Drug Overdose, Loss of Consciousness, and Compartment Syndrome: A Life-Threatening Combination.

Acute extremity compartment syndrome is considered an orthopedic emergency that has serious consequences if a correct diagnosis is not made rapidly. Patients who lose consciousness due to a drug overdose are known to collapse onto their extremities. The limbs are compressed for hours, placing them at an increased risk for acute extremity compartment syndrome and its sequelae. Compartment syndrome due to a compression of a limb from loss of consciousness secondary to drug overdose, presents unique issues to health care providers. In the setting of overdose compartment syndrome, it is similar to the more common traumatic type of compartment syndrome with respect to the pathophysiology, diagnosis and treatment. However, it differs in relation to the muscles affected, physical assessment strategy, and accurately determining the amount of the time from onset of injury to the presentation of symptoms. The purpose of this article is to facilitate emergency department nurses' understanding of the complexities of overdose compartment syndrome, combined with the importance of early recognition of the condition. In addition, the authors review the pathophysiology, the traditional and innovative diagnostic techniques, and the current treatment options available for overdose compartment syndrome.

Introduction of unresponsive patient simulation scenarios into an undergraduate nursing health assessment course.

BACKGROUND: Despite certification in basic life support, nursing students may not be proficient in performing critical assessments and interventions for unresponsive patients. Thus, a new simulation module comprising four unresponsive patient scenarios was introduced into a second-year nursing health assessment course. METHOD: This cross-sectional study describes nursing student experience, knowledge, confidence, and performance of assessments and interventions for the unresponsive patient across 3 years of an undergraduate nursing program. RESULTS: Overall knowledge, confidence, and performance scores were similar between second-, third-, and fourth-year students (N = 239); however, performance times for many critical assessments and interventions were poor. Second-year nursing students' knowledge increased significantly following the new simulation module (p = 0.002). CONCLUSION: Findings suggest a need for more repetition of basic unresponsive patient scenarios to provide mastery. It is anticipated that addition of unresponsive patient scenarios into the second year will enhance performance by the final year of the program.

Communicating with the unresponsive patient: a student review.

Providing patient care for the unconscious population in the intensive care unit can be very challenging. Over time, some nurses may face barriers that prevent them from providing caring behaviors, such as communication. Review of the literature found the attitude of a nurse, hospital technology, and the working environment are barriers that prevent therapeutic nurse-patient communication with a patient who is unconscious or sedated and ventilated. Becoming more knowledgeable about how communication can help and what can be done if such barriers present themselves in the hospital setting is beneficial to improving nurses' care in the intensive care unit.

Pain assessment tools for unconscious or sedated intensive care patients: a systematic review.

AIM: This paper is a report of a systematic review describing instruments developed for pain assessment in unconscious or sedated intensive care patients. BACKGROUND: Intensive care patients who are unconscious or sedated are unable to communicate and therefore recognition and assessment of the pain is difficult. To assess these patients' pain, it is important to use a valid and reliable pain assessment tool. DATA SOURCES: A systematic bibliographical review was conducted, based on seven databases, covering the period from January 1987 to February 2007. A total of 1,586 abstracts was identified and reviewed, 58 papers were selected for full-text review and nine papers were included in the review. METHODS: Two researchers independently reviewed the abstracts and three reviewers extracted the papers. The included papers were evaluated using a quality assessment instrument previously developed to evaluate pain assessment tools. RESULTS: Five different pain assessment tools were identified that had been used with unconscious or sedated intensive care patients. All five instruments included behavioural indicators and three included physiological indicators. Their psychometric properties varied and it was not possible to deduce their clinical utility. CONCLUSION: All instruments were reasonably new. In most of them psychometric testing was in an early stage or even absent. Before any of the reported instruments can be chosen in preference to others, it is essential to test their validity, reliability and feasibility further.

Body piercing and airway management: photo guide to tongue jewelry removal techniques.

Body modification has been practiced in cultures around the world for thousands of years. The ramifications of body piercing on anesthesia practice and airway management have become more evident in recent years. This article reviews the techniques for removal of tongue jewelry and options for maintaining oral piercing patency. To remove or not to remove...that is the question. In the emergency medicine and anesthesia literature, there are arguments both for and against the routine removal of oral jewelry for intubation. Some practitioners feel that if people can eat, drink, talk, and sleep with the jewelry in place, they probably can be intubated safely without removing it. Most case reports present the opinion that tongue jewelry should be removed before oral intubation to minimize jewelry aspiration, bleeding, and medical-legal risks to the anesthetist. This article's focus is to illustrate suggested tongue jewelry removal techniques for awake and unconscious patients from the health practitioner's and body piercer's perspectives.

