Transcript Pain

By Jesusa S. Pagsibigan
Faculty – Adult Health Nursing
UPM College of Nursing
N-124 July 12, 2010
JSPagsibigan. N-124 UPCN. July 12, 2010
JSPagsibigan. N-124 UPCN. July 12, 2010

“Pain is whatever the experiencing person
says it is, existing whenever he or she says it
does.” (McCaffery 1980)

“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage.” (International Society for the Study
of Pain)
JSPagsibigan. N-124 UPCN. July 12, 2010
Sensory
1.

Perception of many characteristics of pain
▪
Mediated through the afferent nerve fibers, spinal cord,
brainstem, and the higher brain centers
Affective
2.

Negative emotions associated with the experience of pain
▪
Mediated through the interaction of the reticular formation, limbic
system, and the brain stem
Cognitive
3.

Meaning of pain
Behavioral
4.

Strategies used to express, avoid, or control pain
Physiological
5.

Nociception and the stress response
JSPagsibigan. N-124 UPCN. July 12, 2010
(McGuire, 1992; Melzack, 1999)
Modulation
Cortex
Perception
Limbic System
Hypothalamus
Reticular formation
Posterior Thalamus
Medial Thalamus
Brainstem
Direct spinothalamic tract
Spinal motor neuron
Indirect spinoreticular tract
Dorsal horn of SC
A-delta fibers (myelinated)
Efferent nerve fibers
C fibers (unmyelinated)
Afferent peripheral
nerve fibers
Transmission
nociceptors
Peripheral muscle
Pain Stimuli
N-124 JSP.UPCN July 12 2010
Transduction
Pain
ANS stimulation
Sympathetic Stimulation
• RR, dilation
of bronchus
• HR, BP
• muscle tension
•Dilated pupils
•Decreased GI motility
• bld. glucose
•Diaphoresis
Parasympathetic Stimulation
•Respiratory
•CVS
•Skeletal muscles
•Pupils
•GIT
•Blood glucose
level
•Temperature
JSPagsibigan. N-124 UPCN. July 12, 2010
•Rapid irregular
breathing
• HR, BP, pallor
•Weakness, or
exhaustion
•Muscle tension
•Nausea, vomiting

ANS
 Vasoconstriction
 ↑HR, & contractility


Heart
 ↑myocardial workload > ↑ O2 consumption
Lungs
 Splinting, ↓respiratory effort, ↓ pulmonary volume & flow
 Hesitation to cough, or breath deeply

Musculoskeletal
 Muscle contraction, spasms, rigidity
 Hesitation to move

Immune system
 Impair function of immune system, delay healing process
JSPagsibigan. N-124 UPCN. July 12, 2010
Neurotransmitters


Inhibits or enhances impulse transmission
1.
Substance P transmit pain impulses from the periphery
to higher brain centers
 Released by pain neurons of the dorsal horn
2.
Serotonin inhibits pain transmission
 Released from the brain stem & the dorsal horn
3.
Prostaglandins increases sensitivity to pain
 Released from the breakdown of phospholipids in the cell
membrane
JSPagsibigan. N-124 UPCN. July 12, 2010
Neuromodulators


1.
Increases or decreases the effects of particular
neurotransmitters by modifying neuron activity, and
adjust transmission of pain stimuli
Endorphins & dynorphins
 Body’s natural supply of morphine-like substances
 Causes analgesia when attached to opiate receptors in the brain
 Located in the brain, SC, and GIT
2.
Bradykinins
 Binds to peripheral nerves and to cells that cause chain reaction
producing prostaglandins
 Released from plasma that leaks from blood vessels
surrounding site of tissue injury
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
Sensory-discriminative
 Transmission between thalamus & sensory cortex
 Perceives location, character, and severity of pain
 Pain perception is decreased in factors that lower
consciousness
▪
▪
▪
Cerebral disease
Analgesics
Anaesthetics
 Pain perception is increased in factors that
increase awareness of stimuli
▪
▪
Anxiety
Sleep deprivation
JSPagsibigan. N-124 UPCN. July 12, 2010
2.
Affective-motivational
 Pain perception resulting from the interaction
between reticular formtion and limbic systems
▪
▪
A defensive response that causes a person to
interrupt or avoid a pain stimuli is created by the
reticular formation
The emotional response and the ability to cope with
pain is under the control of the limbic system
JSPagsibigan. N-124 UPCN. July 12, 2010
3.
Cognitive-evaluative
 Perception of pain as influenced by the higher
cortical centers
 Interpretation of the intensity and quality if pain
determines action
 Culture, emotions, and experience with pain
influence evaluation of the pain experience
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
Anticipation


Occurs before pain is perceived
Knows pain will occur


Occurs when pain is felt
High tolerance to pain is the ability to endure pain without
assistance
Patent with low tolerance to pain will seek relief before pain
occurs
Tolerance depends on values, attitudes, & motivation
Sensation


3.
Aftermath


Pain is reduced or stopped
Other responses resulting from crisis
▪ Physical/ pyschological symptoms
▪ Help gain control and self-esteem to minimize fear of
potential pain experiences
JSPagsibigan. N-124 UPCN. July 12, 2010
Family &
social support
Age
Coping style
Previous
experience
Pain
Experience
Sex
Anxiety
Culture
Attention
Meaning of
pain
JSPagsibigan. N-124 UPCN. July 12, 2010

Acute
 Follows acute injury, disease or surgical intervention
 Rapid onset, of varying intensity
 Lasts for a brief moment
 A warning of injury or disease
 Self-limiting
 Patient expect quick relief
 Eventually resolves when damages areas are healed
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
Chronic Malignant
 Prolonged pain, varied in intensity, lasts more than 6
months or until death
 Caused by uncontrolled cancer or its treatment, or
other progressive disorders

Chronic Non-malignant
 Results from non-progressive, healed tissue injury
 Endorphins may have ceased to function
JSPagsibigan. N-124 UPCN. July 12, 2010

Chronic Pain (recurrent, intractable, progressive)
 Major cause of
o physical and psychological disability
Inability to perform ADL
Sexual dysfunction
Social Isolation
Loss of job
 Have more pain-related negative self-statement, and
conviction of helplessness compared to healthy individuals
 Does not often show overt symptoms, and does not adapt
to the pain
 Creates insecurity because of never knowing how one
would feel
 Symptoms – fatigue, insomnia, anorexia, weight loss,
depression, hopelessness, anger.
JSPagsibigan. N-124 UPCN. July 12, 2010
Location
Characteristics
Superficial/ Cutaneous
Deep visceral
Short, localized, sharp
Diffuse, may radiate, sharp/ dull or
unique to organ involved, lasts
longer than superficial pain
Radiating
Intermittent or constant, feels as
though it travels down or along a
body part
Referred
Felt in body part separate from
source of pain, assume any
characteristic
JSPagsibigan. N-124 UPCN. July 12, 2010

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Amount of tissue damage can accurately indicate
pain intensity
Client with minor illnesses have less pain than
those with severe physical alteration
Psychogenic pain is not real
Chronic pain is psychological
Clients should expect to have pain in the hospital
Drug abusers and alcoholics overreact to
discomfort
Administering analgesics regularly will lead to
drug dependence
Health care personnel are the best authorities on
the nature of a client’s pain.
JSPagsibigan. N-124 UPCN. July 12, 2010
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An experience common to patients in the ICU
Procedures or treatment carried out by nurses
and doctors in the ICU sometimes cause pain
Due to the life-threatening condition of the
patients in the ICU, relief of pain may be a lower
priority
A significant issue because often, it is
undertreated.
 Overly concern about adverse effects, e.g., hemodynamic
and respiratory compromise, oversedation, or drug
addiction
JSPagsibigan. N-124 UPCN. July 12, 2010
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
Pain experiences are described as being
moderate to severe in intensity
Factors inherent in the ICU setting when
experienced together may have a synergistic
effect to compound each other
 Anxiety, sleep deprivation, unfamiliar and
unpleasant environment, separation from
family, loss of control
 Pain can be intensified ,real or imagined
JSPagsibigan. N-124 UPCN. July 12, 2010

Caused by
1. Illness
2. Injury
3. Therapy
4. Diagnostic procedure
JSPagsibigan. N-124 UPCN. July 12, 2010
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Assess pain at regular intervals
Reassess at appropriate intervals after
administration of pain medications
Identify conditions that would complicate
assessment and treatment of pain.
Absence of physical signs or behaviors often are
incorrectly interpreted as the absence of pain
 An effective pain assessment elicits self-report form the patient,
with the integration of behavioral observation and physiological
parameters when appropriate
JSPagsibigan. N-124 UPCN. July 12, 2010

Protective behavior
 Avoidance of movement, guarding, and withdrawal

Palliative behavior
 Rubbing the area, changing positions, requesting pain
medications

Affective behavior
 Crying, moaning, screaming, changes in facial expressions

Patients unable to speak
 Use eye or facial expression, movement of hands or legs to
communicate

Unresponsive patients
 Restlessness or agitation
JSPagsibigan. N-124 UPCN. July 12, 2010

Observe caution in attributing physiologic changes
solely to pain.
 Unexpected increase in severity and intensity of pain,
accompanied by fever, tachycardia, and hypotension may
signal the development of life threatening complication
(wound dehiscence, infection, or deep vein thrombosis)

