higher-than-usual opioid dose ranges C The patient should receive only one type of opioid D The patient may require lower-than-usual opioid dose ranges Answers: C, A, D, B upper endoscopy, or electrical cardioversion The patient is able to breathe spontaneously and maintain his airway, cough and swallow reflexes remain intact, and cardiovascular function is not affected The number and types of procedures performed outside of the operating room are increasing and nurses often provide the sedation Nurses may administer moderate sedation only in the presence of a licensed independent practitioner (ASPMN, 2008) Nursing Management of the Patient Undergoing Moderate Sedation Institutions that provide sedation are required to abide by strict policies, clinical guidelines, and protocols The ­policies must contain age-appropriate considerations and should include: necessary equipment and supplies; mandatory ­ education requirements; process for validating competency; ­interface with Risk Management and Quality Improvement; and required documentation (ASPMN, 2008) Those administering the sedation must be trained to rescue patients who become unstable during the procedure or progress to deeper states of sedation (Pino, 2007) For example, if a patient is undergoing a procedure with moderate sedation and he progresses to a state of deep sedation, the nurse must be prepared to manage the compromised airway and ensure oxygenation and ventilation If that same patient progresses to a state of general anesthesia, the nurse must be competent to manage oxygenation and ventilation as well as an unstable cardiovascular system Before the Procedure Prior to beginning any procedure that requires moderate sedation, the nurse must verify that the patient or family, if indicated, has given informed consent 30/08/14 12:13 PM www.freebookslides.com 99 CH A PTER ▸ Acute Pain Management Table 4–8  Ramsay Sedation Scale Modified to Correlate with TJC Definitions of Minimal Sedation, Moderate Sedation, Deep Sedation, and General Anesthesia Score Modified Ramsay Sedation Scale Score Definition TJC Sedation Definition Awake and alert, minimal or no cognitive impairment Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected Awake but tranquil, purposeful responses Moderate sedation/analgesia: A drug-induced depression of to verbal commands at conversational level consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation No interventions are required to maintain a patent airway and spontaneous ventilation is adequate Cardiovascular function is usually maintained Appears asleep, purposeful responses to verbal commands at conversational level Appears asleep, purposeful responses to commands but at a louder than usual conversational level, requiring light glabellar tap, or both Asleep, sluggish purposeful responses only to loud verbal commands, strong glabellar tap, or both Asleep, sluggish purposeful responses only to painful stimuli Asleep, sluggish withdrawal to painful stimuli only (no purposeful responses) Unresponsive to external stimuli, including pain Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation The ability to independently maintain ventilatory function may be impaired Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate Cardiovascular function is usually maintained General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation The ability to independently maintain ventilatory function is often impaired Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function Cardiovascular function may be impaired From Mace, S E., Ducharme, J., and Murphy, M F (2006) Pain Management and Sedation: Emergency Department Management Reproduced by permission of The McGraw-Hill Companies and the physician has explained the procedure to them This includes, but is not limited to, the medications to be administered, risks, benefits, possible adverse reactions, and alternative treatments It is essential that the nurse managing the care of the patient undergoing moderate sedation has no additional responsibilities during administration that might result in leaving the patient unattended or compromise continuous monitoring (American Association of Critical Care Nurses [AACN], 2010) Nurses must be specifically trained in the care of patients undergoing moderate sedation and have a working knowledge of the legal liability associated with administering moderate sedation (AACN, 2010) The high-acuity nurse who administers medications for procedural sedation must have an understanding of the principles of respiratory physiology and the knowledge and ability to monitor oxygenation and ventilation (ASPMN, 2008) M04_WAGN3408_06_GE_C04.indd 99 During the Procedure Continuous monitoring of oxygen saturation using pulse oximetry (SpO2) is the s­ tandard of care (Guliano & Higgans, 2005) Other physiologic ­measurements that must be monitored during the sedation and recovery period include respiratory rate, blood pressure, heart rate and rhythm, and level of consciousness (AACN, 2010) Capnography has been recommended for moderate sedation but is not mandated Recently published recommendations for the use of capnography during procedural sedation and analgesia in the emergency department conclude that capnography is a more sensitive indicator of respiratory depression than pulse oximetry or clinical assessment, although improved patient outcomes have not yet been demonstrated (Proehl et al., 2010) The equipment listed in Box 4–6 must be available prior to the start of the procedure Back-up personnel trained in airway management, intubation, and advanced cardiac life support (ACLS) should be readily available in the event of an 30/08/14 12:13 PM ... Posttests 28/08 /14 5:05 PM Contents About the Authors   Thank You  6 Preface  8 Part One  Introduction to High- Acuity Nursing? ??  Chapter? ?1 High- Acuity Nursing? ??? ?13 High- Acuity Environment ? ?13  ~ Resource... technology Cluster 1, 7, 9, 12 , 20, and 31: Relates to children Cluster 9, 10 , 13 , and 40: Relates to human experimentation Cluster 3, 7, 8, 11 , 12 , 18 , 19 , 21, 24, 25, 33, 34, 35, 38, and 41: Relates... 2 010 a) For this reason, the nurse should assess each older adult individually to determine Millions 10 0 90 80 70 60 50 40 65 and over 30 20 10 85 and over 19 00 19 10 19 20 19 30 19 40 19 50 19 60 19 70