Intensive Care Unit Part 2 Nursing CE Course

3.0 ANCC Contact Hours AACN Category A

Syllabus

ICU Part 2 (Complications Corresponding with ICU Admission)

Introduction

Critical (intensive) care units are defined as a unit designated to meet the unique needs of acutely and extremely ill patients. A critically ill patient is defined as one who has developed a serious medical problem or is at high risk for a potentially fatal health condition. These patients require attentive nursing care. Patients are routinely admitted to a critical care unit for one of three reasons. The patient may be physiologically unstable and require superior clinical decisions and care. A second reason for admission to a critical care unit is the presence of increased risk for severe complications requiring frequent assessments and interventions. The third reason is a need for intravenous (IV) polypharmacy (multiple medications) or advanced technologies (e.g., mechanical ventilation, hemodynamic monitoring, or continuous renal replacement therapy). Nurses working in critical care areas should be competent in palliative and end of life care due to the high mortality rate among patients in critical care units (Seckel & Bucher, 2017). 

Critical care nursing is a specialty in nursing working with the human response to potentially fatal medical problems. The nurse's responsibilities include assessing serious medical conditions, initiating interventions, evaluating outcomes of performed interventions, and providing education and emotional support to patients and caregivers. Critical care nurses exhibit an abundance of knowledge related to anatomy and physiology, pharmacology, equipment use, and advanced assessment skills. Typical assessments include monitoring for signs of infection, mental status, and skin health. The critical care nurse also plays a vital role in pain management and venous thromboembolism prevention (Seckel & Bucher, 2017).

Sepsis-Definition, criteria, manifestations

Sepsis was first defined by an Islamist philosopher, Ibn Sina, as putrefaction of blood and tissue with fever (Hotchkiss et al., 2016). Sepsis is described by the Centers for Disease Control and Prevention (CDC, 2019) as the body’s intense response to an infection. Up to 30% of sepsis cases have unidentified causative organisms. Sepsis and septic shock have a mortality rate of 25% or higher worldwide (Seckel, 2017). 

Sepsis is characterized by the presence of systemic inflammatory response syndrome (SIRS) and a diagnosed or presumed infection. SIRS is non-specific as it can relate to trauma, infection, inflammation, or ischemia. SIRS diagnosis protocol includes the presence of at least two of the following:

  • Fever higher than 38o C (100.4oF) or less than 36oC (96.8oF).
  • Heart rate above 90 beats per minute.
  • Respiratory rate greater than 20 breaths per minute or arterial blood carbon dioxide (PaCO2) less than 32 mm Hg.
  • White blood cell (WBC) count greater than 12,000/uL or less than 4,000/uL or more than 10% immature (band) forms (Kaplan & Pinsky, 2018).

Sepsis can be tough to diagnose as early symptoms often mimic the common cold or influenza. If sepsis is suspected, the patient will undergo several diagnostic studies. Recent guidelines published by the Surviving Sepsis Campaign indicate that a lactic acid level higher than 2.0 mmol/L is an acceptable threshold for septic shock diagnosis along with persistent hypotension after fluid resuscitation and requiring vasopressors to maintain mean arterial pressure (MAP)  above65 mmHg (Lee & An, 2016).

In unfortunate cases, sepsis may be fatal despite treatment. In addition to the SIRS criteria, sepsis often manifests with hypotension (low blood pressure) and dyspnea (shortness of breath) in response to lung infection (CDC, 2019). Other signs of sepsis are significant edema, hyperglycemia without a diabetes diagnosis, altered mental status, elevated C-reactive protein (CRP), elevated lactic acid or lactate, and elevated procalcitonin (Seckel, 2017).

CRP is a serum diagnostic test, assessing the amount of glycoprotein produced by the liver during any acute inflammatory response. CRP does not diagnose the cause of inflammation but declares when inflammation is present. When the inflammation subsides, the CRP level decreases rapidly (Van Leeuwen, Poelhuis-Leth, & Bladh, 2013). Due to the non-specific nature of CRP, if the result is abnormal additional diagnostic tests will be completed to attempt to determine the source of inflammation (i.e., infection, etc). 