There may be obvious discrepancies among
patient’s self-report, and behavioral and
physiological manifestations
 Self report of 2/10 pain scale score, but tachycardic,
diaphoretic, and splinting with respiration
 Stress importance of factual report. Address any
misconeptions, and knowledge deficit. Treat pain according
to the patient’s self report
JSPagsibigan. N-124 UPCN. July 12, 2010
A.
B.
C.
D.
E.
Ask about pain regularly; assess pain
systematically
Believe the client and family in their report of
pain and what relieves it
Choose pain control options appropriate for the
client, family, and setting
Deliver interventions in a timely, logical, and
coordinated manner
Empower client and their families; enable them
to control their course to the greatest extent
possible
JSPagsibigan. N-124 UPCN. July 12, 2010
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Acuity of patient’s condition
Inability to communicate pain due to altered leel
of consciousness
Restricted or limited movement
Artificial airway (ET, tracheostomy)
 Observe for behavioral cues or physiological indicators
however absence of which should not be interpreted as
absence of pain
 AHCPR recommendation: If the procedure, surgery, or
condition is believed to be associated with pain, the
presence of pain should be assumed and treated
appropriately
JSPagsibigan. N-124 UPCN. July 12, 2010
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Pleuritic chest pain
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Peripheral and may radiate to scapular region
Worsened by inspiratory maneuvers
Knifelike
May be confused with
▪ musculoskeletal pain follwoing exercise
▪ Costochondritis

Pericardial pain
 Localized and nonradiating
 May occur on inspiration

Cardiac pain
 Not related with respiratory variations
 Often on left side of chest and non-radiating
JSPagsibigan. N-124 UPCN. July 12, 2010
Bias
Vague assessment questions > unreliable
assessment data
 Clients who do not provide complete,
pertinent, and accurate pain information
 Clients who lack sufficient medical
knowledge to be able to select information to
help health care providers to make decisions
about the pain
 Use of pain assessment tools that have not
been proven reliable and valid with identical
clients


JSPagsibigan. N-124 UPCN. July 12, 2010
Characteristics
Nursing Interventions
Precipitating Factors Avoid such activities
Quality
Evaluate response to intervention; revise
or modify as appropriate
Radiation/ Relief
Measures
Safe and appropriate measures used by
client
Site
Positioning client off painful site;
application of local treatment
Timing
Peak action of drugs addresses the pain
when it is most acute
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
4.
Reduce incidence and severity of acute pain
(postoperative or posttraumatic)
Educate patients about the need to
communicate unrelieved pain so prompt
evaluation and a more effective treatment can
be received
Enhance patient comfort and safety
Contribute to decreased complications and
shorter hospital stay
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
4.
Physical
Cognitive
Behavioral
Pharmacological
JSPagsibigan. N-124 UPCN. July 12, 2010
Behavioral therapies promote comfort
by placing the patient in control
 Working on the cognitive-behavioral
level reduce pain, anxiety, and the
amount of analgesia needed for pain
control
 Nonpharmacological interventions must
supplement pharmacological
interventions whenever possible

JSPagsibigan. N-124 UPCN. July 12, 2010
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Relaxation Techniques
1. Promote a sense of detachment
2. Gives a sense of control over a particular body
part
3. It requires
–
–
–
–
Quiet environment
Comfortable position
Passive attitude
Concentration
JSPagsibigan. N-124 UPCN. July 12, 2010
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Relaxation Techniques
1. Quieting reflex
– Only 6 seconds to do
– Calms the SNS
– Gives the patient a sense of control over stress and
anxiety
a. Inhale easily and naturally
b. Think “alert mind, calm body”
c. Smile inwardly (with your internal facial muscles)
d. As you exhale, allow your jaw, tongue, and shoulders to
go loose
e. Allow a feeling of warmth and looseness to go down
through your body and out through your toes
JSPagsibigan. N-124 UPCN. July 12, 2010

Relaxation Techniques
2. Deep breathing exercises
a. “Lie or sit comfortably”
b. “Breathe through your nose” (to warm and filter the air)
c. Concentrate on contracting your diaphragm, and breathe from
deep within your abdomen. (Place hand on your abdomen and feel
it rise – to confirm abdominal rather than chest breathing)
d. Begin to inhale and feel your abdomen rise; inhale a full deep
breath
e. “Slowly exhale as much air as you can, contracting your abdomen
towards your spine at the end og exhalation” (Do this within limits
of condition, at own depth, and pae
f. “Repeat breathing in and out this way several times, concentrate
on the rise and fall of your abdomend
g. “Whenever you feel upset, anxious or uncomfortable, few slow
deep breaths to help you break the stress cycle and calm yourself
down.
JSPagsibigan. N-124 UPCN. July 12, 2010
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Relaxation Techniques
3.
Music therapy
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Match selection to client’s taste. Consider age and
background
Use earphones to help client concentrate on the music
Controls must be easy to manipulate, press, and
distinguish
Family members are encouraged to bring tapes from
home
Have client concentrate on music, emphasizing rhythm
by tapping fingers or patting the thigh
Instruct client not to analyze music
Increase volume if pain is acute; decrease as pain
subsides
JSPagsibigan. N-124 UPCN. July 12, 2010
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Relaxation Techniques
4.
5.
6.
Changing internal and external dialogues
Presence
Touch
–
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A positive therapeutic element of human interaction
Promotes and maintains reality orientation
Provides patients in the ICU a greater sense of control over
unfamiliar setting
Improves the sense of well-being of the patient
Has positive effects on perceptual and cognitive abilities
Influences physiologic parameters
N-124 JSP.UPCN July 12 2010
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Ideal method of analgesia should achieve
adequate serum drug levels, maintained
quickly and easily
It should be easily titrated based on patient’s
response
1. Patient’s reported pain score is less than own
predetermined management goal
2. Sedation and respiratory depression is absent

It should be quickly eliminated when no longer
needed
N-124 JSP.UPCN July 12 2010
1.
2.
3.
4.
5.
Use a consistent method for assessing and
documenting pain
Administer analgesics RTC after surgery or
trauma
Whenever possible, use patient-controlled
analgesis
Consider combining different classes of
analgesics
Develop a way to evaluate pain management
as a quality assurance activity
(Alpen MA, Titler MG: Pain management in the critically ill: What do we know and how can we improve?
AACN Clinical Issues 5:159-168, 1995 )
JSPagsibigan. N-124 UPCN. July 12, 2010
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NSAIDs have limited use in the critically ill
patients
1. Risk of GI bleeding and platelet dysfunction

Ketorolac is contraindicated in
1. Patient with recent GI bleed
2. Actual or potential renal impairment
3. Bleeding disorders
JSPagsibigan. N-124 UPCN. July 12, 2010
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Inhibits the synthesis of inflammatory mediators
(prostaglandin, histamine, and bradykinin) at the
site of injury and effectively relieve pain.
 Without causing sedation, respiratory depression, or
bowel/ bladder dycfunction
AHCPR suggest that NSAIDs be the initial choice for
management of mild to moderate postoperative
pain.
 NSAIDs + opioids: opioid dose can be reduced and
still produce effective analgesia. Incidence of
opioid-related side-effects is decreased.

JSPagsibigan. N-124 UPCN. July 12, 2010
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Ketorolac an NSAID approved parenteral
preparation
 Used frequently in the ICU setting as a short-
termn adjuvant to opiods
 Used when opioids are contraindicated (head
injury, or neurosurgery.

Indomethacin is available in supporitory form
and can be combined with opioids
 Should not be used alone for moderate to severe
pain.
JSPagsibigan. N-124 UPCN. July 12, 2010
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Binds to various receptor sites in the spinal cord, CNS,
and change the perception of pain
Most commonly used in the ICU because of their quick
onset and short duration of effect
1.
Morphine sulfate
–
Dose IV: 11-20 mg
–
Dose E: 2 – 5 mg
Peak: 30 minutes
Duration: 4 hours
Peak: 30 – 60 minutes
Duration: 8 – 24 hours
2.
Fentanyl
–
Dose IV: 0.1 mg
Peak: 3 minutes
Duration: 1 hour
–
Dose E: O.1 mg
Peak: 10 – 20 minutes
Duration: 2 – 3 hours
JSPagsibigan. N-124 UPCN. July 12, 2010
Meperidine should be avoided in patients with
compromised renal function due to risk for
normeperidine toxicity
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Accumulation of normeperidine
1.
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CNS excitatory effects – delirium, irritability, and convulsions
Undesirable side effects
1.
2.
3.
4.
5.
Constipation
Urinary retention
Sedation
Respiratory depression
Nausea
JSPagsibigan. N-124 UPCN. July 12, 2010
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Decreasing the opioid dose
Avoiding PRN dosing
Add NSAID to the pain management plan
JSPagsibigan. N-124 UPCN. July 12, 2010
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Life-threatening complication
 RR less than 10/ min, shallow, or irregular
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Identify variations from baseline respiratory rate
and pattern
Monitor sedation level. Decline in LOC can
precede the development of respiratory
depression
 Avoid sedation that impairs the ability to participate in his
own care, and performing deep breathing, and ambulation

Incidence of significant respiratory depression
associated with opioid use in therapeutic doses is
0.09%
JSPagsibigan. N-124 UPCN. July 12, 2010
A pure opioid antagonist
IV administration of Narcan
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1.
2.
Dilute 0.4 mg naloxone in 10 mL Normal Saline
Slowly infuse the drug at a rate of 0.5 mL over 2 minutes
Given to reverse oversedation, and respiratory
depression, not analgesia
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Usually occurs within 1 – 2 minutes
When given IM or subcutaneously, onset of action is within
2 – 5 minutes
Half-life is shorter than most opiods = 1 ½ - 2 hours
JSPagsibigan. N-124 UPCN. July 12, 2010
Addiction rarely occurs regardless of the length
of time opioids are taken
 Pseudoaddiction – develops in patient
inadequately treat ed for pain and is manifested
by drug-seeking behavior to obtain adequate
pain control
 Tolerance – requires an increase in opioid dose
to achieve the same pain relief that was possible
at a previous lesser dose
 Physical dependence – withdrawal syndrome
when opioid is suddenly stopped or naloxone is
administered

JSPagsibigan. N-124 UPCN. July 12, 2010
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Withdrawal is avoided by tapering opioid
doses
Tolerance and physical dependence are
normal physiological responses that should
be expected after 7 days of opiod
administration
JSPagsibigan. N-124 UPCN. July 12, 2010

