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N124Prof. MGAP Batalla

7/12/12

Sleep Disturbances

Cyclic Nature of Sleep

Waking NREM I IVNREM III II REM

-

Deep sleep: associated with NREM III IV and REM

-

Loss of REM and NREM IV: triggers rebound or

compensatory increases on nights following their

loss

-

REM sleep occurs once every 90 minutes

-

REM: morning naps; NREM: afternoon naps

Factors that contribute to sleep pattern disturbance

-

Procedures (e.g. hourly monitoring)

-

Sounds from machines

-

Pain or discomfort

-

Anxiety

Clusters:

1.

Environmental

a.

Loss of day and night orientation

b.

Noise in the ICU

*17-19 decibels: ICU, restaurant, traffic jam

2.

Situational

a.

Personal and social isolation as a result of

complete dependence

b.

Pain and discomfort

c.

Anxiety and fear

3.

Effects of medications

a.

MoSo4 (morphine): increases NREM I and

II

b.

Diazepam: increases NREM I, decreases

REM, NREM III and IV

c.

Barbiturates (except Phenobarbital):

increases NREM II, decreases REM

d.

Phenobarbital: facilitate NREM IV; doses

>200 mg can suppress REM sleep

Promoting Rest and Sleep in the Critical Care Setting

-

Release anxiety of patient

-

Timing of medications (e.g. diuretics NOT at night

time)

-

Address the clients basic needs (e.g. bed bath)

-

Organize nursing care (activity plan)

-

Orient to time (e.g. time for sleep, etc.)

-

Address pain (meds, position)

-

Troubleshoot alarms (not too loud, address

immediately)

Dimming of lights at night

Scheduling of nursing activity

Scheduling doctors rounds at daytime unless

necessary

Use medications judiciously

Adjusting the alarm settings, lower the telephone

volume, observing silence at night

ICU Psychosis

-

Sleep problems are risk factors for ICU psychosis.

Delirium

-

Psychosis is a type of delirium

-

Represent a global impairment of cognitive

process

-

Can be due to:

o Metabolic

o Intracranial

o Organ failure

o Endocrine

o Respiratory

o Drug-related

-

a.k.a Sundowner Syndrome

- A type of acute brain syndrome among ICU

patients

-

Has rapid onset

-

Reversible

Causes of ICU Psychosis

1.

Physiologic factors

2.

Affects of medications

3.

Environmental factors

4.

Psychosocial factors

CM of ICUP

- Fluctuation in LOC

-

Visual hallucinations

-

Disorientation with respect to person

- Severe restlessness

-

Memory impairment

Assessment of ICUP

-

The confusion assessment methods for the ICU

(CAM-ICU)

Feature 1: Acute onset of changes or fluctuations

in the course of mental status

AND

Feature 2: inattention

AND EITHER

Feature 3: disorganized thinking

OR

Feature 4: altered LOC

Psychosis

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Management of Delirium and Promotion of Psychosocial

Adaptation to the Critical Care Setting

-

Provide regular reality orientation

-

Give security information at predetermined intervals

(e.g. presence of health care workers and family to

help him/her)

- Repeat information until patient repeats it

-

Instruct SO to talk to and touch the patient

-

Provide and respect patients need for privacy and

personal space

-

Promote rest and sleep

Management of Delirium

1.

Pharmacologic

a.

Haloperidol is frequently prescribed

2.

Non-pharmacologic

a.

Promoting sleep

b.

Back massage

c.

Music therapy yung may meaning sa

patient

d. Preventing sensory overload

Pain and Pain Management in the Critical Care Setting

Pain

-

Unpleasant and sensory and emotional experience

associated with actual and potential tissue damage

-

Subjective

-

Multidimensional feature

Components of pain

Sensoryperception

Affectivenegative emotions

Cognitiveinterpretation

Behavioralstrategies

*Most valid measure for pain: patientsself-report (very

subjective)

Barrier to pain assessment and management

-

Extremes of age

-

Cultural influences

-

Lack of knowledge

-

Administration of sedative agents

-

Changes in LOC

-

Mechanical ventilation

Components of pain assessment

1.

Subjective

a.

P, Q, R, S, T

i.

P provocative and palliative

factors

ii.