Lactic acid, also known as lactate, is a serum laboratory test. When obtaining a lactic acid specimen, plasma should be placed over ice. Lactic acid is present in the blood as lactate and is typically metabolized in the liver. There are several causative factors for an increased lactic acid level. During sepsis, hypoxia and circulatory collapse cause an overproduction of lactate, leading to increased levels. Normal lactic acid levels for an adult are 0.3-2.6 mmol/L. A critical result in adults is greater than 3.4 mmol/L (Van Leeuwen et al., 2013).  If a critical level is determined, the nurse should notify the health care provider immediately. Most health care facilities have a protocol in place to re-evaluate lactic acid levels at specified intervals. 

Procalcitonin is a serum study used to diagnose bacterial infections. Procalcitonin serum level guidelines include:

  • Less than 0.1 ng/mL: bacterial infection is absent or highly unlikely
  • Less than 0.5 ng/mL: bacterial infection is possible with a low risk for sepsis development
  • 0.5-2 ng/mL: bacterial infection is likely with a possibility of sepsis development
  • 2.1-9.9 ng/mL: high likelihood of bacterial infection with high risk for sepsis development
  • 10 ng/mL or higher: severe bacterial infection with probable septic shock (Van Leeuwen et al., 2013).

Organ dysfunction occurs during the process of sepsis. Poor kidney function is one of the early signs of severe sepsis. Oliguria (very low amount of urine) may occur, defined as 0.5 mL/kg/hour or less for at least 2 hours regardless of adequate fluid resuscitation. Serum creatinine often increases greater than 0.5 mg/dL. Other organ dysfunction may also be noted, such as thrombocytopenia (decreased platelet count) and other coagulation abnormalities, ileus (intestinal disruption with absent bowel sounds), and hyperbilirubinemia (total bilirubin greater than 4 mg/dL) (Seckel, 2017). 

Complications

Sepsis can progress into septic shock. Patients who develop septic shock will be admitted to an intensive care unit (ICU) under close observation. Septic shock has a much higher mortality rate than sepsis due to profound circulatory, cellular, and metabolic abnormalities (Seckel, 2017). 

When septic shock occurs, the body’s response to the causative microorganism is amplified. Gram-negative and gram-positive bacteria most often cause septic shock. Viruses, fungi, and parasites can occasionally be the causative agents. Septic shock presents with three main effects: vasodilation, irregular distribution of blood, and myocardial depression. Vasodilation causes hypotension and hypovolemia and in turn, causes reduced oxygen delivery and worsened tissue hypoxemia (Seckel, 2017).

Initially, the patient with sepsis may hyperventilate as a compensatory mechanism due to metabolic acidosis. Hyperventilation attempts to transition the patient back to neutral. The patient will eventually be unable to compensate, and shift into respiratory acidosis. Respiratory failure occurs in 85% of patients diagnosed with sepsis and often requires mechanical ventilation in the intensive care unit (Seckel, 2017).

Treatment 

The nurse should ensure that there is sufficient access to administer fluids and medications to sepsis patients, ideally two large-bore intravenous (IV) catheters should be available. Fluid resuscitation is the foundational therapy for severe sepsis and shock. If a peripheral IV access cannot be established, a central line or intraosseous (IO) access should be initiated. Isotonic crystalloids (usually normal saline) are typically the IV fluid of choice. Depending on the severity of sepsis, the fluids may be dosed based on weight (30-50 mL/kg) and given as a bolus (rapid infusion). Colloids (dextrans, albumin, or fresh frozen plasma) also may be used for quick volume expansion. Patients receiving fluid resuscitation should be monitored closely for circulatory overload (Seckel, 2017). 

The goal for fluid resuscitation is the reestablishment of tissue perfusion and intravascular volume. Blood pressure, urine output, cognitive function, and peripheral pulses should be used to monitor if this goal was met. If the patient continues to be hypotensive, a vasopressor or inotrope may be initiated. Norepinephrine (Levophed) is the first vasopressor drug of choice, which act to increase blood pressure but can also decrease stroke volume. Inotropic agents (e.g., dobutamine [Dobutrex]) can be added to the treatment regimen to offset the low stroke volume and will increase tissue perfusion (Seckel, 2017).

Antibiotic therapy is also imperative for positive outcomes in sepsis management. Broad-spectrum antibiotics should be initiated within the first hour for patients with severe sepsis or septic shock. Research has proven every hour antibiotics are delayed significantly decreases survival rates (Seckel, 2017). Blood cultures should be obtained before beginning antibiotic therapy without delaying antibiotic therapy past the first hour. Specific antibiotics will be initiated once the causative infective organism has been identified (Seckel, 2017). Staphylococcus aureus, Escherichia coli (E. coli), and various types of Streptococcus are common germs that can cause sepsis (CDC, 2016).

