Hematochezia would occur secondary to upper GI bleeding when there is bleeding in the stomach or small intestine. When bleeding occurs in the upper GI tract, the blood can pass through the entire GI tract without being digested. This causes the stool to appear black and tarry, known as hematochezia, as the blood reaches the colon. Bowel sounds may also be hyperactive during GI bleeding, as the presence of blood in the intestines can stimulate bowel motility.

1. Assignment: When would hematochezia occur
Assignment: When would hematochezia occur ON Assignment: When would hematochezia
occurPlease complete these questions after reviewing the powerpoint.-Why is pain
assessment more challenging in critically ill patients?-Which team members would the
nurse consult to assist with the nutritional of critically ill patients?-What actions and
treatments can reverse AKI at the initiation phase?-When would hematochezia occur
secondary to upper GI bleeding?-Why are bowel sounds often hyperactive in GI
bleeding?Assignment: When would hematochezia
occurattachment_1attachment_2attachment_3attachment_4Unformatted Attachment
PreviewChapter 5 Comfort and Sedation Copyright © 2017 Elsevier Inc. All rights reserved.
Introduction ? ? ? ? ? Pain occurs from a variety of causes Goal—optimal level of comfort
Pain leads to complications, such as sleep deprivation, agitation, and PTSD Pain is the fifth
vital sign Individualize management of pain and anxiety to targeted outcomes Copyright ©
2017 Elsevier Inc. All rights reserved. 2 Pain and Anxiety ? Pain ? ? ? Unpleasant sensory and
emotional experience associated with actual or potential tissue damage Pain is what the
patient says it is Anxiety ? ? Prolonged state of apprehension in response to fear Marked by
apprehension, agitation, and autonomic arousal Copyright © 2017 Elsevier Inc. All rights
reserved. 3 Transmission of Pain Figure 5-1. Transmission of pain signals into the
brainstem, thalamus, and cerebral cortex by way of the “fast” pain pathway and “slow” pain
pathway. (From Guyton A, Hall J. Textbook of Medical Physiology. 13th ed. Philadelphia:
Saunders; 2015.) Copyright © 2017 Elsevier Inc. All rights reserved. 4 Predisposing Factors
of Pain ? ? Disease, procedures, monitoring devices, nursing care, trauma Many factors
influence pain perception ? ? ? ? Expectation Previous pain experiences Emotional state
Cognitive status Copyright © 2017 Elsevier Inc. All rights reserved. 5 Predisposing Factors
of Anxiety ? ? Inability to communicate, noise, light, excess stimulation Examples ?
Endotracheal tube ? Monitor alarms ? Assignment: When would hematochezia occurLack of
mobility ? Unfamiliar surroundings ? Uncomfortable room temperature ? Sleep deprivation
Copyright © 2017 Elsevier Inc. All rights reserved. 6 Physiology of Pain ? ? ? ? ? Pain travels
nervous system to the brain Acute pain activates sympathetic nervous system Chronic pain,
less activation Acute pain travels via A-delta fibers Chronic pain travels via C fibers
Copyright © 2017 Elsevier Inc. All rights reserved. 7 Physiology of Pain (Cont.) ?
Nociceptors most abundant receptors ? ? ? ? ? Mechanical stimuli Chemical stimuli Thermal
stimuli Very little adaptation to pain Initiation of the inflammatory response to tissue injury
Copyright © 2017 Elsevier Inc. All rights reserved. 8 Physiology of Anxiety ? ? ? Anxiety is

2. confined within the brain Purely psychogenic disorder; no actual tissue damage Linked to
reward and punishment center Copyright © 2017 Elsevier Inc. All rights reserved. 9
Positive Effects of Pain/Anxiety ? ? ? Increases performance levels Removes one from
potential harm Fight-or-flight response Copyright © 2017 Elsevier Inc. All rights reserved.
