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Psychological Care 141

TABLE 7.5 Sedation scales

Scale Description Comment
Ramsay sedation scale 76 ● Scores from 1 (agitated/restless) to 6 (no ● Easy to administer
response) ● No differentiation between different levels of anxiety,
● 4 levels of sedation, 1 level of ‘cooperative, restlessness and agitation
oriented and tranquil’ and 1 level of ‘anxious, ● Unable to distinguish between a light plane of
agitated or restless’ unconsciousness and a deep coma
● Lack of clarity between each score
Richmond Agitation– ● Scores from −5 (unarousable) to +4 (combative) ● Assesses patient’s responses in relation to the type of
Sedation Scale ● 4 levels of agitation, 1 level for ‘calm and alert’, stimulus given (i.e. verbal or physical), plus consideration
(RASS) 77 5 levels of sedation of cognition and sustainability
● Good inter-rater reliability
Sedation – Agitation ● Scored from 1 (unarousable) to 7 (dangerous ● Good inter-rater reliability
Scale (SAS) 78 agitation) ● Multiple criteria for each level which, although increase
● 3 levels of agitation, 1 level of ‘calm and complexity, result in better discrimination between scores
cooperative’, 3 levels of sedation
Motor Activity ● Scored from 0 (unresponsive) to 6 (dangerously ● Very similar to SAS
Assessment Scale agitated) ● Limited psychometric testing
(MAAS) 79 ● 3 levels of agitation, 1 level of ‘calm and ● Multiple criteria for each level which, although increase
cooperative’, 3 levels of sedation complexity, result in better discrimination between scores
Vancouver Interactive ● Two domains (interaction and calmness) each ● Thorough assessment of calmness (in contrast to
and Calmness Scale containing five questions agitation) with multiple levels of scoring available
(VICS) 80 ● Each question is scored on a 6 point scale from ● Differentiation between each of the points on the 6 point
‘strongly agree’ to ‘strongly disagree’, resulting scale difficult
in a potential total score of 30 for each domain

● when to commence, increase, decrease or cease use of Pain is almost certainly a sensation widely experienced
sedative agents by critical care patients as it is one of the stressors most
● when to seek review by a medical officer. commonly reported by critically ill patients. 85,86 Arguably
pain management is often not afforded the same empha-
Many sedation protocols will also incorporate an analge- sis as more ‘life-threatening’ conditions such as haemo-
sia component. dynamic instability in critical care. However its alleviation
The aim of sedation protocols is to improve sedation is an essential element of critical care nursing. Myths such
management by encouraging regular discussion of seda- as the possibility that patients may become addicted to
tion goals among the healthcare team, while enabling analgesics and the very young and elderly having higher
nurses to manage the ongoing sedative needs of the tolerance for pain and our cultural tendency to reward
patient. Not all patients’ sedative needs will be met within high pain tolerance may lead to inadequate pain manage-
the sedation protocol; in these instances specific care ment. This is evidenced by a study performed in post-
should be planned and implemented by the multi- coronary bypass surgery patients. Nurses administered
disciplinary healthcare team. only 47% of the patient’s prescribed analgesic medica-
Although sedation protocols have widespread support, tion, and yet these patients reported moderate to severe
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there is mixed evidence regarding the benefits of imple- pain. In critical care, nurses assume a fairly autonomous
mentation of such protocols. A number of studies have role in titrating pain-relieving medication. With this
demonstrated the benefits associated with nurse-led seda- increased autonomy comes a responsibility to be knowl-
tion protocols, yet other studies do not demonstrate a edgeable and aware of effective pain management and
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benefit. Until further research is undertaken, sedation assessment of the ‘fifth vital sign’.
protocols should be implemented on a local basis where
current practice conditions indicate potential benefit PATHOPHYSIOLOGY OF PAIN
from standardisation of care. Appropriate evaluation
of the impact of protocol implementation should be Pain is defined as ‘an unpleasant sensory and emotional
undertaken. experience associated with actual or potential tissue
damage …’. 88, p. 250 Although unpleasant it has a role in
PAIN protecting against further injury. There are three catego-
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ries of pain receptors or nociceptors: mechanical nocicep-
Pain is an unobservable, inherently subjective, experi- tors, that respond to damage such as cutting and crushing;
ence. The nebulous multifaceted nature of pain has led thermal nociceptors, that respond to temperature; and
to significant difficulties in not only understanding the polymodal nociceptors, that respond to all types of
mechanisms underlying the experience for individuals stimuli including chemicals released from injured tissue.
but also assessing and managing the phenomenon. Prostaglandins released from fatty acids in response to