Oxygen therapy also plays a crucial factor in the treatment of sepsis and septic shock. Periodic arterial blood gas results will determine the oxygen delivery method. Patients diagnosed with sepsis or septic shock may require mechanical ventilation to assist with respiration and correction of acid-base imbalances. Pulse oximetry should be used for continuous oxygen saturation monitoring. The probe may need to be attached to the ear, forehead, or nose (per manufacturer’s recommendations) due to poor perfusion to the extremities. An arterial line may be inserted for more reliable oxygenation saturation data. Nurses should monitor the respiratory status and airway patency frequently and assess for ventilator-related complications when applicable (Seckel, 2017).

Other recommendations for patients in the intensive care unit with sepsis or septic shock are to maintain glucose control, provide peptic ulcer prophylaxis, and venous thromboembolism (VTE) prophylaxis. Glucose levels should be monitored and kept below 180 mg/dL, yet rigorous glucose control (81- 108 mg/dL) can increase the risk of mortality in patients with sepsis. Proton pump inhibitors, such as pantoprazole (Protonix), may be prescribed to prevent stress ulcers. Low molecular weight heparin, such as enoxaparin (Lovenox), is most commonly prescribed for VTE prevention (Seckel, 2017). 

Nursing implications

Education is a critical component in sepsis prevention. Performing hand hygiene and ensuring patients receive recommended vaccinations are two significant components in sepsis prevention. Patients and families should be educated on ways to prevent sepsis by avoiding infections and managing chronic illnesses. A CDC evaluation noted about 70% of patients diagnosed with sepsis had a chronic illness requiring medical attention or had recently utilized health care services. Sepsis originates outside of the hospital in 80% of patients (CDC, 2016). 

According to the CDC (2016), early diagnosis and treatment of sepsis is an essential factor in saving lives. Once a patient is diagnosed with sepsis, the nurse should monitor for any worsening signs of infection. The patient’s temperature should be monitored at least every four hours, and fevers greater than 101.5oF should be reported and treated with antipyretic drugs. A cooling blanket may also be used if high fevers continue. The patient should be on continuous telemetry monitoring so that the nurse can report any electrocardiogram (ECG) changes immediately. Urine output should be monitored every hour or two to assess renal function and perfusion. If the patient is not sedated due to mechanical ventilation, the nurse should assess mental status for any cognitive changes at least every hour or two to ensure adequate cerebral blood flow. The nurse should orient the patient to their environment as needed and assist in decreasing sensory overload to prevent intensive care delirium. Bowel sounds should be monitored frequently. Ventilated patients may have a nasogastric tube for enteral nutrition. High protein and caloric intake are vital to mortality reduction, as the body’s metabolic output involved in fighting sepsis has been compared to running a marathon. Personal hygiene is also imperative. Poor perfusion affects the skin and places the patient at high risk for skin breakdown and worsening infection. Bathing, attentive skin care, and frequent repositioning, ensuring positive body alignment, will help prevent pressure injuries and skin breakdown. Mucous membranes may also be dry, requiring more frequent oral care (Seckel, 2017). 

Emotional support is critical in a patient diagnosed with sepsis. Holistic care should be provided to the patient and their family. The nurse should never underestimate the amount of stress and anxiety the patient and family may feel when dealing with a potentially fatal disease process. Mediations may need to be administered to decrease pain or anxiety. The nurse should be precise and thorough with all instructions to reduce the patient’s anxiety. Allow the patient to participate in goals and decision making as often as possible. Spiritual needs should be addressed, and a clergy person can also be present to provide support. The nurse should not socially isolate the patient, but instead allow family and caregivers to spend time with the patient, as they desire. Keep the family and patient informed and well-educated to decrease anxiety. Use therapeutic touch and provide reassurance when possible (Seckel, 2017). 

Skin care/Pressure injury-Definition and criteria

Patients in critical care units have a high risk of skin breakdown. Poor circulation, increased friction, immobility, decreased sensation, and malnutrition are all high-risk factors for wound development (Mayo Clinic, 2018). Other risk factors are advanced age, anemia, diabetes mellitus, fever, obesity, pain, incontinence, and low diastolic blood pressure. Most patients in intensive care exhibit multiple risk factors. The amount and duration of pressure that is applied on the skin are also influential factors to developing pressure injuries (Lewis, 2017).