10 Negative Effects of Pain/Anxiety ? Raises catecholamines ? ? ? Interference with healing
Increased oxygen consumption ? ? ? ? Tachycardia and hypertension End-organ ischemia
Increased respiratory effort and hyperventilation Fighting the ventilator Delay in ventilator
weaning. Copyright © 2017 Elsevier Inc. All rights reserved. 11 Assessment of Pain ? The
2013 Clinical Practice Guidelines ? Assess and treat promptly. ? Use valid and reliable pain
assessment tools. ? Document findings. ? Engage patient in management plan. ? Provide
preemptive treatment. ? Reassess and treat to meet patient’s needs. ? Institute quality
improvement plan related to practice and outcomes. Copyright © 2017 Elsevier Inc. All
rights reserved. 12 Critical Thinking Challenge ? Why is pain assessment more challenging
in critically ill patients? Copyright © 2017 Elsevier Inc. All rights reserved. 13 Subjective
Assessment Tools ? Characteristics of pain ? ? ? ? ? Precipitating cause Severity Location and
radiation Duration Alleviating or aggravating factors Copyright © 2017 Elsevier Inc. All
rights reserved. 14 Subjective PQRST Chest pain characteristics P = provocation or position
Q = quality R = radiation S = severity or associated symptoms T = timing or triggers
Copyright © 2017 Elsevier Inc. All rights reserved. 15 Quick Quiz! The nurse asks a patient
with chest pain if it travels to the neck or shoulders. This is an assessment of: A. B. C. D.
Position Quality Radiation Severity Copyright © 2017 Elsevier Inc. All rights reserved. 16
Subjective Assessment Tools ? Pain score, 0 to 10 rating scale ? ? ? ? 0 = No pain 10 = Worst
pain imaginable FACES scale, series of faces from happy to distressed Visual analog scale
(VAS) ? ? Patient points to a level of pain severity on a 10-cm line Can also be done with
pencil to mark severity Copyright © 2017 Elsevier Inc. All rights reserved. 17 ICU Patient
Communication Application (APP) ? A technology tool for patients unable to communicate ?
? ? Assignment: When would hematochezia occurMechanical ventilation Hearing loss
Speech limitations Copyright © 2017 Elsevier Inc. All rights reserved. 18 Critical Thinking
Challenge ? Which pain scales do you believe would work best in critically ill patients?
Copyright © 2017 Elsevier Inc. All rights reserved. 19 Objective Assessment Tools ? ? For
patients who cannot communicate, no objective tool completely reflects patients’ pain level
Examples ? ? ? Behavioral Pain Scale (Table 5-3) Critical-Care Pain Observation Tool (Table
5-4) Checklist of Nonverbal Pain Indicators Copyright © 2017 Elsevier Inc. All rights
reserved. 20 Behavioral Pain Scale Copyright © 2017 Elsevier Inc. All rights reserved. 21
Critical-Care Pain Observation Tool Copyright © 2017 Elsevier Inc. All rights reserved. 22
Critical Thinking Challenge ? Compare and contrast observations of pain using the
Behavioral Pain Scale (see Table 5-3) and Critical-Care Pain Observation Tool (see Table 5-
4). Copyright © 2017 Elsevier Inc. All rights reserved. 23 Assessment of Agitation ?
Hyperactive psychomotor functions ? ? ? Tachycardia Hypertension Movement Copyright ©
2017 Elsevier Inc. All rights reserved. 24 Treatment of Agitation ? Sedate to limit
hyperactive psychomotor functions. ? Low dose Copyright © 2017 Elsevier Inc. All rights
reserved. 25 Sedation Assessment—Tools ? Sedation medication is given to reduce
symptoms; dose is adjusted based on tools or scales ? ? ? Richmond Agitation-Sedation Scale

3. (RASS) Sedation-Agitation Scale (SAS; Riker) Interobserver agreement in assessment using
various scales is important Copyright © 2017 Elsevier Inc. All rights reserved. 26
Continuous Monitoring of Sedation ? Assess brain activity ? ? ? Application of EEG to bedside
? ? ? Electroencephalogram (EEG) Bispectral Index [BIS]) Bispectral Index Score (BIS)
Patient State Index (PSI) Interpretation of values ? ? Values 0 (flat EEG) to 100 (awake) 40
to 60 deep sedation plus amnesia Copyright © 2017 Elsevier Inc. All rights reserved. 27
Bispectral Index Figure 5-3. The Bispectral Index (BIS) monitor and electrode. (Image used
by permission of Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as
Covidien.) Copyright © 2017 Elsevier Inc. All rights reserved. 28 Delirium ? ? ? Acutely
