Moderate Sedation/Analgesia-Care of the Patient Receiving

MODERATE SEDATION/ANALGESIA-CARE OF THE PATIENT RECEIVING

[Insert facility name or a header]

ADMINISTRATIVE APPROVAL

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Purpose

To provide guidance to perioperative RNs for care of the patient receiving moderate sedation/analgesia. The expected outcomes are that the patient receives correctly administered medication(s), the patient’s respiratory status is maintained or improved from baseline levels, the patient’s cardiac status is maintained or improved from baseline levels, and the patient demonstrates or reports adequate pain control.

Policy

It is the policy of [insert name of facility] that:

·  The patient’s suitability for moderate sedation/analgesia will be determined based on selection criteria established by an interdisciplinary team.

·  The perioperative RN will collaborate with the licensed independent practitioner (eg, physician, anesthesiologist, dentist, podiatrist) in developing and documenting the sedation/analgesia plan of care. The sedation plan will include the

o  medications and route of administration,

o  predetermined depth of sedation to complete the procedure,

o  length of the procedure and sedation, and

o  recovery time.

·  A licensed independent practitioner (eg, physician, anesthesiologist, dentist, podiatrist), will directly supervise the perioperative RN monitoring the patient and administering medications.

·  The supervising licensed independent practitioner will be physically present and immediately available in the procedure suite for diagnosis, treatment, and management of complications while the patient is sedated.

·  Emergency resuscitation equipment and supplies will be immediately available in every location in which moderate sedation is administered.

·  Supplemental oxygen will be immediately available for the patient receiving moderate sedation/analgesia.

·  Opioid antagonists and benzodiazepine antagonists will be readily available whenever opioids and benzodiazepines are administered.

·  Emergency equipment and supplies will include age- and size-appropriate

o  resuscitation medications,

o  opioid and benzodiazepine antagonists,

o  airway and ventilator equipment (eg, laryngoscopes, endotracheal tubes, laryngeal mask airway, oral and nasal airways, mechanical positive bag-valve mask device),

o  defibrillators, and

o  IV fluids and access equipment.

·  Clinical alarms will be audible and set to alert for critical changes in the patient’s status.

·  The perioperative RN must administer moderate sedation/analgesia within the scope of nursing practice as defined by his or her state board of nursing and the state nurse practice act.

·  Perioperative RNs should know the recommended dose, recommended dilution, onset, duration, effects, potential adverse reactions, drug compatibility, and contraindications for each medication used during moderate sedation.

·  The perioperative RN will complete a patient assessment before administering moderate sedation/analgesia.

·  Two perioperative RNs will be assigned to care for the patient receiving moderate sedation/analgesia. One RN will administer the sedation medication and monitor the patient and the other RN will perform the circulator role.

·  The perioperative RN monitoring the patient will have no competing responsibilities that would compromise continuous monitoring assessment of the patient during the administration of moderate sedation.

·  The perioperative RN providing moderate sedation/analgesia will be in constant attendance with unrestricted immediate visual and physical access to the patient.

·  The perioperative RN caring for the patient receiving moderate sedation/analgesia may perform short interruptible tasks (eg, opening additional suture, tying a gown) to assist the perioperative team while remaining within the operating or procedure room.

·  The RN providing moderate sedation/analgesia will not perform short interruptible tasks when propofol is used. The RN will monitor the patient without interruption.

·  Medical supervision of patient recovery and discharge after moderate sedation/analgesia is the responsibility of the operating practitioner or licensed independent practitioner.

·  Discharge criteria for patients receiving moderate sedation/analgesia will be established by a multidisciplinary team. Discharge criteria will include

o  return to preoperative baseline mental status (eg, alert and oriented),

o  stable vital signs,

o  sufficient time interval (eg, two hours) since the last administration of an antagonist (eg, naloxone, flumazenil),

o  use of an objective patient assessment discharge scoring system (eg, Aldrete Recovery Score, Post-Anesthetic Discharge Scoring System),

o  absence of protracted nausea,

o  intact protective reflexes,

o  adequate pain control,

o  return of motor/sensory control,

o  ability to remain awake for at least 20 minutes, and

o  arrangement for safe transport from the facility.

·  A qualified provider defined by [facility-specific policy] will be available in the facility to discharge the patient in accordance with established discharge criteria.

·  The perioperative RN must give the patient and his or her caregiver verbal and written discharge instructions.

o  A copy of the written discharge instructions must be given to the patient and a copy will be placed in the patient’s medical record.

