role of the nurses in sedation

8/3/2019 Role of the Nurses in SEDATION

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Role of the Nurses in

SEDATION


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Moderate Sedation Definition

(Conscious Sedation):

Is defined as a drug-induced depression ofconsciousness during which patients respondpurposefully to verbal commands, either alone oraccompanied by light tactile stimulation.

No interventions are required to maintain a patentairway, and spontaneous ventilation is adequate.

Cardiovascular function is usually maintained.


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Mallampati Airway Class/or Grade

Class I = visualization of the soft palate, fauces,uvula, tonsillar pillars.

Class II = visualization of the soft palate, fauces;

and tip of the uvula obscured.

Class III= visualization of the soft palate andvisualize hard palate only.

Class IV = visualize hard palate only


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Class I = visualization of the soft palate, fauces, uvula,tonsillar pillars.

Class II = visualization of the soft palate, fauces; and tip of the

uvula obscured.Class III= visualization of the soft palate and visualize hardpalate only.

Class IV = visualize hard palate only


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OBJECTIVES OF MODERATE

SEDATION:

1. Blunting of anxiety and fear.

2. To elicit cooperation from the patient.

3. To afford amnesia for the patient.

4. To increase the pain threshold.


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THE NATIONAL

STANDARDS OF CARE AS

DICTATED BY THEAMERICAN

SOCIETY OF POSTANESTHESIA NURSING

INCLUDE:


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1. The administration of IV Moderate sedationmedications by non-anesthetist RNs are

allowed by state law and institutionalpolicy/protocol.

2. A qualified physician selects and orders themedication to achieve IV Moderate sedation.


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3. The RN managing the care of the patientduring the procedure, while giving IV

Moderate sedation, should have no otherresponsibilities that would leave the patientunattended or compromise continuous

monitoring.


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The RN must be able to:

a. Assess respiratory rate, oxygen saturation,blood pressure, cardiac rate, and rhythm andpatients level of consciousness.

b. Understand and demonstrate the ability touse oxygen delivery devices.

c. Anticipate and recognize potential

complications of IV Moderate sedation inrelation to the type of medication beingadministered.


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The RN must be able to:

d. Possess the knowledge and skills toassess, diagnose, and intervene in the eventof complications or undesired outcomes and

to institute nursing interventions in compliancewith orders or institutional protocols orguidelines.

e. Demonstrate skill in airway managementresuscitation.


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HOW TO MONITOR BREATHING DURING

MODERATE SEDATION:

1. Observe the rhythmic rise and fall of thechest.

2. Observe the rate and pattern of breathing.


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SIGNS OF UPPER AIRWAY OBSTRUCTION:

1. Paradoxical thoraco-abdominal rocking motion(abdomen rises/chest falls opposite to normal).

2. Retractions of supraclavicular and intercostalsspaces.

3. Nasal flaring.

4. Stridor- a harsh sound during respiration due toobstruction in the air passages.


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PULSE OXIMETRY IS THE

STANDARD OF CARE:

1. PaO2 is the partial pressure of oxygen in theblood

SaO2 of 100% = a PaO2 of 100

SaO2 of 90% = a PaO2 of 60 = WARNING

SaO2 of 75% = a PaO2 of 40 = DANGER


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PULSE OXIMETRY IS THE

STANDARD OF CARE:

2. Normal PaO2 is between 80 100 mmHg.

3. The accuracy of the pulse oximetryreadings is affected by ambient light,movement of the patient, skin pigment,some nail polish, IV dye, hypothermia,

anemia and or a low cardiac output.


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TIPS ON O2 DELIVERY:

1. Nasal Cannulalow flow system - O2 flow rate of 1-6 L/minute delivers 24-44% O2 Concentration.

2. Face mask low flow system8-10 L/minute = 40-

60% O2 concentration

3. Face mask with O2 reservoir 6L/minute = 60%,10Lminute = 100%

4. Ambu bag = 100% O2 concentration. Delivery isdependent on technique.


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Reminder Nurses!

Experience is important. Head tilt, chin lift,apply mask to face, compress bag with freehand, watch chest rise and fall.

OPENING THE AIRWAY: BLS SKILLS

Head tilt

Chin lift

Place nasal or oral airway


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THE FOLLOWING EQUIPMENT SHOULD BE AVAILABLE IN

THE IMMEDIATE AREA WHERE MODERATE SEDATION IS

ADMINISTERED AND WHERE THE PATIENT RECOVERS FROM

SEDATION:

1. Code cart with monitor, defibrillator and externalpacemaker

2. Oxygen and pulse oximeter

3. Suction

4. Ambu bag and mask

5. Oral, nasopharyngeal airways, endotracheal tubesin various sizes, and stylets


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THE FOLLOWING EQUIPMENT SHOULD BE AVAILABLE IN

THE IMMEDIATE AREA WHERE MODERATE SEDATION IS

ADMINISTERED AND WHERE THE PATIENT RECOVERS FROM

SEDATION:

6. Laryngoscopes and various laryngoscope blades

7. EKG

8. Blood pressure monitoring apparatus

9. Adequate lighting

10. Emergency communications system(s)


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LEGAL ISSUES

1. Common causes of liability

a. Failure to monitor

b. Errors in the use of equipment

c. Failure to communicate adverse reactions

d. Failure to follow policy and procedure

2. Prevention of Liability

a. Personal accountability

b. Knowledge

c. Document, document, document


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PRE-PROCEDURAL FASTING

sedatives and analgesics tend to impair airway reflexes inproportion to the degree of sedation/analgesia achieved

Patients may be at risk of aspirating gastric contents shouldregurgitation occur.