The most common site for pressure injury is the sacrum with the heels being the second most common location (Lewis, 2017). Other areas prone to pressure injury are the scapula, hips, knees, elbows, shoulders, and any additional bony prominence (Department of Health & Human Services, 2019). 

Pressure injuries are categorized by staging. The nurse should assess for blanching if a reddened area is noted over a boney prominence. If a reddened area blanches (turns white briefly when depressed), it is not categorized as a pressure injury. If the reddened area is nonblanchable, it is classified as a stage one pressure injury. Staging includes four stages as the pressure injury progresses. In addition, if a pressure injury is full thickness with tissue loss and depth unknown or suspected deep tissue injury, or covered in eschar, it is an unstageable pressure injury (Lewis, 2017).

Complications

Cellulitis can occur as a result of an untreated pressure injury. According to Lewis (2017), cellulitis is "spreading of inflammation to subcutaneous or connective tissue. Cellulitis can lead to a systemic infection if not treated appropriately. Other complications resulting from pressure injuries are chronic infections (especially musculoskeletal infections such as osteomyelitis or arthritic sepsis) and recurrent pressure injuries (Mayo Clinic, 2018). Patients who develop pressure injuries are at high risk for developing subsequent injuries. Pressure injuries should be taken very seriously, and if left untreated could result in death (Lewis, 2017).

Nursing implications/Wound prevention

Nurses are essential to promoting healthy skin and preventing pressure injuries. Florence Nightingale wrote in 1859, “If he has a bedsore, it is generally not the fault of the disease, but of the nursing” (Lewis, 2017). 

All patients in the hospital setting should receive a full, head to toe, skin assessment on admission. In acute care, the entire skin assessment should be re-evaluated at least every 24 hours or per the facility protocol. A validated assessment tool should be utilized (e.g., the Braden scale) to assess risk and determine how aggressive prophylactic treatment should be. The assessment tool also helps healthcare professionals communicate throughout the continuum of care as nurses and other providers can look for trends in the score from previous assessments (Lewis, 2017).

Patients in the intensive care unit are often immobile and dependent on others for turning and positioning to prevent pressure injuries. Immobile patients should be repositioned every couple of hours, with attention paid to position patients off of bony prominences. Special mattresses may be utilized to help prevent skin breakdown; however, these do not replace the need for frequent turning. Patients in the intensive care unit are also frequently connected to equipment such as ventilators. The endotracheal tube can cause oral pressure injuries to the vulnerable mucous membranes, and the location should be rotated regularly (Lewis, 2017). 

Adequate nutrition also plays a vital role in preventing skin breakdown (Lewis, 2017). Albumin is a common lab that can be utilized to assess and monitor nutritional status. The majority of the body's total protein is a blend of globulins and albumin. Decreased albumin is more useful in determining chronic malnutrition (Van Leeuwen, et al., 2013).

When a pressure injury is noted on a physical exam, the first step for the nurse is to meticulously assess and document the appearance of the wound and surrounding tissue. The assessment should include location, size (longest length and widest width in centimeters), depth, presence of tunneling, wound margin, wound base, and drainage (Lewis, 2017). 

Many facilities require the nurse to obtain pictures of a pressure injury once noted. Initial images should be obtained, as well as additional pictures at regular intervals throughout the treatment regimen. For best results, the nurse should include a ruler against the wound in each image. The picture should be taken from the same angle with the patient in the same position each time. Adequate natural light should be used without a flash for the best color description. Avoid any patient identifiers (e.g., tattoos, jewelry) and assure there are no identifying factors in the background of the pictures (e.g., family members). Remove any shiny objects and take the photo with the wound on a flat, solid background if possible (Lewis, 2017). 

Treatment

Treatment of pressure injuries may include wound cleaning, debridement, dressing application, and release of pressure. The nurse should never turn or position a patient with pressure on an area where redness or a preexisting injury is present. If a pressure injury has necrotic tissue, surgical debridement may be necessary. The goal of debridement is to obtain a clean, granulating base that will provide a suitable wound environment to support moist, healthy skin restoration (Lewis, 2017).

