Sedation Analgesia(Nurse Monitored)

Lisa Rabideau, RN, CPAN

12/01/2012

OBJECTIVES• Understand levels of (nurse monitored)

sedation• Know who can give sedation• Know how to find out• Know what your responsibilities are• Know what equipment is needed• RN responsibility• Know where to get help

Levels of Sedation/Analgesia (Nurse Monitored)

• Minimal Sedation (Anxiolysis)

– First or lowest level of sedation.

– A drug-induced state during which patients respond normally to verbal commands.

– Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

• Moderate Sedation/Analgesia (Conscious Sedation)

– A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

– No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.

– Cardiovascular function is usually maintained.

Levels of Sedation/Analgesia (continued)

• Deep Sedation/Analgesia A drug-induced depression of consciousness during

which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Reflex withdrawal from a painful stimulus is not considered to be a purposeful response.

The ability to independently maintain ventilatory function may be impaired.

Patients may require assistance in order to maintain a patent airway.

Spontaneous ventilation may be inadequate.

Cardiovascular function is usually maintained.

Levels of Sedation/Analgesia (continued)

• Anesthesia

– Is the last, or deepest level of sedation.

– Must be provided by an anesthesia provider (CRNA or anesthesiologist).

– Consists of general, spinal or major regional anesthesia.

Levels of Sedation/Analgesia (continued)

Sedation-to-anesthesia is a continuum

Per JCAHO: Any medication which is used for the purpose of inducing moderate sedation, or any medication, which when used results in a level of moderate sedation would be subject to the standards for moderate or deep sedation.

• Because the response to procedures and medications is not always predictable, it is not always possible to predict how an individual patient will respond

• Patient safety should guide the decision to consider if it is sedation or not

Who can give sedation?• “Individuals administering moderate or

deep sedation and anesthesia are qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.” JCAHO Standard PC 13.20

• “Each patient’s moderate or deep sedation care shall be planned by a qualified individual”

• Physicians must be credentialed by the hospital & Medical Staff to give moderate or deep sedation

Provider QualificationsThe individuals providing moderate or deep

sedation and anesthesia have at a minimum had competency-based education, training, and experience in the following:– Evaluation of patients prior to the sedation

– Methods and techniques required to rescue those patients who unavoidably slip into a deeper level of sedation or anesthesia

– Re-evaluation of the patient IMMEDIATELY before the use of sedation

– Planning for the appropriate level of post-procedure care.

– Administration of pharmacological agents predictably achieve the desired level of sedation

How do I find out?• A list of credentialed physicians is

available in the medical staff office and from the PCC. Should also be available in the unit’s Sedation binder.

Before the Procedure• Physician plans level of sedation• Physician documents H & P (on the chart)• Informed consent obtained• Post procedure care & assessment is planned for• Re-assessment is done just prior to procedure, with

appropriate documentation of:– H & P update

– Airway assessment

– Planned sedation level

– Physical (heart & lungs) & mental status assessed

– Informed Consent verification

• Adherence to the Universal Protocol

RN qualifications to monitor Patient during Sedation

• Must maintain yearly airway & CPR competency

• Must be familiar with monitoring equipment• Must be familiar with the basic pharmacology

of the agents to be used • Must follow “Medication Safety” and

“Medications, Approved List for Administering Intravenous” policies

• Make sure to refer to the Policy “Medications, Approved List for Administering Intravenous”

• Physician MUST be present when sedation is given• FENTANYL & VERSED REQUIRE SPECIFIC

EDUCATION/COMPETENCY before it can be given by an RN

• Fentanyl can only be given in Critical Care and Surgical settings

• Brevital & Propofol can be given ONLY by the Physician

Specific Medication Considerations

What equipment do I need?• Oxygen

• Suction

• Ambu-bag

• Code cart and defibrillator• Reversal agents romazicon or narcan

• Monitoring devices oximeter, B/P cuff, cardiac monitor if required by patient condition

Pre-Procedure RN Responsibilities

• Assessment: VS, LOC, understanding of procedure that H & P is available

• Ensure immediate availability of emergency equipment & meds

• Ensure that post-procedure recovery has been planned for

• Patient/family education

• Verify last oral intake

• Assure vascular access

• Know the drugs and policies!