Q quality of pain: offer choices

(dinadaganan, kinukurot, etc.)

iii.

R region or radiation

iv.

S severity of pain (use a scale)

v.

T timing and duration, interval

vi.

U understanding, management

(Ano sa tingin niyo ang

pinagmumulan ng sakit? Ano ang

ginawa mo?)

VAS (visual analog)

NRS (numerical)

DRS (descriptive)

FPT (facial pain thermometer)

Baker-Wong Faces PRS

Riker-Sedation Agitation Scale

2.

Objective

a.

Behavioral pain scale

For mechanically ventilated patients

i.

Facial expression

ii.

Upper limps

iii.

Compliance with ventilation

b.

CPOT (Critical Care Pain Observation

Tool)

i.

Facial expression

1. Relaxed, natural, tense

2.

Tense

3.

Grimace

Directions:

a.

The patient is observed at

rest for 1 minute to obtain a

baseline value of the CPOT.

b.

The patient is observed

during nociceptive procedures

(e.g. turning, ET suctioning,

wound dressing) to detect

any change.

c. Observed during the peak

effect of analgesic

medications.

*respiratory depression: the most life-threatening effect of

opioid; rescue drug: Naloxone

Pain management

1.

TENS stimulates other non-pain sensory fibers in

the periphery modifies pain transmission; impairs

pain transmission (nililito ang mga nerves)

2.

PCA (Patient Controlled Analgesia): fixed dosage

and interval

Psychosocial Alterations and Holistic Nursing Practice

Florence Nightingale

-

Considered one of the first holistic nurses

-

Believed in care focused on unity, wellness, and

the interrelationship of the human being and the

environment

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Holistic Nursing

-

All nursing practice that has healing the whole

person as its goal (American Holistic Nurses

Association, 1998)

Holistic Care

-

Physical, emotional, social, spiritual needs

Stressors in the Critical Care Setting

-

Threat of death

- Lack of sleep

-

Pain or discomfort

-

Loss of autonomy

-

Threat of survival with significant residual problems

related to illness/injury

-

Loss of control over ones environment

-

Boredom

-

Loss of dignity

-

Loss of ability to express oneself verbally

Assessment

1.

Biologic characteristics

a. Age

b.

Developmental phase

c.

Gender

d.

Body functions

2.

Health and health patterns

a.

Current and past mental, spiritual, and

physical health status

b.

Attitude towards life

c.

Lifestyle practices

d.

Types of coping mechanisms

3.

Psychological characteristics

a.

Perception of current illness

b. Self-concept components: self-esteem,

self-identity, body image

c.

Intellect: educational attainment,

d. Role competency or conflict

e.

Coping mechanisms

f.

Values (?)

4.

Social aspects

a.

Interrelationships

b.

Availability of support system

5.

Environment

a.

Area of residence, condition of living

quarters or workplace

b.

Access to available community resources

c.

Membership/attendance at social/religious

functions

d.

Cultural, social, etc.

e.

Social support system

I love this school. (Batalla, 2012)

Psychosocial alterations

-

Anxiety, hopelessness, powerlessness, etc.

Measurement of self-worth: self-esteem

Mental picture of self/body: body image

Powerlessness

-

cannot change outcome

- perception that ones own action will not

significantly affect an outcome

Hopelessness

-

limited or no options

- subjective state in which an individual sees limited

options

NIC-NOC for Powerlessness and Hopelessness

-

Refer to NANDA!

Nursing Diagnoses

Spiritual Distress

o Impaired ability to integrate meaning and

purpose in life

Readiness for Enhanced Spiritual Well-being

Grief, Death, and Dying

Bereavement

-

Involves loss of a person, object, or state

Grief

-

Human emotion of a loss

-

Active process of learning to adapt to a death

Mourning

-

Behavior that expresses grief over the loss

Continuum of Grieving Styles

Feeling Thinking

Intuitive Blended Instrumental

Preverbal Children

-

very sensitive to environment

Preschoolers

-

believe in death to be reversible and that the dead

person can comeback

-

may regress to an earlier stage, use play to cope

with feelings

School-age

-

tend to avoid speaking of their grief; equate death

with abandonment

-

vulnerable to self-blame and low self-esteem

Adolscents

-

cognitive understanding that death is irreversible

-

acting out or be closer to family members

7 Stages of Grief

1.

