Care essential 4
Assess pain and sedation needs.
Even though your patient can’t verbally
express her needs, you’ll need
to assess her pain level using a reliable
scale. Keep in mind that a patient’s
acknowledgment of pain
means pain is present and must be
treated. Two scales that help you
evaluate your patient’s sedation level
are the Richmond Agitation Sedation
Scale and the Ramsay Sedation Scale.
Should you restrain an agitated
ventilator patient to prevent extubation?
Research shows self-extubation
can occur despite physical restraints.
It’s best to treat agitation
and anxiety with medication and
nonpharmacologic methods, such
as communication, touch, presenceof family members, music, guided
imagery, and distraction.