Should not be used to provide acute pain
relief
1. Alteration in cardiac output and perfusion make
IM absorption extremely variable
2. Painful
3. Anticipated discomfort associated with the
injection increases patient anxiety
4. Repeated IM injection can cause muscle and soft
tissue fibrosis
JSPagsibigan. N-124 UPCN. July 12, 2010
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Opioids diffuse across the dura and
subarachnoid space and bind with opioid
receptor sites providing effective relief and
improved postoperative pulmonary function
For critically ill patients after thoracic, upper
abdominal or peripheral vascular surgery, rib
fractures, orthopedic trauma, or post-op
patients with obesity or pulmonary disease
JSPagsibigan. N-124 UPCN. July 12, 2010

Commonly used are preservative free
morphine and fentanyl
 Preservatives can be neurotoxic and may cause
severe spinal injury
 Fentanyl diffuses more quikly to the opioid
receptor site and cuases fewer side effects
 Morphine is more water soluble and more likely to
accummulate in the CSF and systemic circulation
JSPagsibigan. N-124 UPCN. July 12, 2010
Respiratory depression is the most serious
complication
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
Early respiratory depression within 2 hours of opioid
administration
Late respiratory depression within 6 – 12 hours and occurs
as the opioid diffuses into the CSF and combines with the
opioid receptors in the respiratory centers
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Since more invasive monitor for signs of local or
systemic infection
Contraindications
1.
2.
3.
Systemic infection/ sepsis
Bleeding disorders
Increased ICP
JSPagsibigan. N-124 UPCN. July 12, 2010
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Incidence of severe respiratory depression is
less than 1%
1. Respiratory assessment should be done hourly
during the 1st 24 hours of therapy and every 4
hours thereafter
2. Have Naloxone readily available and
administered in the event of serious respiratory
depression or arrest
3. Prepare for airway and respiratory support – O2,
head tilt-jaw lift, endotracheal intubation,
manual ventilation
JSPagsibigan. N-124 UPCN. July 12, 2010
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Opioid is injected into the subarachnoid
space located between the spinal cord and
the dura mater
10 x more potent than epidural analgesis, less
medication is needed to provide effective
analgesis
Used to deliver one-time dose of analgesic
JSPagsibigan. N-124 UPCN. July 12, 2010
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A local anesthetic is combined with epidural
or intrathecal analgesia, acting
synergistically, and have a dose-sparing
effect
Prevents nerve cell depolarization and thus
blocks pain
Has side effects
 Hypotension, and motor weakness
JSPagsibigan. N-124 UPCN. July 12, 2010
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A percutaneous catheter is inserted between
the parietal and visceral pleura of the lung, or
administered through a pleural chest tube
Local anesthetics diffuse across the parietal
pleura and block intercostal nerve roots
providing effectie analgesia without adverse
effects of systemic opioids
Pneumothorax can occur during catheter
placement; catheter can be misplaced into a
blood vessel and cause systemic toxicity
JSPagsibigan. N-124 UPCN. July 12, 2010

Benzodiazepines (midzolam, diazepam, lorazepam)
 used for short-term relief of anxiety
▪ Rapid onset: 30 – 90 seconds after IV
administration
▪ Short duration: 1.5 – 4.5 hours (increased in older, or obese
patients, and those with liver disease)
▪ It has retrograde amnesia effect making it beneficial during
procedures
 They are reversible agents
▪ If respiratory depression occurs, benzodiazepinespecific reversal agent Flumazenil, reverses the sedative
and respiratory depressant effect without reversing
opioid analgesia
JSPagsibigan. N-124 UPCN. July 12, 2010
Titrate Flumazenil so that the smallest effective
amount is used
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Undesirable effect are prevented
▪
▪
▪
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Anxiety
Perceptual distortion
confusion
Flumazenil Administration
1.
Slow IV @0.2 to 0.5 mg/ min until desired effects are seen
up to a total dose of 3 – 5 mg
–
2.
Seen within 5 – 10 minutes
Closely observe the patient for at least 2 hours after reversal
1.
Oversedation can reoccur because flumazenil may wear off before
benzodiazepine is cleared from the body.
JSPagsibigan. N-124 UPCN. July 12, 2010
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No analgesic properties
Minimal amnesic effects
Onset: 40 seconds
Half-life: 5-8 minutes
Given IV bolus or as a continuous IV infusion
Ideal agent for patients requiring sedation
during painful procedures
It has no preservative, and is formulated in a
white, oil-based emulsion containing soybean
oil, egg lecithin, and glycerol
Most serious adverse effects: respiratory
depression, and hypotension
JSPagsibigan. N-124 UPCN. July 12, 2010
AHCPR guidelines “only when immediate treatment of
cardiorespiratory instability is required, or if a
competent patient declines treatment, should
analgesia be withheld for a painful procedure”
 Before procedure, patient should be premedicated;
procedure should be performed only when medication
has taken effect.
 During procedure

 IV opioids are used for analgesia. Additional doses are given
for breakthrough pain
 Anxiolytics can be given as adjuncts to relieve anxiety during
the procedure
 Monitor patient’s response during the procedure
JSPagsibigan. N-124 UPCN. July 12, 2010










Linens – tight and smooth
Check temperature of hot or cold application
Loosen constricting bandages; change wet
dressings
Lift client in bed – do not pull
Position client in anatomical alignment
Position client correctly on bedpan
Position tubings on which client is lying
Avoid exposing skinand mucous membrane to
irritants
Prevent constipation
Prevent urinary retention
JSPagsibigan. N-124 UPCN. July 12, 2010

Acute post-op pain (Marks & Sacher 1973)
 41% of patients experienced moderate unrelieved pain;
 32% had severely unrelieved pain

Unrelieved pain in Med-surg units (Donovan,
Dillon, and McGuire 1987)
 57.5% had “horrible, excruciating pain at some time”

Opiates given IM on an “as-needed” basis (Oden
1989)
 Poor control on a large number of patient’s pain
JSPagsibigan. N-124 UPCN. July 12, 2010
Lack of well-controlled clinical studies of
methods for pain management
1.


Most tests done on various drugs
Smaller portion on nonpharmacological
approaches
Lack of use by practitioners of what is
already known about pain management
2.

As reflected in the studies previouslymentioned
JSPagsibigan. N-124 UPCN. July 12, 2010


Acute pain and cancer pain are significantly
undertreated in hospitals
Chronic nonmalignant pain often is
overtreated by medication
JSPagsibigan. N-124 UPCN. July 12, 2010

American Pain Society (APS)
 Advocates regular monitoring of pain, including
noting patient’s response to intervention, as the
5th vital sign

Agency for Health Care Policy & Research
(AHCPR)
 Developed clinical practice guidelines for the
management of acute pain and cancer pain
JSPagsibigan. N-124 UPCN. July 12, 2010
JSPagsibigan. N-124 UPCN. July 12, 2010
Nurse as advocate when
There are unmet needs
Family
Self-preservation:
Physiological
adaptation
representing major
body systems
• Air
•Circulation
•Nutrition
•Metabolism
•Coordination
•Elimination
Safety &
security
Psychological
Social
adaptation Interaction
• Spirituality
•Sense of
belonging
•Connectedness
Needs of
critically ill patients
Hudak CM, Gallo,BM, Morton PG, Critical Care Nursing: A Holistic Approach,
7th edition, 1990
JSPagsibigan. N-124 UPCN. July 12, 2010

The body requires energy for
 growth
 physical activity
 physiological processes even at rest

Homeostasis is maintained by achieving a
balance between energy supply and total
energy expenditure
JSPagsibigan. N-124 UPCN. July 12, 2010
Coping
behaviors
Increased demand
for energy
Ineffective
behavior
Effective
behaviors
Decreased
tension state
Increased
tension
Free
energy
Stress & Coping
JSPagsibigan. N-124 UPCN. July 12, 2010

Fats (lipids) are stored as triglycerides which
have the highest caloric content of all
nutrients.
 Triglycerides are broken down to fatty acids and
glycerol and used as energy sources when calorie
intake is restricted
 Glycerol is converted to glucose, fatty acids are
converted to ketones which can be a source of
energy during periods of starvation.
JSPagsibigan. N-124 UPCN. July 12, 2010

Proteins are found in approximately 75% of body
solids; are essential for the formation of all body
structures
 There are 20 AA in body proteins where most of AA
are stored.
 AA in excess of those needed in protein synthesis are
converted to fatty acids, ketones, or glucose may be
used as a metabolic fuel

Nitrogen balance is essential to cellular structure
and function, being a major component of AA,
the building block of protein
JSPagsibigan. N-124 UPCN. July 12, 2010

Carbohydrates are
 synthesized in the form of glucose which is an
efficient fuel that breaks down to CO2 & H2O
when metabolized in the presence of O2
 Stored in limited quantities as glycogen (liver,
skeletal muscles, skin, and some glandular
organs), or
 Converted to fatty acids, and stored in fat cells as
triglycerides
JSPagsibigan. N-124 UPCN. July 12, 2010

Glycogenolysis – maintain blood sugar levels
during periods of fasting and strenuous
exercise
 Epinephrine stimulates glycogen break down in
muscles
 Glucagon elicits a more sensitive response from
the liver in stimulating glycogen break down
 Enzyme glucose-6-phosphatase in the liver
removes the phosphate group from the
phosphorylated glucose molecule, allowing the
glucose molecule to enter the blood stream
JSPagsibigan. N-124 UPCN. July 12, 2010

Gluconeogenesis – provides the glucose
needed to meet the metabolic needs of the
brain and nervous system, and other
glucose-dependent tissues.
 Some are stored in the liver as glycogen AA,
lactate, and glycerol are converted to glucose

Hormones that stimulate gluconeogenesis
 Glucagon
 Glucocorticoids
 Thyroid hormone
JSPagsibigan. N-124 UPCN. July 12, 2010

Results from heat production mechanisms
(thermogenesis)
1.
2.
3.
4.