changing mental status Key word: inattention Types ? ? ? ? Hyperactive—agitated,
combative, disoriented Hypoactive—quiet delirium Mixed—fluctuating between the two
Many risks Copyright © 2017 Elsevier Inc. All rights reserved. 29 ABCDE Bundle for
Preventing Delirium ? ? ? ? ? ? Awakening Breathing Coordination Choice of Sedation
Delirium monitoring Early mobility and exercise Resource: www.icudelirium.org Barr J,
Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM,
Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN,
Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice
guidelines for the management of pain, agitation, and delirium in adult patients in the
intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306. www.iculiberation.org
Copyright © 2017 Elsevier Inc. All rights reserved. 30 Delirium ? Assessment ? Acute change
in mental status ? Inattention ? Assignment: When would hematochezia occurDisorganized
thinking ? Altered level of consciousness ? Confusion Assessment Method for the ICU
(CAMICU) ? Intensive Care Delirium Screening Checklist (ICDSC) ? ? Patient care outcome—
keep the patient safe Drug of choice—haloperidol Copyright © 2017 Elsevier Inc. All rights
reserved. 31 Quick Quiz! To assess patients for delirium, which term is most helpful in
initial assessment? A. B. C. D. Combative Inattention Paranoid Wild Copyright © 2017
Elsevier Inc. All rights reserved. 32 Management of Pain Copyright © 2017 Elsevier Inc. All
rights reserved. 33 Nonpharmacological Management ? ? ? ? ? Environmental manipulation
Guided imagery Music therapy Aromatherapy Animal-assisted therapy Copyright © 2017
Elsevier Inc. All rights reserved. 34 Critical Thinking Challenge Discuss how
nonpharmacological methods for pain and anxiety treatment strategies can be implemented
in the critical care setting. Copyright © 2017 Elsevier Inc. All rights reserved. 35
Pharmacological Management Even with the most aggressive nonpharmacological
therapies, many critically ill patients require medications to relieve pain, anxiety, or both.
Copyright © 2017 Elsevier Inc. All rights reserved. 36 Management—Opioids ? Rapid onset,
ease of titration, lack of accumulation, low cost ? ? ? ? ? Fentanyl—fastest onset Morphine—
longer duration Hydromorphone Administration: IV bolus, IV infusions, patientcontrolled
analgesia (PCA), patch (fentanyl) Scheduled versus as-needed administration Copyright ©
2017 Elsevier Inc. All rights reserved. 37 Opioids ? Concerns ? ? ? ? ? ? Respiratory
depression Hypotension CNS depression Hallucinations Constipation (gastric ileus and
retention) Geriatric Copyright © 2017 Elsevier Inc. All rights reserved. 38 Patient-
Controlled Analgesia (PCA) ? ? PCA can be effective but patient must be able to manage the
pump Best suited for patients with: ? Elective surgery ? Large surgical or traumatic wounds

4. ? Normal cognitive function ? Normal motor skills Copyright © 2017 Elsevier Inc. All rights
reserved. 39 Management—Epidural ? ? ? Opioid or local anesthetic Facilitates mobility and
pulmonary hygiene Contraindications ? Coagulopathy ? Physical instability ? Sepsis ? Spine
injury ? Infection of the skin ? Alcohol intoxication ? Patient refusal Copyright © 2017
Elsevier Inc. All rights reserved. 40 Spinal Analgesia Side Effects ? Spinal analgesia ? ? ? ? ?
Respiratory depression Sedation Nausea and vomiting Urinary retention Spinal analgesia
with local anesthetics ? ? ? ? Sympathetic blockade (hypotension, venous pooling) Motor
weakness Sensory block Urinary retention Copyright © 2017 Elsevier Inc. All rights
reserved. 41 Management—NSAIDs and Acetaminophen ? ? NSAIDs may decrease need of
opioid Risks of GI bleeding and renal (ibuprofen) or liver (acetaminophen) insufficiency
Copyright © 2017 Elsevier Inc. All rights reserved. 42 Analgesics ? ? ? ? Acetaminophen for
mild to moderate pain Used in combination with opioids Ofirmev is an intravenous form of
acetaminophen Concern for hepatic function with use of acetaminophen Copyright © 2017
Elsevier Inc. All rights reserved. 43 Management—Sedatives ? Pharmacological treatment
for anxiety ? ? ? ? Benzodiazepines Propofol Dexmedetomidine Titrate to an end point
(sedation scales or tools) Copyright © 2017 Elsevier Inc. All rights reserved. 44 Quick Quiz!
