The American journal of nursing
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The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. ⋯ This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.
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Properly documenting care in a patient's medical records is essential and, in the event of a lawsuit, provides evidence that the care that was provided met professional standards. Even nurses who meet the standards of care must document that care fully and accurately to avoid being vulnerable to accusations of malpractice that may result in costly jury verdicts and court decisions.