BMR
Diet-induced
Exercise-induced
Response to environmental conditions
Age, body size, rate of growth, and state of
health are factors that determines the
amount of energy needed to be used
JSPagsibigan. N-124 UPCN. July 12, 2010

Chemical reactions occurring at rests that
are essential to provide energy needed to
maintain






Normal body temperature
Cardiovascular and respiratory function
Muscle tone
Other essential activities in the resting body
BMR accounts for 50% - 70% of total energy
expenditure
Measured by determining O2 consumption
under basal conditions and can predict
caloric needs for nutrition maintenance
JSPagsibigan. N-124 UPCN. July 12, 2010

Basal conditions:
1. After a full night’s sleep
2. After at least 12 hours without food
3. While a person is awake and at rest in a warm and
comfortable room

BMR = Calories/ hour




Young women 53 calories/ hour
Young men 60 calories/ hour
In general, women have 5% - 10% lower BMR than men
BMR is affected by age, sex, physical state, and
pregnancy
JSPagsibigan. N-124 UPCN. July 12, 2010


Energy expended during digestion,
absorption, and assimilation of food after
ingestion
Accounts for 10% of the total energy
expended
JSPagsibigan. N-124 UPCN. July 12, 2010

Energy expended for physical activity which
is determined by
 The type of activity performed
 Length of participation
 Person’s weight
 Physical fitness
JSPagsibigan. N-124 UPCN. July 12, 2010
Form of Activity
Sleeping
Awake lying still
Sitting at rest
Dressing & undressing
Tailoring
Light exercise
Walking slowly (2.6 mph)
Swimming
Running (5.3 mph)
Walking Up stairs
Calories/ hr
65
77
100
118
135
170
200
500
570
100
(Extracted from data compiled by Prof M.S. Rose, Guyton A.C.et.al. [1996].
Medical Physiology [9th ed]. Philadelphia: W.B. Saunders)
JSPagsibigan. N-124 UPCN. July 12, 2010

A continuing supply of glucose is essential
for survival
 CNS uses 115 g of glucose/ day. RBCs, bone
marrow, kidneys, and peripheral nervous system
uses 36 g of glucose/ day
 1% of calories stored in carbohydrate sources are
depleted within 12 – 24 hours
 Gluconeogenesis wherein glycerol, lactate and
AA are used by the liver in the synthesis of
glucose
 Fatty acids & ketones become the predominant
fuel after 1st few days of starvation
JSPagsibigan. N-124 UPCN. July 12, 2010

Last stages of starvation would utilize
protein as a fuel source.
 Loss of lean body tissue and fat
 Diuresis
 Ketosis
 Increased nitrogen excretion
 Tissue wasting
 Daily weight loss

Wound healing is poor
JSPagsibigan. N-124 UPCN. July 12, 2010






Generalized multiple immunologic
malfunction
Altered hypothalamic function related to
ketosis results in diminished appetite,
decreased desire for fluids
Decreased libido
Anovulation and amenorrhea in females
Decreased testicular function in males
Kidneys: calcium and phosphate are
excreted as bone is dissolved, and uric acid is
retained, which can cause gout
JSPagsibigan. N-124 UPCN. July 12, 2010





Muscles of breathing become weak
Respiratory function becomes compromised
as more muscle proteins are used as fuel
source
Depression and emotional lability is
common
GI tract undergoes mucosal atrophy, with
loss of villi in the small intestines resulting
from malabsorption
Loss of protein from cardiac muscle
decreases its contractility and cardiac output
JSPagsibigan. N-124 UPCN. July 12, 2010
Has difficulty in eating a healthy diet because
the patient commonly has restrictions on food
and water intake r/t tests and surgery
 Anorexia, nausea, and vomiting can be caused
by stress, pain, medications, and special diets
 Motivation to eat may be lost because of being
alone in a room where unpleasant treatment
may be given

JSPagsibigan. N-124 UPCN. July 12, 2010



May be too hemodynamically unstable to be
fed
Though on bedrest, a hypermetabolic state
caused by illness, or trauma exists resulting in
an increase in O2 consumption and energy
expenditure
There may be an increased need for protein to
support tissue repair after trauma or surgery.
JSPagsibigan. N-124 UPCN. July 12, 2010




Lack of communication among members
of the health team
Frequent diagnostic tests and procedures
necessitating feeding interruption
Insufficient monitoring of nutrient intake
Inadequate use of supplements, tube
feedings, or TPN to maintain nutritional
status of patients
JSPagsibigan. N-124 UPCN. July 12, 2010









Respiratory failure requiring a ventilator
Pressure ulcers
Infection
Sepsis
Wound dehiscence
Longer hospital stay
Higher incidence of complications
Higher hospital costs
Mortality
JSPagsibigan. N-124 UPCN. July 12, 2010
Increased attention
& arousal
Sleep Alteration
Cerebral cortex
Limbic System
Thalamus
RAS
Hypothalamus
Pituitary
Adrenal cortex
Alteration in glucose
fat, & protein metabolism
Suppression of inflammatory
& immune responses
ANS
Increased HR & BP
Pupil dilation
Dry mouth
Increased sweating of
hands
increased coagulability
of the blood
JSPagsibigan. N-124 UPCN. July 12, 2010
Increased
Muscle Tension
Immune system
Decreased resistance
to infection
Alterations in immune
response
Hypothalamus
•CRF
•Pain
•Stress
•Hypovolemia
•ADH
•Hypoxia
Renin•Inflammation Angiotensin
•Infection
•Necrosis
•Mineralocorticoids
Kidney
•Trauma
(Aldosterone)
•Glucocorticoids
(Cortisol)
gluconeogenesis
JSPagsibigan. N-124 UPCN. July 12, 2010
Pituitary
•ACTH
(Corticotropin)
Adrenal Gland
•Catecholamines
(epinephrine,
norepinephrin)
Glucagon
(Pancreas)
glycogenolysis

Ebb Phase – occurs immediately after the
tissue injury and may last for 24 – 48 hours
 Initially, the systemic circulation is reduced resulting
to hypoxia and hypovolemia’s; body metabolic rate
decreases.
 There is an increased production of glucose through
glycogenolysis, and gluconeogenesis
 The hyperglycemic state renders insulin production
insufficient
JSPagsibigan. N-124 UPCN. July 12, 2010

Flow Phase –it usually lasts 5 – 10 days
following the ebb phase
 The metabolic rate is increased
 Protein catabolism is increased by breaking down skeletal




muscle protein initially through gluconeogenesis to preserve
visceral proteins.
Glycogen is no longer available
Cellular resistance to insulin further aggravates hyperglycemia
Insulin hinders the breakdown of fat stores for energy source.
Persistence of hypermetabolic and hypercatabolic state
without adequate nutrient support can cause multi-organ
system failure and consequently death.
JSPagsibigan. N-124 UPCN. July 12, 2010

Ebb Phase
 Early nutritional support is recommended
 May be delayed until hemodynamic stability is
achieved

Flow Phase
 Nutritional support is aimed at providing for the
body’s need for energy (CHO, and fats) and
protein which is in direct proportion to the
severity and duration of the metabolic stress
response. Requirement of electrolytes, vitamins,
and other trace elements need to be determined
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
Identify patients who are malnourished or
are at risk of malnutrition
Determine nutritional needs of individual
patients
Select appropriate nutrition support for
patients with or at risk of developing
nutritional deficits
JSPagsibigan. N-124 UPCN. July 12, 2010
1. Anthropometric measurements
▪ To detect changes in measurements over time
▪ Indicator of underweight or overweight
▪ Determine appropriateness of weight for height
▪ Detect changes in body water & its distribution
▪ Determine the composition of te body in relation to lean
body mass and fat tissue
▪
▪
▪
▪
Arm circumference
Skinfold thickness
Bioelectrical impedance
CT scan
JSPagsibigan. N-124 UPCN. July 12, 2010
2. Biochemical lab data
▪ S. albumin – protein status
▪ Hematologic values
▪ Anemia
 Normocytic –common with protein deficiency
 Microcytic – can be from blood loss; iron deficiency
 Macrocytic – common in folate and vit B12 deficieny
 Lymphocytopenia – Common in protein deficientcy
JSPagsibigan. N-124 UPCN. July 12, 2010
3. Clinical signs
▪ Protein-Calorie Malnutrition
a. Hair – loss, brittle, dry, dull, loss of hair pigment
b. Subcutaneous tissue – muscle wasting, loss of
subcutaneous tissue
c. Wound – poor healing, decubitus ulcer
d. Hepatomegaly
e. Edema
JSPagsibigan. N-124 UPCN. July 12, 2010
3. Clinical signs
▪ Vitamin Deficiencies
a. Skin – dry, scaly, + hyperkeratosis, skin appearing
continually to have gooseflesh (Vit. A)
b. Cornea, and conjunctiva – dry (Vit. A)
c. Gingivitis, poor wound healing (Vit. C)
d. Corners of the mouth cracked, and tongue inflammed
(Riboflavin [B2], Niacin, B12, other B vitamins, Folic acid)
e. Petechiae, ecchymosis – (Vit C or K)
f. Edema, heart failure (Vit B1)
g. Confusion, confabulation (Vit B1)
JSPagsibigan. N-124 UPCN. July 12, 2010
3. Clinical signs
▪ Mineral Deficiencies
a. Blue sclerae, pale mucous membrane, spoon-shaped
nails (Iron)
b. Hypogeusia (poor sense of taste); dysgeusia (bad taste);
eczema, poor wound healing (Zinc)
▪ Excessive Vitamin Intake
a. Hair loss; dry skin; hepatomegaly (Vit A)
JSPagsibigan. N-124 UPCN. July 12, 2010
4. Diet and pertinent health history
▪ Inadequate intake of nutrients – alcohol abuse,
anorexia, severe or prolonged N/V, confision, coma,
poor dentition, poverty
▪ Inadequate digestion or absorption of nutrients –
previous GI surgeries, certain medications (antacids,
histamine H2-receptor antagonists reduce upper small
bowel acidity; cholestyramine binds fat-soluble
nutrients); anticonvulsants
4. Diet and pertinent health history
▪ Increased nutrient losses – blood loss, severe
diarrhea, fistulae, draining abscesses, wounds,
decubitus ulcer, pertineal dialysis or hemodialysis,
corticosteroid therapy (increased tissue catabolism)
▪ Increased nurient requirement – fever, surgery,
trauma, burns, infection, some types of cancer,
increased physioloic demands – pregnancy, lactation,
and growth