Procedure Interventions

Patient Assessment

·  Perform a nursing assessment before administering moderate sedation that includes a review of the patient’s

o  consent that explains the risks, benefits, and alternatives to sedation;

o  medical history;

o  age, height, weight, and BMI (body mass index);

o  pregnancy test results, when applicable;

o  current medications (eg, prescribed, over-the-counter, alternative/complementary therapies, supplements), dosage, last dose, and frequency;

o  drug use (eg, marijuana, street drugs, non-prescribed prescription drugs);

o  tobacco and alcohol use;

o  laboratory test results;

o  diagnostic test results;

o  baseline cardiac status (eg, heart rate, blood pressure);

o  baseline respiratory status (eg, rate, rhythm, blood oxygen level [SpO2]);

o  baseline neurological status;

o  airway (eg, obstructive sleep apnea, difficult mask ventilation);

o  allergies and sensitivities (eg, medications, latex, chemical agents, foods, adhesives, tape);

o  NPO status;

o  ability to tolerate and maintain the required position for the duration of the planned procedure;

o  need for IV access’

o  previous adverse experiences with moderate sedation, including

·  delayed emergence from anesthesia or sedation,

·  postprocedure nausea and/or vomiting,

·  adverse effects from anesthetic or sedative medications, and

·  airway or breathing problems;

o  sensory impairment (eg, visual, auditory);

o  level of anxiety;

o  level of pain; and

o  arrangement for a responsible adult caregiver to escort him or her home.

·  Use the American Society of Anesthesiologists (ASA) Physical Status Classification to determine patient acuity.

ASA I: A normal, healthy patient.

ASA II: A patient with mild systemic disease.

ASA III: A patient with severe systemic disease.

ASA IV: A patient with severe systemic disease that is a constant threat to life.

ASA V: A moribund patient who is not expected to survive without the operation.

ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes.

o  Consider patients who are classified as ASA I, ASA II, and medically stable ASA III as appropriate for RN-administered moderate sedation/analgesia.

·  Assess the patient for characteristics that may indicate difficulty with mask ventilation, including

o  age 55 years;

o  BMI ≥ 30 kg/m2;

o  missing teeth;

o  presence of a beard;

o  short neck;

o  limited neck extension;

o  small mouth opening;

o  jaw abnormalities;

o  large tongue;

o  nonvisible uvula;

o  a history of snoring, stridor, or sleep apnea;

o  a history of problems with anesthesia or sedation;

o  advanced rheumatoid arthritis;

o  chromosomal abnormality (eg, trisomy 21); and

o  tonsillar hypertrophy.

·  Assess the patient for obstructive sleep apnea using a sleep apnea assessment screening tool.

·  Screen pediatric patients for obstructive sleep apnea. Screening criteria may include

o  weight above the 95th percentile for age and sex;

o  intermittent vocalization during sleep;

o  parental report of restless sleep, difficulty breathing, struggling respiratory effort during sleep;

o  night terrors;

o  unusual sleep positions;

o  new onset of enuresis;

o  somnolence (eg, appears sleepy during the day, is difficult to arouse at usual awakening time);

o  easily distracted;

o  overly aggressive;

o  irritability; and

o  difficulty concentrating.

·  Consult with an anesthesia professional if the patient presents with a history of obstructive sleep apnea.

·  Implement additional precautions (eg, non-invasive positive pressure ventilation with continuous positive airway pressure [CPAP] or bilevel positive airway pressure, careful titration of opioids, non-opioid analgesia techniques, multimodal pain management) for patients with sleep apnea who will undergo moderate sedation.

·  Consult with an anesthesia professional and develop a perioperative plan of care if the patient presents with any of the following:

o  known history of respiratory or hemodynamic instability,

o  history of coagulation abnormality,

o  history of neurologic or cardiac disease that may be affected by medications administered for moderate sedation/analgesia,

o  previous difficulties with anesthesia or sedation,

o  severe sleep apnea or other airway-related issues,

o  one or more significant comorbidities,

o  pregnancy,

o  inability to communicate (eg, aphasic),

o  inability to cooperate,

o  multiple drug allergies,

o  multiple medications with potential for drug interaction with sedative analgesics,

o  current substance use (eg, street drugs, herbal supplements, nonprescribed prescription drugs),

o  ASA physical classification of unstable ASA III, or

o  ASA physical classification of ASA IV or above.