The nurse is concerned about administering opioid medication to a patient in pain because
the patient is weaning from mechanical ventilation. The nurse consults with the clinical
pharmacist, who suggests trying a/an: A. B. C. D. Neuromuscular blockade PCA pump with
fentanyl Sedative such as lorazepam (Ativan) Intravenous nonsteroidal agent Copyright ©
2017 Elsevier Inc. All rights reserved. 45 Neuromuscular Blockade ? Indications ? ? ? ? No
sedative or analgesic properties ? ? Facilitate treatment or procedures, including emergency
or difficult intubation Improve tolerance of mechanical ventilation, especially
nontraditional modes Manage elevated ICP Must provide sedation! Monitor level with train-
of-four (TOF) ? Peripheral nerve stimulator Copyright © 2017 Elsevier Inc. All rights
reserved. 46 Peripheral Nerve Stimulator Figure 5-5. A train-of-four peripheral nerve
stimulator. (Courtesy Fisher & Paykel Health Care, Auckland, New Zealand.) Copyright ©
2017 Elsevier Inc. All rights reserved. 47 Nursing Care Neuromuscular Blockade ? ? ? TOF
testing Sedation Care of immobile, paralyzed patient ? ? ? ? ? ? ? Assignment: When would
hematochezia occurMechanical ventilation and airway management Eye lubrication DVT
prophylaxis Repositioning and range of motion Oral care Urinary catheter Routine vital
signs and assessments Copyright © 2017 Elsevier Inc. All rights reserved. 48 Tolerance and
Withdrawal ? ? ? Physiological dependence Drug tolerance Drug withdrawal symptoms ? ?
Opioid Sedative Copyright © 2017 Elsevier Inc. All rights reserved. 49 Management
Challenges ? Invasive procedures ? ? Substance abuse ? ? ? Procedural or conscious sedation
May have higher-than-normal threshold Alcohol withdrawal syndrome (AWS) Restraining
devices ? Complications from immobility Copyright © 2017 Elsevier Inc. All rights reserved.
50 Management Challenges (Cont.) ? Elderly patients ? ? ? ? ? Physical changes associated
with aging Comorbidities Multiple medications Physical frailty Cognitive or sensory deficits
Copyright © 2017 Elsevier Inc. All rights reserved. 51 Chapter 6 Nutritional Therapy
Copyright © 2017 Elsevier Inc. All rights reserved. Introduction ? ? All critically ill patients
are assumed to be at nutritional risk Nutritional is an important part of overall care plan
Copyright © 2017 Elsevier Inc. All rights reserved. 2 Anatomy and Physiology Review ? GI

5. System Copyright © 2017 Elsevier Inc. All rights reserved. 3 Utilization of Nutrients ? Cells
require: ? Carbohydrates ? Proteins ? Fats ? Water ? Electrolytes ? Vitamins ? Trace elements
Copyright © 2017 Elsevier Inc. All rights reserved. 4 Utilization of Nutrients (Cont.) ? ? ?
Nutrients are ingested orally Mouth first breaks down food with saliva Stomach stores and
mixes food with gastric secretions ? ? Secretes intrinsic factor for vitamin B12 absorption
Secretes fluids high in Na+ and K+ Copyright © 2017 Elsevier Inc. All rights reserved. 5
Utilization of Nutrients (Cont.) ? Duodenum ? ? ? Jejunum ? ? Pancreas and liver empty here
Absorbs minerals Glucose and water-soluble vitamins absorbed Ileum ? Protein broken
down and absorbed ? Absorbs fat-soluble vitamins Copyright © 2017 Elsevier Inc. All rights
reserved. 6 Utilization of Nutrients (Cont.) ? Colon ? Vitamin K formed ? Absorbs Na+ and K+
? Water reabsorbed ? Absorption of short-chain fatty acids Copyright © 2017 Elsevier Inc.
All rights reserved. 7 Utilization of Nutrients (Cont.) ? Pancreas ? ? Liver ? ? Secretes
digestive enzymes Multiple functions Gallbladder ? Assists in emulsifying fats Copyright ©
2017 Elsevier Inc. All rights reserved. 8 Nutritional Assessment ? ? ? ? ? Provides baseline
subjective and objective data regarding nutritional status Determines nutritional risk
factors Identifies nutritional deficits Establishes nutritional needs Identifies medical,
psychosocial, and socioeconomic factors Copyright © 2017 Elsevier Inc. All rights reserved.