Illness or surgery that interferes with
nutritional intake – chewing, and
swallowing
Chronic Disease – anorexia, n/v
Chronic use of Modified Diet
Increased metabolic requirement
Poverty
JSPagsibigan. N-124 UPCN. July 12, 2010

Weight
 Involuntary weight loss or gain of a significant
amount (In 1 month - >5% of usual BW; in 6 months >10% of usual BW)
 20% +/- than IBW

BMI
 <18.5 or >25

Nutrient intake
 Inadequate for >7 days

Number of regular medications taken
 ≥3
JSPagsibigan. N-124 UPCN. July 12, 2010

An estimate of the caloric needs of a resting, unstressed,
and fasting individual (REE) based on
 Body size (height in cm; weight in kg)
 Sex
 Age



Male: 66.4 + (13.7 x wt [kg]) + (5 x ht [cm]) –
(6.8 x age)
Female: 65.5 + (9.6 x wt [kg]) + (1.7 x ht [cm]) –
(4.7 x age)
Quantify stress factor if used in hypermetabolic state
JSPagsibigan. N-124 UPCN. July 12, 2010
Clinical Condition
 Well-nourished,
unstressed
 Surgery
 Minor
 Major



Cancer
Sepsis (acute)
Sepsis
(recovery)
Clinical Condition
1.0


1.2
1.2-1.5
1.0-1.5
1.2-1.7
1.0

Multiple trauma 1.1-1.5
(acute)
Multiple trauma 1.0-1.2
(recovery)
Burned (before
skin graft)
1.2-1.5
– 20-40%
1.5-2.0
– 0-20% BSA
1.8-2.5
– >40%
JSPagsibigan. N-124 UPCN. July 12, 2010
Sex & Age
Range (Yr)
Equation to Derive REE
in kcal/ day
Male
0-3
3-10
10-18
18-30
30-60
>60
(60.9 x wt) - 54
(22.7 x wt) + 495
(17.5 x wt) + 651
(15.3 x wt) + 679
(11.6 x wt) + 879
(13.5 x wt) + 487
(Adapted from Food & Nutrition Board, National Research Council, NAS. [1989])
JSPagsibigan. N-124 UPCN. July 12, 2010
Sex & Age
Range (Yr)
Equation to Derive REE
in kcal/ day
Female
0-3
3-10
10-18
18-30
30-60
>60
(61.0 x wt) - 51
(22.5 x wt) + 499
(12.2 x wt) + 746
(14.7 x wt) + 496
(8.7 x wt) + 829
(10.5 x wt) + 596
(Adapted from Food & Nutrition Board, National Research Council, NAS. [1989])
JSPagsibigan. N-124 UPCN. July 12, 2010

During Health: REE x 1.2

During Illness: REE x 1.5
JSPagsibigan. N-124 UPCN. July 12, 2010
Overweight
Normal
Underweight
Sedentary
Moderate
20-25 kcal/ kg 30 kcal/ kg
30 kcal/ kg
35 kcal/ kg
30 kcal/ kg
40 kcal/ kg
Active
35 kcal/ kg
40 kcal/ kg
45-50 kcal/ kg
Adapted from Goodhart R.S., Shils M.E. [1980], Modern nutrition
in health and disease [6th ed]. Philadelphia: Lea and Febiger)
JSPagsibigan. N-124 UPCN. July 12, 2010


Indirect Calorimetry is the measurement of O2
consumption (VO2) and CO2 production (VCO2)
in order to get an estimate of an individual’s
caloric need or energy requirement.
VO2 & VCO2 measurement can also calculate
the Respiratory Quotient (RQ) which gives
information about the amount of fuel
consumption of the body
 Can be used to determine if patient is overfed or
underfed.
JSPagsibigan. N-124 UPCN. July 12, 2010
•CHO – 50% - 60%
•Fats - 50% - 40%
•Protein – needed for wound healing, immune
system, and organ function
Hypercatabolic state – 1.5 – 2.0 g/kg/day
Healthy, unstressed state – 0.8 – 1.0 g/kg/day
Variations in calorie distribution depends on
energy used by the body
•
JSPagsibigan. N-124 UPCN. July 12, 2010

Anthropometric measurement
 Overweight/ obesity; underweight (cardiac
cachexia)
 Waist circumference (F - >88 cm; M - >102 cm)

Biochemical data
 Elevated total s. cholesterol, LDL cholesterol,
and/ or triglycerides

Clinical findings
 Wasting of muscles or subcutaneous fat
JSPagsibigan. N-124 UPCN. July 12, 2010

Heart Failure
 Reduce preload by fluid retention
a. Sodium limitation
b. Limiting fluid daily

Cardiac cachexia
 Concentrate nutrients into a small volume
a. Restriction of sodium and fluid
b. Small, frequent feedings
c. Give calorie-dense food and supplemetns
d. Enteral feeding 1 calorie/ ml or more concentrated
product
 Monitor fluid status (breath sounds, peripheral
edema, weight
JSPagsibigan. N-124 UPCN. July 12, 2010

Anthropometric measurement
 underweight

Biochemical data
 Elevated Pco2 related to overfeeding

Clinical findings
 Edema, dyspnea, signs of pulmonary edema r/t
fluid volume excess

Diet or health history
 Poor food intake R/T dyspnea, unpleasant taste
in the mouth, ET
JSPagsibigan. N-124 UPCN. July 12, 2010

Prevent severe nutritional deficit
 Small frequent feedings
 Mouth care before meals and snacks
 Give bronchodilator meds with meals

Reduce the risk for pulmonary aspiration
(artificial airway)
 Head kept elevated at 450 angle during feeding
 Keep cuff of the artificial airway inflated during
feeding
 Check for increasing abdominal distention
 Check tube placement before each feeding
JSPagsibigan. N-124 UPCN. July 12, 2010


Avoid overfeeding – increases PaCO2
that
can make weaning from the ventilator difficult;
excess lipids can impair capillary gas exchange
in the lungs; S. triglyceride > 400 mg/dL amy
indicate inadequate lipid clearance
Prevent fluid volume excess
 Accurate I & O (usual intake 35 – 40 ml/kg/day)
 Reduce fluid intake by using 20% lipid emulsions,
tube feeding formulas of 2 cal/ ml, and choosing
oral supplements that are low in fluids, e.g.,
cottonseed oil (Lippomul) 6 cal/ ml
JSPagsibigan. N-124 UPCN. July 12, 2010

Biochemical data
 Hyperglycemia with corticosteroid use

Clinical findings
 Wasting of muscles and subcutaneous fat r/t disuse
or poor food intake

Diet or health history
 Poor dietary intake r/t altered state of
consciousness, dysphagia, chewing or swallowing
difficulties, ileus from spinal cord injury, or use of
pentobarbital
 Hypermetabolism
 Pressure ulcers
JSPagsibigan. N-124 UPCN. July 12, 2010

Prevention or Correction of Nutritional Deficits
 Oral Feeding
1. Soft moist foods are easier to swallow
2. Upright position during meals allowing gravity to
facilitate swallowing
3. Beverages may be thickened with commercial thickening
product, infant cereal, or with yoghurt
4. Fruit nectar may be better tolerated than thinner juice
5. Do not rush the patient. Give small, frequent feeding
6. Suction equipment should be kept available
7. Aspiration precaution – impaired gag reflex, delayed
gastric emptying, those likely to have seizures
JSPagsibigan. N-124 UPCN. July 12, 2010

Prevention or Correction of Nutritional Deficits
 Tube Feeding/ TPN
▪ Prompt nutritional support must be given to the
unconscious, unable to eat because of sever dysphagia,
weakness, or ileus
▪ Protein and calorie needs are increased by infection and
fever
▪ Protein, calories, vitamin C, and zinc are needed greatly
during wound healing as in trauma patient and those with
decubitus ulcer
JSPagsibigan. N-124 UPCN. July 12, 2010

Prevention of overweight or obesity
 Fruits and vegetables without added fat or sauces
(low in fat, with enough fiber)
 Reduce calorie intake by refraining from high-fat
food – shakes, ice cream, butter, margarine, and
pastries
JSPagsibigan. N-124 UPCN. July 12, 2010

Anthropometric measurement
 Underweight, maybe masked by edema

Biochemical data
 Electrolyte imbalance
 Decreased albumin, hg/ RBC; increased
triglycerides

Clinical findings
 Wasting of muscles and subcutaneous tissue

Diet or health history
 Poor dietary intake r/t protein and electrolyte
restrictions and alterations in taste.
JSPagsibigan. N-124 UPCN. July 12, 2010

Balance adequate calories, proteins, vitamins,
and minerals, while avoiding excesses of
protein, fluid, potassium, phosphorus, and
other nutrients with potential toxicity
 Provide adequate amount of protein to prevent
continued catabolism of body tissues
▪ Protein losses during dialysis, wounds, fistula
▪ Aggravation of catabolism due to increased secretion of
catecholamines, corticosteroid, and glucagon
▪ Persistent protein breakdown r/t metabolic acidosis
▪ Catabolic conditions such as trauma, surgery, and sepsis
JSPagsibigan. N-124 UPCN. July 12, 2010

Balance adequate calories, …
 Fluid restriction is necessary only when urine output
has been diminished in patients with renal
insufficiency,
 Those undergoing hemodialysis are limited to a gain
of no more than 1 lb/day = Daily intake of 500 – 750
ml + volume lost in urine
 Liberal fluid allowance permits more nutrient
delivery
JSPagsibigan. N-124 UPCN. July 12, 2010

Balance adequate calories, …
 Adequate calories must be provided to avoid
catabolism of body tissues
 All protein consumed must be used for anabolism
rather than meeting energy needs
 All sources of carbohydrate intake must be
identified to prevent increase of triglycerides.
▪ Major dietary carbohydrate must come from complex
carbohydrates
▪ Dietary fiber daily (20 – 25 g daily) help control triglyceride
levels
JSPagsibigan. N-124 UPCN. July 12, 2010