Pressure injuries should be cleaned with noncytotoxic solutions, such as normal saline, that do not damage or destroy cells. Appropriate irrigation pressure is necessary to adequately clean the wound without causing trauma. A 30 mL syringe with a 19-gauge needle is one option to obtain this ideal pressure. After cleaning the wound, it should be covered with an appropriate dressing. A slightly moist dressing will increase re-epithelialization. If a pressure injury is categorized as stage two or higher, an antimicrobial medication may be required (Lewis, 2017).  

Education to promote healthy skin care

Pressure injuries commonly reoccur and affect the quality of life of both patients and caregivers. The nurse should provide education and prevention techniques to patients and caregivers to avoid the development of pressure wounds. The patient should be notified of any wound risk factors that applies to them. The etiology of pressure injuries should be discussed. Caregivers should be educated on proper hygiene for incontinence, the importance of using absorbent pads or briefs, and how to reposition a patient and the frequency required. Patients and caregivers should inspect the skin daily to note any new areas of redness or concern. Caregivers may also need to learn proper wound care and understand the “no-touch” technique when changing dressings (Lewis, 2017).

Patients and caregivers should also be educated on proper diet to promote healthy skin. The required caloric intake to maintain adequate nutritional balance is at least 30 to 35 calories/kg/day and 1.25 to 1.5 g/kg of protein daily. A dietician referral may be necessary if malnutrition is a significant concern (Lewis, 2017).  

Delirium-Defined

According to the Critical Illness, Brain Dysfunction, and Survivorship Center at Vanderbilt University Medical Center (2019), delirium is defined as “a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period (hours to days) and fluctuates over time (para. 1).”

Up to 80% of patients who are admitted to the intensive care unit requiring mechanical ventilation develop delirium. ICU delirium is associated with adverse outcomes such as increased length of hospital stay, mortality rate, and neurological dysfunction. Patients may exhibit one of three subtypes of delirium: hyperactive delirium is often called ICU psychosis; hypoactive delirium is noted as quiet delirium; mixed delirium is a combination of hyperactive and hypoactive (Vanderbilt University Medical Center, 2019). 

Risk factors

Risk factors of ICU delirium are preexisting dementia, history of alcohol abuse, hypertension, and the presence of severe illness on admission. Physical weaknesses may lead to delirium. Patients experiencing hypoxemia (decreased oxygenation), hypercarbia (carbon dioxide retention), severe infections, and electrolyte or hemodynamic instability are at greater risk for developing delirium. Environmental factors can also be causative agents for ICU delirium. Those factors may include sleep deprivation, anxiety, immobilization, and sensory overload (Seckel & Butcher, 2017).  

According to Kaplow (2017), patients in the ICU report poor sleep quality. Alterations in sleep quality may lead to longer hospital stays, delirium, and other complications, including death. Poor sleep quality is often related to fragmented sleep, loss of circadian rhythm, excessive lighting, and frequent arousal. Exposure to artificial light has been proven to suppress melatonin, which interrupts the circadian rhythm. Patients are often sedated in the ICU to allow for physical healing. Although it appears patients are asleep while sedated, the type of sleep experienced is physiologically different than the sleep attained without a sedative medication (Kaplow, 2017).

Nursing Implications

Nurses should monitor all patients admitted to the ICU for delirium. Patients should be monitored using the “ABCDEF” or “A2F” guidelines (Vanderbilt University Medical Center, 2019). A2F includes:

A: Assess, prevent, and manage pain.

Patients in the ICU frequently experience pain. Delirium is a complication that can stem from uncontrolled pain. Pain should be monitored in all ICU patients. If the patient cannot self-report their pain, a validated pain scale such as the Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) should be utilized (Vanderbilt University Medical Center,, 2019).

B: Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)

Awakening and breathing trials give the patient a daily sedative and narcotic break (when applicable). During trials, these medications are titrated down as the patient tolerates to allow safety screens that improve client outcomes. Positive outcomes from these trials include decreased delirium, decreased length of stay in the ICU, reduced time on the ventilator, and improved one-year survival rate (Vanderbilt University Medical Center,2019).

