N124

Prof. MGAP Batalla

7/12/12

Sleep Disturbances
Cyclic Nature of Sleep

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.

Waking NREM I IV NREM III II REM

-

Factors
-

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
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.

3.

Situational
a. Personal and social isolation as a result of
complete dependence
b. Pain and discomfort
c. Anxiety and fear
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

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
1.
2.
3.
4.

of ICU Psychosis
Physiologic factors
Affects of medications
Environmental factors
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

Promoting Rest and Sleep in the Critical Care Setting

Feature 2: inattention
-

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)

AND EITHER
Feature 3: disorganized thinking
OR
Feature 4: altered LOC

Psychosis

Dimming of lights at night

Management of Delirium and Promotion of Psychosocial

Adaptation to the Critical Care Setting
-

vi. U understanding, management

(Ano sa tingin niyo ang
pinagmumulan ng sakit? Ano ang
ginawa mo?)

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

2.

Management of Delirium
1.
2.

Pharmacologic
a. Haloperidol is frequently prescribed
Non-pharmacologic
a. Promoting sleep
b. Back massage
c. Music therapy yung may meaning sa
patient
d. Preventing sensory overload

Unpleasant and sensory and emotional experience

associated with actual and potential tissue damage
Subjective
Multidimensional feature

Components of pain
Sensory perception
Affective negative emotions
Cognitive interpretation
Behavioral strategies
*Most valid measure for pain: patients self-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

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.

Pain and Pain Management in the Critical Care Setting

Pain
-

VAS (visual analog)

NRS (numerical)
DRS (descriptive)
FPT (facial pain thermometer)
Baker-Wong Faces PRS
Riker-Sedation Agitation Scale

*respiratory depression: the most life-threatening effect of

opioid; rescue drug: Naloxone
Pain management
1.

2.

TENS stimulates other non-pain sensory fibers in

the periphery modifies pain transmission; impairs
pain transmission (nililito ang mga nerves)
PCA (Patient Controlled Analgesia): fixed dosage
and interval

Psychosocial Alterations and Holistic Nursing Practice

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

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

Holistic Nursing
- All nursing practice that has healing the whole
person as its goal (American Holistic Nurses
Association, 1998)

Powerlessness
- cannot change outcome
- perception that ones own action will not
significantly affect an outcome

Holistic Care
- Physical, emotional, social, spiritual needs

Hopelessness
- limited or no options
- subjective state in which an individual sees limited
options

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

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

2.
3.
4.
5.
6.
7.

Denial
Anger
Bargaining
Guilt
Depression
Acceptance and Hope

Calculated if BMR increases by 10 15 %

Fever, post-op state, infection increases in

RME

Energy intake: food alcohol

Energy expenditure: physical activity, basal metabolism,
thermogenesis

*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
2. CHON
o
o

Main source of energy

Building blocks
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
o

Protein spares
Concentrated source of energy

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
malnutrition decreased immunocompetence, poor
wound healing infection increased 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
-

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

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

Albumin a role in transport of drugs that bind with protein

OGT/NGT sizes: refer to book!

Nutritional Assessment
- Risk for Malnutrition
o chronically-ill patients; patients on longerterm 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

Verification of tube placement: X-ray

Methods of Enteral feeding
- Intermittent: over a 24 hour period, 3-6 equal
feedings; by gravity
- Continuous: similar to typical gastric emptying;
controlled delivery of a prescribed volume of
formula
- Bolus: by gravity over a short period of time;
should not be used for intestinal feedings

*BMI is not a specific indication of protein deficiency.

Computing of OF volume for Enteral Feeding

Anthropometrics
Hair loss: dull, dry brittle hair
Loss of SC tissue, muscle wasting

Intake = [TCR/dilution]/# of feedings in 24 hours

*TCR = total calorie requirement

Labs: serum proteins, hematology studies, urine creatinine,

electrolytes

*Excessive CHO loading in a patient on mechanical

ventilation can lead to respiratory acidosis

Serum proteins
- Decrease in CHON and liver failure
- Albumin: slow to change in response to
malnutrition
- Prealbumin: falls in response to trauma and
infection

*PCO2 by product of metabolism

Hematology studies
- Microcytic anemia: IDA
- Macrocytic anemia: foale and VB12
- Lymphocytophenia
Urine creatine
- Nitrogen balance
Electrolytes
- Patients clinical status and management

Parenteral nutrition
- Nutrients via IV route
- Given to patient who:
o Cannot eat
o Do not eat
o Do not eat enough
o Do not eat totally
o Unable to eat for 7 days
- Goals
o Improve nutritional status
o Establish (+) nitrogen balance
o Maintain muscle mass
o Promote healing
TPN
-

large diameter vein (superior venacava, subclavian

vein)
highly concentrated dextrose or hyperosmolar
solutions

Nutritional Assessment Parameters

CHI = actual urinary creatinine
Predicted creatinine

x 100

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

Nurses
-

Roles: Parenteral nutrition

catheter care: q shift
administration of solutions
prevention of complications
evaluation of patient responses to IV feedings

Reading assignment
Body weight
Serum albumin
S. transferring
Total lymphocyte count
CHI

<80% IBW
<3 g/dL
<200 mg/dL
<80%

Nurses Roles in Enteral nutrition

- Prevention and detection of complications
- Response to feedings

Nursing management of:

1. Complication of enteral tube feedings
2. Complications of parenteral tube
feedings