Balance adequate calories, …
 Increased triglyceride levels can be controlled and
still provide concentrated calories in minimal fluid by
using fat to supply as much as 40% of patient’s
caloric need. Limiting alcohol intake also reduces
levels of triglyceride
 To control hypercholesterolemia, use unsaturated
fats and oil. (IV lipids, and long-chain fats found in
commercial enteral formulas are polyunsaturated.
Lowering meat, milk, and other protein food will
also help lower cholesterol and saturated fat intake,
JSPagsibigan. N-124 UPCN. July 12, 2010

Balance adequate calories, …
 Potassium and phosphorus are restricted because
they are excreted by the kidneys
 Water soluble vitamins and trace minerals have to be
supplemented as necessary because they pass freely
through the dialysis filter
 Patients with ESRD have decreased clearance of Vit
A levels of which must be monitored
JSPagsibigan. N-124 UPCN. July 12, 2010

Anthropometric measurement
 Underweight related to malabsorption, anorexia,
or poor intake due to pain caused by eating

Biochemical data
 Decreased albumin, calcium, magnesium,
hemoglobin/ RBC

Clinical findings
 Wasting of muscle and subcutaneous fat
 Wernicke-Korsakoff syndrome

Diet or health history
 steatorrhea
JSPagsibigan. N-124 UPCN. July 12, 2010

Hepatic Failure
 Impaired ability to deactivate hormones
▪ Elevated levels of glucagon, cortisol, and epinephrine that
exhaust glycogen stores and promote catabolism of body
tissues
 Decreased ability to metabolize lipids for energy
 Inadequate production of bile salts resulting in
malabsorption of fat in the diet
▪ Body proteins are used as energy source
▪ AAA precursors of neurotransmitter serotonin and
dopamine in the CNS accumulates and promotes synthesis
of false neurotransmitter that competes with the
endogenous neurotransmitter causing encephalopathy
JSPagsibigan. N-124 UPCN. July 12, 2010

Hepatic Failure
 Ammonia also remains in the circulation and
accumulates in the brain contributing to brain edema
and encephalopathic symptoms
 Monitor fluid and electrolyte status
▪ Weigh patient daily
▪ Control fluid retention through fluid and sodium restriction
 Provide adequate protein to help suppress
catabolism and promote liver regeneration. Evaluate
response to dietary protein
 Monitor levels of potassium, phosphorus, Vit
A,D,E,K, and zinc
JSPagsibigan. N-124 UPCN. July 12, 2010

Liver transplant
 Post-op: Intake should be adequate to support
repletion and healing
 Immunosuppressant therapy (corticosteroids,
cyclosporine) contributes to glucose intolerance.
This can be prevented by
1.
2.
3.
4.
Fat should supply approximately 30% of dietary calories
Complex carbohydrates
Eating several small meals daily
Moderate exercise
JSPagsibigan. N-124 UPCN. July 12, 2010

Pancreatitis
 Loss of exocrine function leads to
malabsorption and steatorrhea; loss of
endocrine function results in impaired glucose
intolerance
 Feeding stimulate the production of digestive
enzyme and perpetuate tissue damage
JSPagsibigan. N-124 UPCN. July 12, 2010

Pancreatitis

Preventing further damage to the pancreas and
Preventing Nutritional Deficits
▪
Enteral nutrition infused into the distal jejunum bypasses the
stimulatory effect of feeding on pancreatic secretion.
Infections and metabolic complications are fewer as compared
with TPN
▪ Reduced cost, risk of sepsis, and improved clinical outcome
▪
▪
Low-fat food given in frequent small feedings are least likely
to cause discomfort
Alcohol worsens tissue damage and pain.
JSPagsibigan. N-124 UPCN. July 12, 2010

Anthropometric measurement
 Overweight/ Obesity

Biochemical data
 Hyperglycemia
 Hyperlipidemia

Clinical findings
 Vomiting, and diarrhea
 Delayed gastric emptying

Diet or health history
JSPagsibigan. N-124 UPCN. July 12, 2010

Nutrition Support & Blood Glucose Control

Patient with DM type I cannot use dietary CHO to
meet energy needs. Tissue catabolism results in
weight loss and malnutrition
 Patient with DM type 2 though more likely to be
overweight can be subjected to trauma, acute or
chronic illnesses, major surgery, and other illness
and may become malnourished
JSPagsibigan. N-124 UPCN. July 12, 2010

Nutrition Support & Blood Glucose Control

Poorly controlled diabetes impair granulocyte
adherence, chemotaxis, and phagoscytosis reducing
immune function
 During the 1st 24 – 36 hours post-op a persistent
glucose level of 206 – 220 mg/ dL or higher were
associated with higher rates of nosocomial infection
▪
Insulin in TPN may be of a higher dose
▪ Some of the insulin adhere to the glass bottle, plastic bags, or
administration set
JSPagsibigan. N-124 UPCN. July 12, 2010

Nutrition Support & Blood Glucose Control

Nausea and vomiting in DM type I
▪ Adequate carbohydrates and fluids
▪ Antiemetic medication
▪ Prokinetic drugs must be given to improve gastric
emptying
▪ Small amount of feeding every 15 – 20 min
JSPagsibigan. N-124 UPCN. July 12, 2010

Nutrition Support & Blood Glucose Control
▪ Meals
▪
1.
2.
3.
Based on heart-health diet principles:
Limited saturated fat and cholesterol
Protein covers 15% - 20% of total calories
Majority of carbohydrates
– Whole grain
– Fruits, vegetables
– Low-fat milk
– Sucrose-containing food can be included
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
4.
Gastrointestinal function
Baseline nutritional status
Present catabolic state and possible duration
Risks associated with the type of nutritional
support
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
4.
Maintains gut morphology and function
Maintain immunologic function and less risk
of bacterial translocation
Decreased risk of complications
Lower Cost
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
3.
4.
Adynamic ileus
Intractable vomiting
Proximal high output enterocutaneous
fistula
Bowel rest required
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
N/ V
2.
Diarrhea
hyperosmolar feed
rapid infusion
obstruction
delayed gastric emptying
contaminated solution or
infusion set
bacterial overgrowth
JSPagsibigan. N-124 UPCN. July 12, 2010
3.
4.
5.
6.
7.
8.
Malnutrition loss of microvilli, loss of brush
border enzymes, reduced intestinal absorptive
surface area
Hypoalbuminemia
Mechanical Feeding tube occlusion
Hypo/ hyperglycemia
Electrolyte imbalance
Aspiration pneumonia
JSPagsibigan. N-124 UPCN. July 12, 2010
IV delivered solution that is nutritionally complete,
composed of AA, dextrose, fats, electrolytes,
vitamins, and trace elements
2. Indicated when nutrition cannot be delivered through
the GI tract – bowel rest, or disruption of functional
GIT
3. TPN is contraindicated in patients with functioning
usable GIT capable of adequate nutrient absorption;
anticipated dependence is less than 5 days;
aggressive support is not warranted; risks of TPN
outweighs the potential benefit
1.
JSPagsibigan. N-124 UPCN. July 12, 2010
4.
5.
6.
Highly concentrated TPN solution requires
being administered via the central vein –
subclavian vein is prefered (large, turbulent
flow, able to apply an occlusive dressing on the
site)
Sterile aseptic technique should be observed
during insertion and maintenance of the site
Single-lumen catheter is preferred with less
risk of infection
JSPagsibigan. N-124 UPCN. July 12, 2010
1.
2.
Septic complication (catheter-related sepsis)
Metabolic complications
 Same as enteral nutrition
 Prerenal azotemia
 Hepatic dysfunction
3.
Mechanical Complications
 From catheter insertion
JSPagsibigan. N-124 UPCN. July 12, 2010
JSPagsibigan. N-124 UPCN. July 12, 2010

Sleep
 A reversible behavioral state of perceptual disengagement
from, and unresponsiveness to the environment
 A period of inactivity and restoration of mental and physical
function
 A process governed by the interaction of
▪ Neurochemical systems
▪ Endogenous pacemakers
▪ Circadian – the cycle of body systems within a 24-hour period

Wake
 A time of mental activity and energy expenditure
JSPagsibigan. N-124 UPCN. July 12, 2010

In optimal condition
 Waking during the day
 Sleeping at night

During illness, and/ or admission to CCU
 Wakefulness intrudes into the sleeping period
 Sleep intrudes into the wake period
JSPagsibigan. N-124 UPCN. July 12, 2010

External influences in the circadian rhythm
 Posture
 Exercise
 Light – the most influential zeitgeber for sleep
JSPagsibigan. N-124 UPCN. July 12, 2010
NREM sleep – non-rapid eye movement/
synchronized sleep



Stage 1:
▪
▪
▪
▪
▪
▪
A brief transition between waking and sleeping
Serves as transitional stage for repeated sleep cycles
Can be easily aroused
1 – 7 minutes
2% - 5% of total sleep time
EEG is low voltage, mixed frequency
Stage 2:
▪
▪
▪
▪
Deeper sleep
EEG is interrupted by sleep spindles (high frequency waves = 1214Hz)
10 – 25 minutes
45% - 55% of total sleep time
JSPagsibigan. N-124 UPCN. July 12, 2010
NREM sleep – non-rapid eye movement/ synchronized
sleep


Stage 3:
▪
▪

Lasts only a few minutes and transitional to stage 4
3% - 9% of the cycle
Stage 4:
▪
▪
▪
▪
▪
▪
▪
▪
Deep sleep, arousal needs incremental larger stimuli
EEG is high voltage, low frequency (1 – 3 Hz) or slow wave/ delta wave
Muscles: relaxed
Posture: adjusted intermittently
HR, BP: decreased
GI activity: slowed
20 – 40 minutes
10% - 15% of the cycle
JSPagsibigan. N-124 UPCN. July 12, 2010
REM sleep – rapid eye movement/
desynchronized sleep