C: Choice of analgesia and sedation

The first correlation between frequently prescribed sedative medications and delirium was noted in 2006. Current investigations sponsored by the National Institutes of Health are underway to determine the best antipsychotics for delirium and sedation sparing results. Goals of analgesia and sedative therapy are adequate pain management and anxiety relief while attempting to avoid oversedation and promote timely extubation (discontinuation of endotracheal tube). Nurses should utilize sedation scales to help accomplish these goals. Five types of scales currently used in practice are the Ramsay scale, the Sedation Agitation Scale (SAS), the Motor Activity Assessment Scale (MAAS), the COMFORT scale for predication clientele, and the Richmond Agitation Sedation Scale (RASS) (Vanderbilt University Medical Center, 2019).

The RASS was developed at Virginia Commonwealth University and is one of the most highly recommended delirium scales. The RASS uses the length of eye contact following verbal stimulation as the primary target to titrate intravenous sedation. The RASS has proven to have excellent reliability in ICU patients when compared to other scales. The RASS takes less than 20 seconds to perform on average and requires minimal training. The RASS has a ten-point scale that determines the patient's responsiveness and guides the nurse or healthcare provider in titrating medications (Vanderbilt University Medical Center, 2017).

D: Delirium – assess, prevent, and manage 

Colleagues at the University of Chicago studied the outcomes of patients regarding delirium in the ICU. The Confusion Assessment Method (CAM-ICU) was developed to determine if a patient was experiencing delirium. Step one in CAM monitoring is determining the level of consciousness, utilizing the RASS tool. Next, criteria are based on the onset of cognitive changes, inattention, altered level of consciousness, and disorganized thinking. If the criteria are met, a patient is defined as being CAM-ICU positive or delirium present. If the criteria are not met, the patient is CAM-ICU negative meaning no delirium (Vanderbilt University Medical Center, 2017).

E: Early mobility and exercise

Early mobility has been the solitary intervention confirmed to decrease days of delirium. Studies have proven early mobility is a safe and practical way to produce positive outcomes in ICU patients. Any member of the interdisciplinary team can perform early mobility. Mobility activities can be determined by the patient’s RASS score and may vary from passive range of motion to ambulation (walking) (Vanderbilt University Medical Center, 2017).

F: Family engagement and empowerment

Nurses should empower family members by allowing them to actively participate in inpatient care. The family often brings in aspects of holistic care that the nurse may unintentionally overlook. The nurse should establish rapport with the patient's family and caregivers. Three basic strategies the nurse may use to provide effective communication with the patient and family are:

  1. Use simplified speech – patients experiencing delirium better understand basic vocabulary. The nurse should refrain from medical jargon when speaking to patients or family members. 
  2. Be concrete – the nurse should refrain from metaphors and conceptual vocabulary. When providing education, the nurse should use easily understood language. 
  3. Take your time – patients and family members may not understand or adequately absorb rapid communication. Sitting down with patients and explaining information rather than reading off a list or speaking a memorized educational topic will be more beneficial (Vanderbilt University Medical Center, 2017).

Nurses can also be active contributors to decreasing the likelihood of ICU delirium by limiting noise levels and decreasing sensory overload. Phones should be muted, televisions turned off, and unnecessary alarms eliminated. Conversations can also be a stressful noise. Nurses should find suitable places to hold discussions and only include the patient and family members when necessary (Seckel & Butcher, 2017).

The nurse may use clocks and calendars to help reorient the delirious patient. Implementing early mobility protocols is another important function of the nurse. Medications to decrease insomnia or delusions may also be necessary (Seckel & Butcher, 2017).  

Pain management

Pain in the intensive care unit has been proven to impact patient outcomes. Up to 70% of patients in critical care report moderate to severe unalleviated pain. Pain can decrease relaxation and sleep, increase morbidity and mortality, and increase the length of hospital stay. Health care providers may underestimate the severity of pain, especially when assessing patients who cannot self-report pain. The CPOT or NRS assessment tools should be utilized in patients who are not able to self-report their pain (Roos-Blom et al., 2019). 

Risk factors

Patients in ICU at highest risk for pain include:

  • those with medical conditions including ischemia, inflammation, or infection.
  • those who are immobilized.
  • those with invasive monitoring devices (e.g., endotracheal tube).
  • those who require frequent procedures (invasive or noninvasive) (Seckel & Butcher, 2017).

Opioid epidemic and pain management

The opioid epidemic is a known problem in the United States. Managing pain for patients affected by this epidemic can be difficult in the critical care setting. A 2017 study including 162 hospitals in 44 states revealed overdose-related ICU admissions rose 34% in seven years (Karamchandani, Carr, Bonavia, & Tung, 2018).