Shock or disbelief

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2.

Denial

3.

Anger

4. Bargaining

5.

Guilt

6.

Depression

7.

Acceptance and Hope

*Anticipatory Grieving

Nutritional Alterations and Support in the Critically-Ill Patient

Nutrition and Metabolism

Metabolism process at which nutrients is used at cellular

level

Major purposes

-

For energy!

Nutrients

1.

CHO

o Main source of energy

2.

CHON

o Building blocks

o 1 g = 4 kCal

Nitrogen Balance a measure in assessment

of protein nutrition (by product of protein use)

o Positive nitrogen balance intake >

excretion

Preservation of protein reserves is a KEY GOAL in

critical care.

3.

Fats

o Protein spares

o Concentrated source of energy

Hormonal and Metabolic Changes in Acute Stress

Effects of acute stress

-

Increase the speed of metabolism

-

Mobilization of glucose and AA

-

Acceleration of loss of clean body tissue

Hormonal changes

* READ THE BOOK.

Total Energy Expenditure (TEE)

-

Physical activity + growth +BMR

Basal Metabolic Rate (BMR)

-

Energy required to perform essential physiologic

processes at rest

Resting Metabolic Expenditure (RME)

-

Energy require for minimal activity

-

Calculated if BMR increases by 10 15 %

Fever, post-op state, infectionincreases in

RME

Energy intake: food alcohol

Energy expenditure: physical activity, basal metabolism,

thermogenesis

Malnutrition

Results from:

- Lack of intake of necessary nutrients

-

Improper absorption and distribution of nutrients

-

Excessive intake of some nutrients

Stress, Malnutrition and Infection

Stress increase TEE + inadequate nutritional support

malnutritiondecreased immunocompetence, poor

wound healing infectionincreased TEE

Protein-Calorie Malnutrition (PCM)

- Direct result of inadequate dietary protein together

with a deficient intake of CHO and lipids

-

Body CHONs are broken down for gluconeogenesis

Specific Types of PCM

-

Marasmus

o Severe cachexia

o

Chronic, easily recognized

o With intact immune system and wound

healing

-

Kwashiorkor

o

d/t acute CHON deficiency, low serum

albumin and total lymphocytes; a/w

incompetence of the immune system

o

at risk for infection; with poor wound

healing

-

Cardiac cachexia

Associated with chronic CHF:

o

Anorexia

o Nutrient loss from malabsorption and

failure to transport nutrients

o Hypermetabolic stage

Consequences of malnutrition

-

Skin breakdown, pressure sores

-

Infection, sepsis

-

GI changes

-

Poor drug tolerance

-

MOF (multiple organ failure)

-

Longer length of confinement

-

Death

Iron: not essential in wound-healing

Requirement production

Malnutrition causes a decrease in the number and function

of intestinal border cells due to lack of protein

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Albumina role in transport of drugs that bind with protein

Nutritional Assessment

-

Risk for Malnutrition

o chronically-ill patients; patients on longer-

term TPN, OF

o

Weight loss:

More than 10% in 6 months,

more than 5% in one month

o Inadequate nutrient intake for > 7 days

o Regular use of 3 day medications

*BMI is not a specific indication of protein deficiency.

Anthropometrics

Hair loss: dull, dry brittle hair

Loss of SC tissue, muscle wasting

Labs: serum proteins, hematology studies, urine creatinine,

electrolytes

Serum proteins

- Decrease in CHON and liver failure

-

Albumin: slow to change in response to

malnutrition

-

Prealbumin: falls in response to trauma and

infection

Hematology studies

-

Microcytic anemia: IDA

-

Macrocytic anemia: foale and VB12

-

Lymphocytophenia

Urine creatine

- Nitrogen balance

Electrolytes

- Patients clinical status and management

Nutritional Assessment Parameters

CHI = actual urinary creatinine x 100

Predicted creatinine

Nitrogen Balance = [24 hr protein intake/6.25] (urinary

urea N + 4g N)

0 nitrogen balance exists

(+) protein synthesis is occurring

(-) protein catabolism is occurring

Body weight