External sensory inputs are inhibited; internal
sensory circuits (auditory and visual systems) are
aroused
▪

Previous memory can be replayed but cannot acquire
new sensory information
Motor systems controlling body movements are
inhibited
▪
Loss of muscle movements and muscle tone
JSPagsibigan. N-124 UPCN. July 12, 2010
REM sleep – rapid eye movement/
desynchronized sleep


ANS controlled function changes
▪
▪
▪
▪

BP, HR, RR increase and fluctuate
Temperature regulation is lost
Cerebral blood flow and metabolic rate decrease
Sleep – related penile erection occurs
20% - 25% of total sleep
JSPagsibigan. N-124 UPCN. July 12, 2010
Wakefulness
Stage 1
NREM
Stage 2
NREM
Stage 3
NREM
REM
Stage 2
NREM
Stage 4
NREM
Stage 3
NREM
JSPagsibigan. N-124 UPCN. July 12, 2010
Wakefulness
Stage 1
NREM
Stage 2
NREM
Stage 3
NREM
REM
Stage 2
NREM
Stage 4
NREM
Stage 3
NREM
JSPagsibigan. N-124 UPCN. July 12, 2010

NREM sleep alternating with REM sleep
 NREM occurs more generally during the 1st half of
the night (Stages 3 & 4).
▪ 70% - 75% of the sleep cycle
 REM occurs more during the 2nd half
▪ 20% - 25% of the sleep cycle

4 – 6 cycles in young adults
 90 – 120 minute cycles
JSPagsibigan. N-124 UPCN. July 12, 2010
 NREM sleep
 Stage 1 & 2: Cyclic waxing and waning of tidal
volume and respiratory rate which may include
brief periods (5-15 seconds) of apnea. (Periodic
breathing pattern)
 Stage 3 & 4: breathing becomes more regular
when sleep has stabilized
▪ Ventilation is less (1 – 2 L/ minute)
▪ Involuntary respiratory control mechanisms are
intact – response to hypercapnia, hypoxia, and
lung inflation
JSPagsibigan. N-124 UPCN. July 12, 2010

REM sleep
 Respiration becomes irregular but not periodic,
with short periods of apnea
 REM breathing has features of voluntary control
that integrates breathing with acts of walking,
talking, and swallowing
▪ influence on breathing is diminished

JSPagsibigan. N-124 UPCN. July 12, 2010
Like other physiologic process, it is essential to learning
and memory processing
 May be the result of CNS reprogramming (rearranging
previous experiences) in preparation for the next day’s
conscious experiences
 Occur during all stages of sleep

 About 80% occur during REM and sleep onset (Stage 1 & 2)
 Stage 1 & 3
▪ Shorter, with fewer association, lack color and emotion
 REM
▪ Bizarre, with colorful, story-book-like detail.
JSPagsibigan. N-124 UPCN. July 12, 2010
Neocortex
Hippocampus
Limbic System
Basal Ganglia
Forebrain
SCN
Attention, memory,
emotion, psychomotor
performance, sensorimotor
integration
Anterior Pituitary
Thalamus
Hypothalamus
Hypothalamus
Brain stem
Reticular formation
Pineal Gland
JSPagsibigan. N-124 UPCN. July 12, 2010
Regulation of hormone
levels (thyroid, cortisol,
growth and sex
hormone,
Regulation of body
temperature and
metabolism
Regulation of ANS
function and sleepwake cycles
Melatonin


Light is needed to facilitate assessment of
nursing action
Social interaction of nurses, doctors, and
other health care workers with patients are
frequent interruptions to sleep
JSPagsibigan. N-124 UPCN. July 12, 2010

NREM sleep
1. Restoration of biochemical and physiological
processes through
▪
▪
▪
Protein synthesis
Cell division
growth
2. Conservation of energy by
▪ Reducing body’s metabolic rate
▪ Lowering the body’s temperatue
(Silber et al, 2004)
JSPagsibigan. N-124 UPCN. July 12, 2010

REM sleep
1. Brain restoration
2. Consolidation of memory
3. Erasure of inappropriate memory
JSPagsibigan. N-124 UPCN. July 12, 2010
(Siegel, 2001)
REM requires 90 – 100 minute total sleep period
before it occurs
 Promotes REM sleep
 After periods of worry, there is an increased need
for REM sleep
 REM sleep

 Helps to maintain optimism, attention span, and self
confidence
Lack of REM sleep increases Adrenal Hormone
production, which suppreses immune function
 Deprivation of REM sleep impairs memory, and
learning abiity, and produces hallucination

JSPagsibigan. N-124 UPCN. July 12, 2010
 Definition: Insufficient duration or stages of sleep that
causes discomfort and interferes with ones quality of life
 Etiology:
▪ Psychologic stress associated with illness and the critical care
environment
▪ Surgical stress
▪ Noise interruptions for care
▪ Painful procedures
▪ Physiologic processes
▪ Excessive bright light
▪ Muscular & joint discomfort from immobility/ bed rest
▪ Medications – benzodiazepines, barbiturates, scopolamine,
systemic opiods
JSPagsibigan. N-124 UPCN. July 12, 2010
 Most frequently mentioned factors in the CCU
resulting to sleep pattern disturbance
▪ Inability to get comfortable or lie comfortably (70%)
▪ Inability to perform one’s usual routine before going to
sleep (57%)
▪ Anxiety (55%)
▪ Pain (54%)
JSPagsibigan. N-124 UPCN. July 12, 2010
 Effects
▪ Mental status change
▪ Glucose tolerance, and thyrotropin concentration
decreased
▪ Evening cortisol production, and nervous system activity
increased
▪ Psychologic alterations – mood and performance,
fatigue, irritability, and feelings of persecution
▪ Pain intensification – release of substance P, and
decreased somatostatin
JSPagsibigan. N-124 UPCN. July 12, 2010


Decreased sleep at night, increased sleep
during daytime during immediate post-op
period
Total 24-hour sleep time
 Before surgery – 421.1 minutes
 1st 24-hour after surgery – 483.2 minutes
 2nd 24-hour after surgery – 433.2 minutes
JSPagsibigan. N-124 UPCN. July 12, 2010



None have normal sleep
12 did not experience sleep at all
8 demonstrated findings consistent of severely
disrupted sleep during polysomnography
 Excessive daytime sleep
 Cogniive impairment

Sleep disturbances do not resolve with
extubation and discharge
JSPagsibigan. N-124 UPCN. July 12, 2010

Description of multiple sleep-related factors
 Normal sleep pattern – awakenings, naps, normal bedtine, and walking








time
Customary habits that enhance sleep – pillows, blankets, bedtime rituals,
medications
Recent changes in the normal sleep pattern resulting from the acute
illness
Recent history of difficulty falling asleep o staying asleep, snoring,
gasping for breath at night, stopping of breathing t night, excessive
daytime sleep
Frequency and duration of daytime naps
Severity, duration, and history of chronic illnesses
How sleep in the hospital compares with sleep at home
Psychologic response to admission
Sleep record of patient’s sleep for the past 48 – 72 hours
 Assess actual quantity of sleep
 Assess necessary and unneccesary awakenings
▪ Number and lengths of awakenings
JSPagsibigan. N-124 UPCN. July 12, 2010
Promote consolidated nocturnal sleep time
and a daytime nap
1.






Coordinate care among other disciplines
Limit interruptions for care procedures
Curtains or blinds should be opened during the
day to allow bright natural light, and lights
dimmed at night
Minimize noise from staff, carts that squeak,
alarms, doors slamming, and phones ringing
Offer earplugs
Enforce quiet times in the afternoon
JSPagsibigan. N-124 UPCN. July 12, 2010
Promote relaxation and comfort
2.




Massage consistently reduce anxiety and pain
Audiotapes of the oceans or the rain
significantly increase sleep quality
Provide a relaxed, caring environment that
encourages confidence in care providers
Allow close family members to sit quietly at the
bedside while the patient rests
JSPagsibigan. N-124 UPCN. July 12, 2010

Hypnotics
 Nonbenzodiaziepine
 Zolpidem
 Zaleplon
 Have few side effects and little effect on sleep
architecture

Sedatives
JSPagsibigan. N-124 UPCN. July 12, 2010
Simultaneous recording of an EEG, EMG,
EOG, respiratory patterns, and pulse
oximetry


The only method of measuring sleep
1.
2.
3.
4.
Sleep stages
Arousals
Abnormal movements
Disturbed breathing during sleep
▪
▪
▪
▪
Number and length of apnea
Airflow
Respiratory effort
O2 desaturation
JSPagsibigan. N-124 UPCN. July 12, 2010
Polysomnographic Measures


Mechanically ventilated patients
1. Shorter sleep time
2. Sleep was fragmented by frequent arousals and
awakenings
3. Sleep was distributed throughout the day with 50% of
sleep obtained during the day
4. Sleep was mostly stage 1 NREM. Stage 2, 3,4,and REM
decreased

Burn patient
1. Total sleep time was adequate bt spread across the day.
2. Decreased SWS, and REM
JSPagsibigan. N-124 UPCN. July 12, 2010
Polysomnographic Measures


Cardiac
1. Multiple stresses in the ICU result in poor quality
sleep

Cancer
1. 68% reported moderate to severe insomnia

Medical-Surgical
1. Lack of sleep and rest contributes to anxiety and fear
2. Poor quality of sleep and daytime sleepiness were
common problems in all types if ICUs
3. 61% reported of feeling sleep deprived
JSPagsibigan. N-124 UPCN. July 12, 2010
Sleep History
1.

Patients may come in the ICU with pre-existing sleep
disorder or with chronic sleep deprivation
Demographics
2.

The elderly have
▪
▪
▪

Increased sleep fragmentation
Decreased amount of deep sleep
Increased daytime napping
Age-related changes
▪
▪
▪
Nocturia
Elevated ANS activity resulting in greater susceptibility to
arousal
Decreased strength of circadian rhythm
JSPagsibigan. N-124 UPCN. July 12, 2010
Psychosocial
3.