9 Nutritional Assessment Objective and Subjective Data Patient’s medical history ?
Malabsorption syndrome ? Laboratory values • What is important? • Review laboratory
alert ? Input and output ? Daily weight ? ? Assignment: When would hematochezia occurGag
reflex ? Dysphagia ? Adequate dentition ? Oral mucosa ? Hydration status Copyright © 2017
Elsevier Inc. All rights reserved. 10 Critical Thinking Challenge ? Which team members
would the nurse consult to assist with the nutritional of critically ill patients? Copyright ©
2017 Elsevier Inc. All rights reserved. 11 Nutrition Care Plan ? Determine: ? ? ? ? Patient’s
calorie, protein, and fluid needs Intake targets Route of administration Set measurable
short- and long-term goals ? ? Weight gain Stable laboratory values Copyright © 2017
Elsevier Inc. All rights reserved. 12 Quick Quiz! Patients who are not able to meet their
nutritional needs orally should be started on enteral nutrition within what time frame? A. 6-
12 hours B. 12-24 hours C. 24-48 hours D. 5 days Copyright © 2017 Elsevier Inc. All rights
reserved. 13 Enteral Nutrition ? Any patients who cannot meet their nutritional needs orally
should be started on enteral nutrition in the first 24 to 48 hours. Copyright © 2017 Elsevier
Inc. All rights reserved. 14 Enteral Nutrition (Cont.) ? ? Delivery of nutrients to GI tract
Preferred method ? ? ? ? ? Lower risk of infection Less expensive Short-term nutrition:
Small- versus large-bore nasogastric tubes for delivery Gastric versus small bowel feeding
Long-term nutrition: PEG or jejunostomy Copyright © 2017 Elsevier Inc. All rights reserved.
15 Guidelines for Enteral Feeding ? Short-term enteral feeding ? ? ? ? Nasogastric route
Nasoduodenal route Nasojejunal Long-term enteral feeding ? ? Gastrostomy tube
Jejunostomy tube Copyright © 2017 Elsevier Inc. All rights reserved. 16 Enteral Formulas ?
Standard 1 calorie/mL ? ? Specialized formula examples ? ? ? ? ? Contain protein, fats,
carbohydrates, vitamins, and trace elements Elemental High protein Fiber enriched Wound
healing Immune-enhancing formulas Copyright © 2017 Elsevier Inc. All rights reserved. 17
Quick Quiz! The nurse would suggest oral or enteral feedings for which patient? A. A patient
with a GI obstruction B. A patient who is severely malnourished C. A patient who has been

6. NPO for 36 hours D. A patient experiencing intractable vomiting Copyright © 2017 Elsevier
Inc. All rights reserved. 18 Nutritional Therapy Goal ? ? Goal is nutritional consistent with
metabolic needs and disease process while avoiding complications. Interdisciplinary team
Copyright © 2017 Elsevier Inc. All rights reserved. 19 Practice Guidelines for Enteral
Feeding (Cont.) ? Feeding schedule ? ? ? Intermittent: gastric Continuous: small bowel
feedings Assess gastric residuals ? ? ? How? How often? What is significant? Differences
between gastric and small bowel locations Copyright © 2017 Elsevier Inc. All rights
reserved. 20 Quick Quiz! When flushing a feeding tube, the nurse knows to use how many
mL of water? A. 15 mL B. 30 mL C. 50 mL D. 100 mL Copyright © 2017 Elsevier Inc. All
rights reserved. 21 Tolerance of Enteral Nutrition ? ? ? ? Presence of bowel sounds in four
quadrants, as determined by auscultation Presence of bowel motility or bowel movements
Palpation of a soft abdomen Percussion of the abdomen revealing tympanic findings
Copyright © 2017 Elsevier Inc. All rights reserved. 22 Signs of Intolerance ? ? ? ? ? Nausea or
vomiting Absent bowel sounds Abdominal distension Cramping Diarrhea Copyright © 2017
Elsevier Inc. All rights reserved. 23 Preventing Complications ? ? ? Enteral tube obstruction
Aspiration and improper tube placement Diarrhea ? ? ? ? Consider Clostridium difficile
Dumping syndrome Hyperglycem …Assignment: When would hematochezia occur