Acute pain is habitually under-treated in the ICU when opioid dependence is present. Recognizing pain in patients is the first step to develop an appropriate analgesic plan. A detailed physical and social history is imperative to note the amount of opioids used daily prior to hospital admission. If a history is unobtainable, the healthcare provider should attempt to estimate the usage. The estimate is best accomplished by "calculating the 24-hour oral morphine-equivalent doses, which provides a basis for comparing strengths of different opioid regiments and helps calculate equianalgesic doses for oral, transdermal, and intravenous preparations" (Karamchandani et al., 2018).

See figure 1 below for oral morphine equivalent dosages for many common analgesic medications. Oral to IV morphine conversion is 3:1.

The equivalent amount of opioids should be administered to address the baseline need. Short-acting opioids may be required to supplement and achieve the goal of acute pain management. Patients should have hemodynamic and respiratory monitoring. Nurses and healthcare providers should frequently evaluate narcotic needs. The promotion of therapeutic approaches to pain management, such as cognitive behavioral therapy will likely increase in the future to provide the best care for patients with opioid dependence in the ICU (Karamchandani et al., 2018).

Treatment/Nursing implications

Nurses should assess pain in all patients admitted to the ICU. Self-reporting is the gold standard and is an acceptable way to assess pain in patients who are verbal. However, cultural considerations can make pain assessment challenging. For example, patients of Chinese, Japanese, and Hebrew origin have minimal expressions for pain, which may inhibit their ability to express pain. The English language has more expansive options with at least 64 words to describe pain (Fraser & Gagnon, 2016). 

Pharmacological or non-pharmacological pain management options may be used. Pain medications are generally subdivided into three categories: nonopioids, opioids, and adjuvant drugs. Nonopioids may control mild pain. Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen (Advil) are commonly used nonopioids that are effective in treating pain without developing physical tolerance. Moderate to severe pain may require opioids. Pure opioid agonists (morphine-like opioids) are the most common type of opioid used for acute and chronic pain. Patients who have other types of pain, such as neuropathic pain, usually require adjuvant drug therapy (Polomano & Fillman, 2017).

Nonpharmacological techniques for pain control can reduce the need for analgesics. This type of pain relief also increases the patient’s sense of control over their pain management. Nonpharmacological techniques may be subdivided into physical pain relief strategies and cognitive therapies (Polomano & Fillman, 2017). 

Physical pain relief strategies include massage, exercise, transcutaneous electrical nerve stimulation (TENS), acupuncture, heat therapy, and cold therapy. Nurses may offer several of these strategies to patients in the ICU. Massage can be beneficial in both acute and chronic pain. The most common type of massage the nurse may offer is a superficial massage. This includes either slow or brisk strokes or circles over the desired area. A trigger point is noted as a hypersensitive area with a tight band of muscles. It feels like a knot under the skin upon palpation. Exercise is another way nurses can help alleviate pain in critical care patients. Activity may include passive or active range of motion, aerobic fitness, stretching, or strengthening exercises. Cardiovascular fitness has been proven to increase circulation, decrease edema (swelling), enhance muscle strength, and improve physical and psychosocial functioning (Polomano & Fillman, 2017). 

Heat and cold therapy are also nonpharmacological pain management options in the ICU. Cold therapy is considered to be more beneficial than heat for pain control. Nurses should educate patients and caregivers on the proper use of heat and cold therapies. Heat therapy should not be used on areas treated with radiation. Regions with decreased sensation, active bleeding, and recent injuries (within 24 hours) should also be avoided. Menthol-containing products (e.g., Vicks, Icy Hot) should not be combined with heat therapy. Heat and cold therapy sources should be covered with a towel before applying to the skin to prevent skin or tissue damage. Cold therapy should also be avoided in areas with open wounds, poor circulation, and radiation therapy. If the cold cannot be applied directly to a painful site, it may be beneficial to apply cold to the area precisely above or below the pain (Polomano & Fillman, 2017).

Cognitive therapies used to treat pain are distraction, hypnosis, and relaxation strategies. Nurses may use distraction and relaxation strategies in the ICU when applicable. Distraction can be utilized by engaging the patient in any activity that may hold their attention. Playing music, watching television, and making conversation are positive distraction options. Relaxation strategies may include music, breathing techniques, mindfulness, meditation, art, and imagery (Polomano & Fillman, 2017).