Anxiety can interfere with process S causing physiologic
arousal
Patients with reported lack of sleep in the ICU
contributed to their fear and anxiety
Patients with delirium display alteration of sleep – wake
cycle
▪
▪

Agitation and inability to sleep at night
Somnolence during the day
Lack of sleep and loss of environmental cues have also
been identified as possible precipitating factors in the
development of ICU delirium
JSPagsibigan. N-124 UPCN. July 12, 2010
Disease Related
4.

Chronically ill
▪
▪
▪
▪

Pain
▪
▪
▪
▪

Difficulty getting to sleep
Frequent sleep interruption
Daytime sleepiness
Fatigue
It was discovered that the areas in the brain that process pain signals also
regulate NREM sleep explaining the interaction of pain and poor sleep
Sleep is fragmented due to the arousing quality of pain
Have reduced amount of SWS
Persons in the ICU frequently experience pain
Sleep-disordered breathing
▪
▪
▪
ICU patients have acute conditions that may compromise their respiratory
status.
Cardiovascular and lung disease are accompanied by alteration of
respiration
Sleep influences respiratory control
JSPagsibigan. N-124 UPCN. July 12, 2010
Treatment Related
5.

Intensive care technologies
▪
▪
Both generalized discomfort and routine patient care activities
in the ICU can interfere with sleep homeostasis (process S) by
inhibiting sleep onset and precipitating arousal
Mechanical ventilation and surgery have been associated with
interruption in biorhythms (process C)
▪
▪
Circadian rhythm markers are altered – meltonin, cortisol, and
body temperature
 Melatonin normally rises at night – promotes sleep
 Cortisol normally low at night but rise rapidly in the early
morning
 Body temperature is at its lowest in the early morning
Mechanical ventilation may disrupt sleep
▪
▪
▪
Lack of synchrony between patient and the ventilator
Mode of ventilation
Pressure support may lead to abnormal breathing patterns
JSPagsibigan. N-124 UPCN. July 12, 2010
Treatment Related
5.

Medication
▪
▪
▪
▪
▪
▪
▪
▪
Impaired renal, hepatic, or neurologic function in the critically ill
patient can predispose the patient to adverse effects from
medication
Opiods:↓arousal, ↓ stage II NREM, ↓REM sleep
Tricyclic antidepressant: ↑TST, ↓REM sleep
Dopamine antagonists antiemetics: drowsiness, sedation,
↓REM sleep
Beta-adrenergic receptor antagonists: Daytime sleepiness,
insomnia, vivid dreams, nightmares
Anxiolytics: ↓SWS/ REM sleep, ↑ stage II NREM
Corticosteroids: insomnia, bad dreams
Bronchodilators: ↑arousal, ↓TST
JSPagsibigan. N-124 UPCN. July 12, 2010
Environmental factors
6.

Noise
▪
▪

Accounted for 15% - 30% of arousals from sleep in ICU patients
(Freedman, Kotzer, & Schwab, 1999; Gabor et al., 2003)
Noise from equipment, monitors, and procedures are inevitable in
the ICU. However, 50% of peak sound have been identified as human
behavior related (Kahn et al., 1998)
Light
▪
Regular light-dark cycles set the biological clock and play an
important role in maintaining sleep-wake cycles (Silber et al., 2004)
▪
▪
Limited exposure or no exposure to natural bright light
24 hours illumination of artificial light
JSPagsibigan. N-124 UPCN. July 12, 2010
Environmental factors
6.

Ambient temperature
▪
▪
▪
▪
When ambient temperature is thermoneutral, TST with
all stages of sleep were maximal
Warm environment increases wakefulness (↓TST, REM,
and NREM)
Cold environment causes difficulty getting to sleep,
staying asleep, increased movements, and reduction
in REM sleep
ICU temperatures that are lower or higher than the
patient’s comfort zone may interfere with process S,
contributing to poor sleep
JSPagsibigan. N-124 UPCN. July 12, 2010

Impairment in cognitive function
 Reduced attention
 Short-term memory decline
 Problem-solving ability weakened



Sleepiness in the waking hours
Delirium
ANS stimulation




Increased catecholamine production
Increased BP
Arrythmias
Progression of heart failure
JSPagsibigan. N-124 UPCN. July 12, 2010

Increased catabolic state
 Negative nitrogen balance
 Alter immune function
 Increase O2 consumption and CO2 production
 Disrupt thermoregulation
JSPagsibigan. N-124 UPCN. July 12, 2010

Occurs when airflow is absent or reduced
 Types of Sleep Apnea
1. Obstructive – caused by obstruction in the upper
airway
2. Central – absence of airflow due to lack of ventilatory
muscle effort
3. Mixed - in one apneic event, there occurs a
combination of both obstructive and central patterns
 An apnea-hypopnea index = 5 or greater is diagnostic
of sleep apnea syndrome (Number of apneas and
hypopneas per hour, divided by hours of sleep
JSPagsibigan. N-124 UPCN. July 12, 2010

1.
2.

Physiological Changes
Arterial desaturation
Hypoxemia
Pathophysiology
▪
▪

Central respiratory rhythm control center failed to
generate a stable rhythm
Cyclic oscillations more frequently at night, and are
further exacerbated by mouth breathing
Among employed ages 30 – 60, at least 2%
of women, and 4% of men have sever OSA
JSPagsibigan. N-124 UPCN. July 12, 2010

During sleep, the control of the respiratory motor
neurons varies and cause decreased neural activity
that results in the narrowing of the airway.
 Prevalent during REM sleep when the motor neurons are
hypotonic
Unstable control of the respiratory nerves of the
diaphragmatic, intercostal, and upper airway
muscles can cause sleep apneas.
 Hypothyroidism can alter respiratory controls
 Obesity, kyphoscoliosis, and autonomic dysfunction
can contribute to the development of OSA

JSPagsibigan. N-124 UPCN. July 12, 2010

Inspiratory, subatmospheric, intrathoracic
pressures are abnormally elevated
 Tendency for airways to collapse that results in
hemodynamic and electrographic changes


Systemic and pulmonary pressures are
elevated
Cycles of hypoxemia, hypercapnia, and
acidosis occurs with each episode of apnea
 Apnea > alveolar hypoventilation > hypercapnia >
resumption of airflow > ventilation improves > no
retention of CO2.
JSPagsibigan. N-124 UPCN. July 12, 2010


Patient at risk – snoring, obesity, short, thick
neck circumference (M-17 collar size; F-16
collar size), CVDs, Systemic and pulmonary
hypertension, sleep fragmentation, GERD,
impaired QOL
Sleep arousals causes sleep fragmentation
and daytime sleepiness > irritability, poor job
performance, troubled relationships,
depression, and impaired QOL
JSPagsibigan. N-124 UPCN. July 12, 2010



Educating patient and family about the syndrome and
the consequences of noncompliance of treatment
regimen
Monitor patient – breathing pattern, hours of sleep,
and pulse oximetry
Compliance wih the CPAP system
1.
2.
3.
4.
5.
6.
Use CPAP as part of their regular sleep routine
Ensure proper fit of the CPAP mask
No air blowing into the patient’s eyes
Correct airway pressure
No pressure sores from the mask
No gastric insufflation
JSPagsibigan. N-124 UPCN. July 12, 2010

Post-op monitoring after
uvulopalatopharyngoplasty (UPPP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Risk of aspiration
Pain management
Anxiety relief
Patient education
Monitoring for respiratory complications
Hemorrhage
Infection
Impaired speech, nutritional concerns
Sleep disturbance

JSPagsibigan. N-124 UPCN. July 12, 2010

Mild OSA
Weight loss
Sleeping on the sides if apnea is associated in lying
supine
3. Avoid sedative medications and alcohol before
bedtime
4. Avoid sleep deprivation
1.
2.

Moderate to severe OSA
1.
2.
3.
Mechanical
Surgical
Pharmacologic
JSPagsibigan. N-124 UPCN. July 12, 2010

Moderate to severe OSA
1.
Mechanical
▪
▪
2.
CPAP
Dental appliances/ bite blocks
Surgical
▪
▪
▪
Laser uvulopalatopharyngoplasty (LAUP) – removal of excess
tissue at the soft palate leel
Somnoplasty – inserting a small electrode into the soft palate and
heating the tissue > causing shrinking and tightening of the area
Uvulopalatopharyngoplasty (UPPP) – large tonsillectomy with
remoal of redundant tissues. (50% of patient experienced
improvement)
JSPagsibigan. N-124 UPCN. July 12, 2010

Moderate to severe OSA
3. Pharmacologic
▪ Protriptyline
▪
▪
REM sleep apnea frequency is decreased thus reduce excessive
daytime sleepiness
O2
▪
Reduces hypoxemia and nocturnal desaturation
JSPagsibigan. N-124 UPCN. July 12, 2010
A pause in respiration without ventilatory effort
A complete loss of electromyographic activity
Chemoreceptors of the brain have become adjusted
to high levels of CO2.
 Momentary cessation of breathing because of the
transient withdrawal of CNS drive to the muscles of
respiration
 Hypercapnic – neuromuscular conditions
 Nonhypercapnic – periodic breathing at high
altitude, renal/ metabolic disturbances



JSPagsibigan. N-124 UPCN. July 12, 2010

Hypercapnic







Respiratory failure
Cor pulmonale
Peripheral edema
Polycythemia
Daytime sleepiness
Snoring
Nonhypercapnic
 Normal body weight
 Mild or intermittent snoring
 Awakening accompanied by choking or feeling short of
breath
JSPagsibigan. N-124 UPCN. July 12, 2010

1.
2.
3.


Patient education
Patient’s condition and treatment regimen
to ensure patient’s compliance
Caution to avoid alcohol and sedatives
If patient is obese, recommend weight loss
program/ strategies
Address fear and anxiety of going to sleep
Monitor and assess the respiratory status of
the patient
JSPagsibigan. N-124 UPCN. July 12, 2010