Page 168 - ACCCN's Critical Care Nursing

Psychological Care 145

TABLE 7.8 Analgesics

Drug/drug dose Properties Side Effects Nursing implications
Morphine sulphate ● Water-soluble ● Vasodilatory effect ● Intermittent doses rather the
1–10 mg/h (IV infusion), ● Peak effect 30 min ● Decreased gastric motility need for continuous
1–4 mg (IV bolus) ● Half-life: 3–7 h ● Respiratory depression infusions 34
● Sedative effect and release of ● Nausea and vomiting 89
histamines 34
Fentanyl 25–200 µg/h (IV ● Lipid-soluble ● Respiratory depression Useful where:
infusion), 25–100 µg/h (IV ● Synthetic opioid ● Bradycardia ● Hypotension or tachycardia
bolus) ● 80–100 times more potent than ● Muscular rigidity needs to be avoided
morphine ● Gastric and/or histamine side
● Peak effect in 4 min effects occur with morphine
● Half-life: 1.5–6 h 90
Tramadol hydrochloride ● Soluble in water and ethanol ● Nausea, vomiting ● Intermittent doses only
100 mg (IV bolus), then ● Synthetic ● Dizziness, dry mouth
50–100 mg 4–6/24 ● Centrally acting opioid-like ● Headache
analgesic ● Sweating
NSAIDs ● Analgesia and antipyretic ● Gastrointestinal ● Oral or rectal
● Some have anticoagulant ● Renal clearance
side effects
Ketamine 20 mg (IV bolus), ● Analgesic and dissociative ● Hypertension and ● Use for painful procedures e.g.
then 10–20 mg every anaesthetic for painful procedures respiratory depression wound dressings
5–10 min 89 ● Onset of action 1–2 min (administer slowly) ● Administer 2 mg of midazolam
● Analgesic/anaesthetic effects last ● Increased intracranial at the start of the procedure or
5–15 min pressure continue midazolam infusion
● Half-life 3 h ● Hallucinations to minimise the dysphoric and
hallucinogenic side effects
NSAIDs = non-steroidal anti-inflammatory drugs

injury). Ketamine is usually administered in conjunction with very few experiencing deep or rapid eye movement
with midazolam to reduce any potential emergent effects. sleep. 114-116 Sleep is highly disrupted and distributed
across 24 hours with roughly equal amounts occurring in
Pain relief is a primary goal for critical care nursing and 117
requires regular assessment of pain intensity using reli- the day and at night. These findings obtained using
able, objective, patient friendly instruments. No single polysomnography (PSG) have been corroborated by
118
medication is ideal for all patients, and clinicians need patients’ self reports of their sleep in critical care.
to carefully select, monitor and titrate the doses of any Patients consistently rate the overall quality of their sleep
agent selected. In the case of, for example, cardiac surgery as poor and more specifically they report light sleep with
patients, patient-controlled analgesia may provide the frequent awakenings and considerable difficulty falling
119-121
most effective pain management strategy (see Chapter asleep and returning to sleep. Many factors are
12). Non-pharmacological strategies add to the relief of thought to affect the patient’s ability to sleep, including
pain and come under the domain of nursing care. Without discomfort, treatment, medications, environmental noise
117,122
adequate pain management, patients will be unable to and illness.
achieve adequate rest and sleep, both essential to healing Sleep in the healthy adult comprises one consolidated
processes and wellbeing. period of 6–8 hours (mean 7.5 hours) in each 24 hour
period occurring at night according to natural circadian
rhythms. 123 There are two main sleep states; rapid eye
SLEEP movement sleep (REM) (approximately 25% of total
sleep time [TST]) and non-rapid eye movement sleep
The function of sleep is not yet fully understood however (non-REM) (approximately 75% of TST). Non-REM sleep
it is considered to be required for many bodily func- is comprised of 4 stages*; stages 1 and 2 or light
110
tions. It is vital for wellbeing and sleep disruption or sleep and stages 3 and 4 or slow wave sleep (SWS) or
deprivation leads to psychological and physical ill deep sleep, which must be completed in sequence in
health. 111-113 Sleep is considered to be physically and psy- order to enter REM sleep. The consolidated sleep period
chologically restorative and essential for healing and consists of 4 to 6 sleep cycles; stages 1–4 followed by REM
recovery from illness. Arguably critically ill people are in
greater need of undisrupted sleep but are more likely to
experience poor quality sleep. *More recent sleep staging guidelines have combined stages 3 and 4 so that there
Evidence suggests that although critically ill patients may are now only 3 stages of non-REM sleep. 162 However the system has not yet been
widely adopted and up to the date of publishing, few studies published on sleep
experience normal quantities of sleep, the quality is poor in critical care have used the system.