Clinical tools for the assessment of pain in sedated critically ill adults.

AIM: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. BACKGROUND: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. SEARCH STRATEGY: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: 'pain assessment' and 'sedated' or 'unconscious' or 'critically ill' or 'critical illness' or 'critical care'. CONCLUSIONS: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical-Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non-verbal Pain Scale (NVPS). IMPLICATIONS FOR PRACTICE: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.

Monitoring and recording patients' neurological observations.

This article provides a detailed account of how to monitor and record neurological observations. It outlines the importance of neurological observations in acutely ill patients and focuses on carrying out observations using the Glasgow Coma Scale.

Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients.

UNLABELLED: Current empirical evidence supports claims that pain in sedated, unconscious Intensive Care Unit (ICU) patients is underrated and under-treated. Given the severity of ICU patients' illness pain management, whilst important, may not be considered a priority and therefore can be easily overlooked. The aim of this study was to validate the Behavioural Pain Scale (BPS) for the assessment of pain in critically ill patients by evaluating facial expressions, upper limb movements and compliance with mechanical ventilation. METHODS: A prospective, descriptive repeated measures study design was used to assess the validity and reliability of the BPS for assessing pain in critically ill patients undergoing routine painful (repositioning) and non-painful (eye care) procedures. RESULTS: An average of 73% of BPS scores increased (indicating pain) after patients were repositioned, as opposed to 14% after eye care. This increase was statistically significant for repositioning (p < 0.003) but not for eye care (p > 0.3). The odds of an increase in BPS between pre- and post-procedure assessments was more than 25 times higher for repositioning compared with eye care (p < 0.0001), after controlling for analgesics and sedatives. CONCLUSION: The BPS was found to be a valid and reliable tool in the assessment of pain in the unconscious sedated patient. Results also highlighted that traditional pain indicators, such as fluctuations in haemodynamic parameters, are not always an accurate measure for the assessment of pain in unconscious patients and as such more objective pain assessment measures are essential. Finally, further validation of the BPS and identification of other painful routine procedures is needed to enhance pain management delivery for unconscious patients.

Consciousness, coma, and caring for the brain-injured patient.

In this article, a preliminary conceptual framework is presented for exploring nursing interventions and research aimed at improving care of the unconscious brain-injured patient during the early subacute phase of brain injury. The cue-response framework presented is derived from multidisciplinary sources and has specific clinical relevance to critical care nurses caring for unconscious brain-injured patients. A key aspect of this framework is the attention focused on the timing of nursing interventions in response to how nurses interpret the physical, physiological, and secondary cues they observe when caring for comatose patients. A case exemplar is used to present one example of how this framework may be used in the clinical setting.

Nursing the unconscious patient.

Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient group. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care.

Communication with critically ill patients.

AIM: This paper reports a study that investigated the experiences of a group of critical care Jordanian nurses concerning verbal communication with critically ill patients. BACKGROUND: There is evidence that communication in critical care settings is not sufficiently implemented in practice. Inadequate nurse-patient communication results in increased levels of stress and anxiety. Verbal communication can help patients preserve their self-identity and self-esteem, which in turn will enhance their well-being and optimism. METHOD: The study was guided by the phenomenological hermeneutics of Heidegger. Data were generated in 2002 from in-depth interviews and overt participant observation, and analysed qualitatively. FINDINGS: Unconscious patients received less verbal communication and interaction than verbally responsive patients. CONCLUSION: Communication with sedated or unconscious patients in intensive care units should not be viewed as only an interactive process. Rather, it should be perceived as the means to give the information and support that such patients need.

What is the current evidence on pain and sedation assessment in nonresponsive patients in the intensive care unit?

Assessing pain and sedation in nonresponsive patients is challenging. A major challenge is the confounding effect of sedation on objective indicators of pain. Clinicians might infer that adequate sedation means different patient states: promotion of amnesia, sleep/rest, patient safety, ventilator synchrony, and hemodynamic stability. Hence, an ideal measure that can adequately address the complexity and individualize the nature of the goals of pain and sedation therapy remains elusive. Furthermore, the behavioral responses to pain and anxiety/agitation (eg, restlessness, ventilator dyssynchrony, and movement) have many similarities. Tolerance to mechanical ventilation has been suggested to have validity in both an ICU pain scale and a sedation scale. Additional research is needed to establish the validity, sensitivity, and specificity of these pain indicators in sedated patients. In the meantime, in circumstances where patients are nonresponsive to external stimuli, clinicians should integrate other information such as actual or potential risks of pain (eg, extensiveness of injury, invasive therapies, intubation) and risks of pain-related functional impairment into their pain assessment in nonresponsive, sedated patients.