Patient Monitoring

·  Monitor and document the patient’s physiological and psychological responses, identify nursing diagnoses based on assessment of the data, and implement the plan of care.

·  Obtain and document baseline patient monitoring of

o  pulse,

o  blood pressure,

o  respiratory rate,

o  SpO2 by pulse oximetry,

o  end-tidal carbon dioxide by capnography,

o  pain level,

o  anxiety level, and

o  level of consciousness.

·  Obtain and document intraoperative patient monitoring of

o  cardiac rate and rhythm,

o  blood pressure,

o  respiratory rate,

o  SpO2 by pulse oximetry,

o  end-tidal carbon dioxide by capnography,

o  depth of sedation assessment,

o  pain level,

o  anxiety level, and

o  level of consciousness.

·  Obtain and document postoperative patient monitoring of

o  cardiac rate and rhythm,

o  blood pressure,

o  respiratory rate,

o  SpO2 by pulse oximetry,

o  pain level,

o  sedation level,

o  level of consciousness,

o  intravenous line (eg, patency, site, type of fluid),

o  condition of dressing and wound, and

o  type and patency of drainage tubes.

·  Verify that monitoring equipment, oxygen source, masks and cannulas, suction source, tubing and tips, and oral and nasal airways are working correctly and immediately available in the room where the procedure will be performed.

·  Verify that clinical alarms are audible and set to alert for critical changes in the patient’s status.

·  Verify that the emergency resuscitation cart is immediately available in the location where moderate sedation/analgesia will be administered.

·  Verify that opioid antagonists (ie, naloxone) and benzodiazepine antagonists (ie, flumazenil) are readily available when administering opioids and benzodiazepines.

·  Before administering medications,

o  verify the licensed independent practitioner’s order,

o  verify the correct dosing parameters,

o  verify the correct dosing parameters, and

o  identify the patient-specific maximum dose by consulting either the medication formulary, a pharmacist, a physician, or the product information sheet or other published reference material.

·  Administer intravenous medications one at a time, in incremental doses, and titrated to desired effect (ie, moderate sedation that enables the patient to maintain his or her protective reflexes, airway patency, and spontaneous ventilation).

·  Adjust doses of sedatives and analgesics when caring for an older adult, as directed by the licensed independent practitioner.

·  Allow sufficient time for drug absorption and onset before considering additional medication when administering medications by a non-intravenous route (eg, oral, rectal, intramuscular, intranasal, transmucosal).

·  Assess the patient’s level of consciousness by evaluating the patient’s ability to respond purposefully to verbal commands, either alone or with light tactile stimulation.

·  Assess and document the depth of sedation using the [facility-specific objective scale] (eg, ASA Continuum of Sedation Scale, Ramsay Sedation scale).

·  Determine the necessity, method, and flow rate of oxygen administration under the direction of the supervising licensed independent practitioner based on the patient’s optimal level of oxygen saturation as measured with pulse oximetry.

·  Document the moderate sedation/analgesia medications administered, including the

o  medication,

o  strength,

o  total amount administered,

o  route,

o  time,

o  patient response, and

o  adverse reactions.

Patient Discharge

·  Evaluate the patient for discharge readiness based on established discharge criteria.

·  Evaluate the need for delaying discharge when the patient

o  has obstructive sleep apnea,

o  receives morphine,

o  receives dexmedetomidine,

o  receives an antagonist, or

o  experiences postoperative nausea and vomiting.

·  Evaluate the need for prolonged pediatric patient discharge when

o  the child receives a medication with a long half-life (eg, chloral hydrate), and

o  only one responsible adult is accompanying a child recovering from moderate sedation/analgesia.

·  Provide additional discharge instruction for the adult responsible for care of an infant or toddler riding home in a car seat, including the need for

o  careful observation of the child’s position to avoid airway obstruction and

o  care by two responsible adults (ie, driver and observer).

·  Verify that the patient or a responsible adult is able to verbalize an understanding of the discharge instructions.

Documentation

The perioperative RN will document the care of the patient receiving moderate sedation/analgesia throughout the continuum of care.

Competency

Perioperative RNs participating in procedures involving moderate sedation/analgesia will receive education and complete competency verification activities on managing patients receiving moderate sedation/analgesia.

Quality

Perioperative RNs will participate in quality assurance and performance improvement activities related to managing patients receiving moderate sedation/analgesia.

Glossary

Licensed independent practitioner: A physician, dentist, nurse practitioner, nurse midwife, or any other individual permitted by law and the organization to provide care and services without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges.