The Glasgow Coma Scale, the Richmond Agitation and Sedation Scale, and other instruments provide a fuller picture for nurses to evaluate the level of consciousness for critically ill patients, before, during, and after sedation. Scales provide an objective method to avoid giving too much or subtherapeutic doses of drugs. Both can cause unstable vital signs and iatrogenic harm to the patient. Communication difficulties challenge both nurses and patients, but more accurate sedation and analgesia and improved patient adherence are two additional benefits.2 Of course, assessing sedation and pain in this context is a practical, immediate measure to titrate sedation, not simply documentation to chart.
If sedation is temporarily halted to assess neurological status, some patients can motion with their fingers to indicate pain intensity on a numeric scale. Nurses favor numeric scales unless educated about more reliable alternatives for nonverbal patients.13 Charts that the patient can point to or write on, agreed signals for “yes” and “no” if the patient is unable to nod or speak, and other nonverbal signaling should complement observational pain scales whenever possible to procure the patient’s own report of pain.
Many pain instruments are specifically appropriate for the sedated patient. Most take into account oxygen saturation and other variables that are continuously monitored in patients. One example is the Non-Verbal Pain Scale (NVPS), derived and validated as a more specific, adult version of the Face, Legs, Activity, Cry, Consolability (FLACC) tool. Researchers compared the NVPS to the Behavioral Pain Scale (BPS), which nurse researchers specifically developed to provide nurses with the ability to differentiate noxious from non-noxious stimuli in sedated and mechanically ventilated patients. Observation of the face and upper limbs and respiratory factors such as compliance with the ventilator are the only parameters measured by the BPS. This simplicity is a distinct advantage because one of the purposes of comparing pain scales is to determine whether staff nurses can use the tools as effortlessly and reliably as trained nurse investigators.14
But can’t nurses determine pain needs by observing patient vital signs? Chronic pain rarely causes increased pulse rate and blood pressure like acute pain, and many patients requiring conscious sedation are in acute pain situations. The problem is that respiratory rate and other physiologic parameters in the acute care settings are influenced by disease process and the multiple medications required to keep these patients stable.
NVPS and BPS pain scores do not show objective data to indicate increased pain for the patient. With this in mind, it is essential for nurses to be aware of the preconceived notions about anesthesia and analgesia. Generally, pain scores are low for patients who receive continuous sedation or analgesia, but nurses rarely find a consensus value at which most patients require pharmacologic intervention.14
The amount of time nurses should spend communicating with sedated patients also lacks consensus. In one study, nurses spoke to patients for a maximum of 2 minutes per 3-minute encounter, and the worse the patient scored on sedation and consciousness scales, the less time they spent trying to ascertain their needs.15 Training of perception of communication is one method to improve care for sedated patients. Nurses test much better after receiving education about how communication is perceived. However, quality indicators such as the need for physical restraints and heavy sedation did not change after nurse education, and neither did pain score documentation or the prevalence of ICU-acquired pressure sores.16 Information about receptor sites with pharmacologic action or better ways to assess patients does not improve care by itself. As mentioned earlier, nurses need a combination of education and supervised clinical training to better care for these complex patients. Misplaced caution from lack of knowledge can lead to inadequate sedation. Conversely, misinterpreting movement as justification to administer more anesthesia or analgesia can lead to overdosing the patient.
When a patient is unstable, an induction agent such as etomidate or ketamine and a paralytic drug to facilitate intubation should be considered. Paralytics do not have amnestic or analgesic affects but effects the skeletal muscle receptors for the neurotransmitter acetylcholine. Cardiac and smooth muscle remain unaffected, but the diaphragm is a skeletal muscle, having paralytic effects. Succinylcholine or rocuronium are common paralytics, but they have differing onsets and duration. Like rocuronium, atracurium and cisatracurium can be titrated for long-term use but have the added benefit of reliable elimination independent of kidney and liver function. If the patient is unable to maintain an adequate oxygen saturation, the nurse may need to rely on ACLS skills and ventilate a patient with a bag and mask while waiting for intubation or reintubation.17