Recommendations include patients undergoingsedation/analgesia for elective procedures should not drink fluidsor eat solid foods for a sufficient period of timeto allow for gastricemptying before their procedure


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Fasting (NPO) Protocol:

1) Patients should be NPO for solids andnon-clear liquids after midnight or for six toeight hours prior to the procedure;

patients, however, may have clear liquids upto four hours prior to the procedure.

Medications and enteral feedings may becontinued as ordered.


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Fasting (NPO) Protocol:

2) In emergent situations or with impairedgastric emptying (bowel obstruction,pregnancy, opioids, pain), pulmonary

aspiration risk should be considered indetermining timing of the procedure andtarget level of sedation.


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PRE-PROCEDURAL CARE

1. PRIOR TO MODERATE SEDATION, THEFOLLOWING INFORMATION MUST BEAVAILABLE IN THE PATIENTS MEDICAL

RECORD:a. Current medications.

b. Anesthetic and sedation history, adverse

reactions.c. Drug allergies.


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FOLLOWING INFORMATION MUST BE AVAILABLE IN

THE PATIENTS MEDICAL RECORD

d. Pertinent laboratory and diagnostic studies ifrequired.

e. American Society of Anesthesiologists (ASA)Physical Status Classification.

f. Airway evaluation to determine if deformitiesof the airway anatomy or resistance toopening mouth exist.


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FOLLOWING INFORMATION MUST BE AVAILABLE IN

THE PATIENTS MEDICAL RECORD

g. Proposed procedure.

h. Proposed plan for moderate sedation (sedation notemust include various items such as risks,

alternatives, informed consent for moderatesedation and procedure, labs reviewed etc. as perpolicy).

i. Documentation of informed consent that includes theuse of moderate sedation and properly completedconsent form.


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PRE-PROCEDURAL CARE

2. ANESTHESIA CONSULTATION MAY BEREQUESTED BY THE OPERATING PHYSICIAN,BASED UPON PREPROCEDURE EVALUATIONOF THE PATIENT.

3. Verify the presence of a driver to take the outpatienthome following the procedure.

4. The patients compliance with dietary restrictionsand/or pre-procedure instructions is confirmed anddocumented.


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PRE-PROCEDURAL CARE

5. Baseline vital signs, level of consciousness,peripheral oxygen saturation and airwaystatus (cough, gag, and swallow reflexes) are

assessed and documented.

6. Pulse oximetry and continuous cardiacmonitoring are initiated.

7. IV access is established and maintainedduring the procedure.


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PRE-PROCEDURAL CARE8. Immediately prior to the procedure, the operating physician performs

a clinical assessment of the patient to determine that thediagnostic or therapeutic plan remains consistent with the patientscurrent status.

9. Preoperative patient assessment

Reason for seeking care; orientation and cognitive state;

emotional state;

communication ability;

history and physical examination;

current medical problems; surgical history;

tobacco use and substance abuse history; and

height, weight, and age


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INTRAPROCEDURAL CARE.

1. Blood pressure, heart rate and rhythm, respiratoryrate, oxygen saturation and level of consciousnessare continuously monitored with documentation onthe moderate sedation flow sheet at intervals

appropriate to the patient condition.

2. For cases lasting one hour or less, documentationis required every 5 minutes, as long as the

sedation is being administered.


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3. For cases lasting longer than one hour,monitoring and documentation occurs everyfive minutes for the first hour and no less

often than every fifteen minutes after the firstsixty minutes.

4. Following a repeat dose of medication,

monitoring is documented every five minutesfor at least fifteen minutes.


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5. Sedation is administered by the physician or by aregistered nurse under the direct physiciansupervision.

a. The medication is titrated to the patients response.

b. There must be a physician order for the total doses ofeach medication given during moderate sedation.

c. The moderate sedation flow sheet completed by theregistered nurse will reflect the divided doses of themedication and the time that it was delivered.


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6. During the procedure, assessment of the: patients condition

all pharmacological agents administered,

fluids and blood products administered, untoward events, any treatment rendered,

patients condition at the conclusion of the

procedure are documented.


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7. The qualified RN entrusted with the observationof the patient receiving moderate sedation shallnot have other responsibilities that would

compromise monitoring during the procedure.

8. Before transport to the post-procedure recovery

area, the patient should have stable vital signsand a stable patent airway.


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THE NURSING STAFF IS RESPONSIBLE FOR:

1. Nursing staff, in collaboration with thephysician and other staff, ensure thatappropriate equipment is available and in goodworking order.

2. Verifying and documenting that eachoutpatient is accompanied by a responsible

adult.


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3. Documenting baseline patient assessment toinclude Vital Signs (heart rate, blood pressure,respiratory rate, oxygen saturation), EKGrhythm, allergy statue, pregnancy status (orderBeta HCG per Anesthesia protocol), pre-procedure medications, Pre-procedure AldreteScore

4. Confirm and document compliance with pre-procedure instructions. Document last time foodor fluids intake occurred.


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5. Conduct a TIME OUT immediately before

starting the procedure, following JCIsestablished procedure for Universal Protocol.

6. Intra-procedure and post-procedure

monitoring and documentation of patientparameters (Vital Signs, EKG rhythm, level ofconsciousness) until discharge criteria are met.

7. Establishing and maintaining IV access untilDischarge Criteria met.

8. Providing post-procedure instructions to thepatient and/or accompanying adult.


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THANK YOU

role of the nurses in sedation

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