• Complete Universal Protocol checklist, including consent verification

Intra-Procedure RN Responsibilities

• Do “time out” just prior to procedure

• Have no other responsibilities other than monitoring the patient

• Administer meds within hospital policy recommendations, in small, incremental doses, titrated to effect.

• Administer Oxygen as needed/ordered

• VS, LOC every 5 min. Use Modified Ramsey Scale

• Document response to meds, complications, interventions, etc.

Post-Procedure RN Responsibilities

• Directly monitor the patient until “discharge” criteria met (see policy)– Easily aroused & oriented (or at baseline)– Can cough & swallow– VS stable & O2 sat >92% on room air or O2 ordered, Aldrete

score > 8– It has been >30 min since last dose of sedating medication– It has been >45 minutes since given narcan or romazicon (or 2

hours if romazicon was given for valium, ativan or >10 mg versed)

• Document assessment and discharge instructions if applicable

• Make sure that physician documents orders for all medications given

Documentation• Use sedation analgesia (or unit

specific) flow sheet– Pre-procedure assessment & care– Intra-procedure VS, LOC, pain,

medications– Post-procedure Aldrete score,

discharge/safety instruction• Universal Protocol Checklist• Complete Audit Tool and give to

manager after any adverse event.

Champlain Valley Physicians Hospital Medical Center

PROCEDURAL SEDATION FLOWSHEET – NON-SURGICAL SETTING Date:________________________________ Procedure:_________________________________________________ Physician performing sedation:____________________ Physician performing procedure:________________________

Nursing Pre-Procedure Care/Assessment Physician Drug Orders

Time Drug/Dose/Route

Patient weight: kgs Last meal/drink: ___________hours ago Allergies/Sensitivities:______________________________________ “Time Out” verification immediately pre-procedure Time/Initials Correct patient identity _________ Agreement on procedure _________ Correct side & site (MD to initial same, unless N/A) _________ Correct patient position _________ Availability of special equipment _________ (See Procedural Sedation Checklist)

(Record Vital Signs (SpO2 , Pulse, Resp, BP) and LOC (Modified Ramsey Scale, see back) 5 minutes after administering IV drug, and every 5 minutes up to 30 after last dose given or until all vital signs and LOC are back to baseline)

Intra-Procedure Nursing Documentation of Care

Time Drug: Dose/Route/Administered By SpO2 P R BP LOC* O2

LPM Comments

Baseline data immediately pre-procedure:

Post-Procedure Nursing Documentation of Care

Vital signs and LOC (*Modified Ramsey Scale) at end procedure and end sedation protocol are documented above

See Additional Nurses Notes on T Sheet (ECC only)

Discharged and/or Protocol dc’ed @ (time) PATIENT:

Aldrete Score: (must be > 8) Able to dress/ambulate consistent w/age (ECC)

PATIENT LABEL

RN signature: ____________________________MD signature: ___Form # 100S1 revised 7/07

New Flow Sheet

Time Out Section

Physican Order Section (can be used as orders if doc signs bottom)

Joint Commission RequirementsMonitoring of Adverse Events Related to Sedation

(PI 01.01.01 EP 6 and LD 04.04.04 EP 2)

Sedation provided by a non-Anesthesiologist is considered a high risk procedure, because an Anesthesiologist is not present if the patient loses their airway.

All adverse events related to sedation must be reviewed.

Upon an adverse event occurring, the RN in the procedural area will document the adverse event, report the adverse event to their immediate supervisor, and complete their department-specific QA Monitoring Tool.

What are Adverse Events?

• Initiation of bag valve mask

• Reversal agents administered in a rescue attempt

• Patient turned over to anesthesia staff

• Unplanned intubation

• Unplanned admission related to the use of sedation

HELP!• Policy

– “Moderate or Deep Sedation/Analgesia Administered /Directed by Non-Anesthesiologists”

• PCC• Unit reference binder• Unit Management,

Clinical Education Managers

• IV Therapy/Resource Nurse

References

• CVPH Medical Staff Policy: Sedation/Analgesia for Diagnostic or Therapeutic Procedures

• CVPH Administrative Policy: Moderate or Deep Sedation/Analgesia Administered/Directed by a Non-Anesthesiologist

• CVPH Policy: Medications, Approved List for Administering Intravenous

• CVPH Policy: Obtaining Informed Consent

• JCAHO Standards 2012

• CBO Credentialing Program, ASPAN 2002