Unrelieved pain may be the most traumatic memory for patients in the ICU. The goal of pain management is to keep patients as safe and comfortable as possible. Nurses in the ICU should assess for pain at least four times per 12 hour shift and within thirty minutes of administering pain medications (Fraser & Gagnon, 2016).

Venous thromboembolism (VTE) prophylaxis-Definition/etiology

Venous thrombosis is defined as the formation of a thrombus (blood clot) and inflammation of the vein. VTE represents a variety of pathology from deep vein thrombosis (DVT) to pulmonary embolism (PE) (Wipke-Tevis & Rich, 2017). 

Virchow's triad includes three essential factors that can lead to the development of VTE. These factors include venous stasis, endothelium (inner lining of the vein) damage, and hypercoagulation of the blood. Patients admitted to the ICU are at increased risk for venous stasis because of prolonged immobility. Sepsis is a common diagnosis in the ICU and can lead to indirect endothelial vessel damage. Several diagnoses and medications can cause hypercoagulability of blood (Wipke-Tevis & Rich, 2017). 

Risk factors 

Patients in critical care have a high risk of developing VTE due to prolonged immobility. Other risk factors that may contribute to VTE in patients admitted to ICU include:

  • Advanced age
  • Atrial fibrillation 
  • Chronic heart failure
  • Obesity
  • Stroke
  • Recent surgery
  • Hypertonic IV medications
  • History of prior VTE
  • Central venous catheter access
  • History of IV drug abuse
  • Trauma
  • Dehydration
  • Malnutrition
  • Hormone therapy
  • Cancer
  • Oral contraceptives
  • Tobacco use

(Wipke-Tevis & Rich, 2017)

Treatment/Nursing implications

The Joint Commission and National Quality Forum developed VTE prophylaxis guidelines for high-risk hospitalized patients. It is also recommended that hospitals have a VTE prophylaxis policy for all adult patients. According to Wipke-Tevis and Rich (2017), as many as 80% of physically ill patients receive inadequate VTE prophylaxis. 

The nurse should carry out VTE prophylaxis interventions based on the patient’s current condition and needs. Interventions are based on bleeding risks, past medical history, current medication usage, current diagnosis, scheduled procedures or surgery, and patient requests. Early and aggressive mobility is the best and most cost-effective way to minimize VTE risk. Patients who are immobilized should be repositioned every two hours and range of motion should be encouraged every two to four hours while in bed (Wipke-Tevis & Rich, 2017).

Devices used for VTE prophylaxis include compression stockings and intermittent pneumatic compression (IPC) devices. Compression stockings should be fitted for the patient’s correct size and height. Proper application includes placement of the toe hole under the toes without any wrinkles in the stockings. The stockings should not be cut, folded, or altered for correct fitting. Patients should be educated on the benefits of the compression stocking and encouraged to wear them from admission until discharge. Compression stockings may be used in conjunction with anticoagulation for optimal prophylaxis effect. Intermittent pneumatic compression devices use inflatable sleeves that compress the calf. Some devices also squeeze the thigh and ankle. The sleeves have tubing that is connected to an electric pump. The sleeve must be fitted to the patient for optimal results. Compression devices may be removed for bathing, assessments, and ambulation. If a patient is diagnosed with a lower extremity DVT, the compression device should not be worn due to the risk of PE (Wipke-Tevis & Rich, 2017).

Pharmacologic agents are also commonly used for VTE prophylaxis. Subcutaneous thrombin inhibitors are routinely prescribed for VTE prophylaxis in the critical care setting. Thrombin inhibitors may include unfractionated heparin or low molecular weight heparin (enoxaparin [Lovenox]). With heparin, therapeutic effects can be measured regularly by the aPTT. Routine coagulation studies are not required with enoxaparin (Lovenox). Both medications are administered subcutaneously, preferably into abdominal adipose (fatty) tissue. Administration sites should be rotated. Patients should be educated not to rub the injection site to prevent excessive bruising (Wipke-Tevis & Rich, 2017).

Complications regularly arise in the intensive care unit. The nurse plays a fundamental role in minimizing these risks. Nurses must practice with an inquisitive and passionate attitude to provide the essential care needed to high-risk patients.

References

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