Practice: Moderate Sedation/Analgesia, Care of the Patient Receiving RN

[Insert Facility Name]

Competency Verification Tool—Perioperative Services

Practice: Moderate Sedation/Analgesia, Care of the Patient Receiving -- RN

Name: Date:

Competency Statement: The perioperative RN has completed facility or health care organization-required education and competency verification activities related to care of the patient receiving moderate sedation/analgesia.1

1. Guideline for care of the patient receiving moderate sedation. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:617-648.

Outcome Statement: The patient receives correctly administered medication(s).2

The patient’s respiratory status is maintained or improved from baseline levels.3

The patient’s cardiac status is maintained or improved from baseline levels.4

The patient demonstrates or reports adequate pain control.5

2. Petersen C, ed. Medication administration. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:203-210.

3. Petersen C, ed. Respiratory status. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:294-300.

4. Petersen C, ed. Cardiac status. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:301-307.

5. Petersen C, ed. Pain control. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:308-311.

Competency Statements/Performance Criteria / Verification Method
[Select applicable code from legend at bottom of page] / Not Met
(Explain why)
DEM/
DO/DA / KAT / S/SBT/
CS / V / RWM/
P&P / O
Patient Assessment
1. Recognizes that the patient’s suitability for moderate sedation/analgesia is determined based on selection criteria established by an interdisciplinary team.
2. Performs a nursing assessment before administering moderate sedation that includes a review of the patient’s
a. consent explaining the risks, benefits, and alternatives to sedation;
b. medical history;
c. age, height, weight, and BMI (body mass index);
d. pregnancy test results, when applicable;
e. current medications (eg, prescribed, over-the-counter, alternative/complementary therapies, supplements), dosage, last dose, and frequency;
f. drug use (eg, marijuana, street drugs, non-prescribed prescription drugs);
g. tobacco and alcohol use;
h. laboratory test results;
i. diagnostic test results;
j. baseline cardiac status (eg, heart rate, blood pressure);
k. baseline respiratory status (eg, rate, rhythm, blood oxygen level [SpO2]);
l. allergies and sensitivities (eg, medications, latex, chemical agents, foods, adhesives, tapes);
m. NPO status;
n. ability to tolerate and maintain the required position for the duration of the planned procedure;
o. need for IV access;
p. previous adverse experiences with moderate sedation, including
· delayed emergence from anesthesia or sedation,
· postprocedure nausea and vomiting,
· adverse effects from anesthetic or sedative medications, and
· airway or breathing problems;
q. sensory impairment (eg, visual, auditory);
r. level of anxiety;
s. level of pain; and
t. arrangement for a responsible adult caregiver to escort him or her home.
3. Uses the American Society of Anesthesiologists (ASA) Physical Status Classification to determine patient acuity.
4. Identifies patients who are classified as ASA I, ASA II, and medically stable ASA III as appropriate for RN-administered moderate sedation/analgesia.
5. Assesses the patient for characteristics that may indicate difficulty with mask ventilation, including
a. age > 55 years;
b. BMI 30 kg/m2;
c. missing teeth;
d. presence of a beard;
e. short neck;
f. limited neck extension;
g. small mouth opening;
h. jaw abnormalities;
i. large tongue;
j. nonvisible uvula;
k. a history of snoring, stridor, or sleep apnea;
l. a history of problems with anesthesia or sedation;
m. advanced rheumatoid arthritis;
n. chromosomal abnormality (eg, trisomy 21); and
o. tonsillar hypertrophy.
6. Assesses the patient for obstructive sleep apnea using a sleep apnea assessment screening tool.
7. Screens pediatric patients for obstructive sleep apnea. Recognizes that screening criteria may include
a. weight above the 95th percentile for age and sex;
b. intermittent vocalization during sleep;
c. parental report of restless sleep, difficulty breathing, struggling respiratory effort during sleep;
d. night terrors;
e. unusual sleep positions;
f. new onset of enuresis;
g. somnolence (eg, appears sleepy during the day, is difficult to arouse at usual awakening time);
h. easily distracted;
i. overly aggressive;
j. irritability; and
k. difficulty concentrating.
8. Consults with an anesthesia professional if the patient presents with a history of obstructive sleep apnea.
9. Implements 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 a patient with sleep apnea who will undergo moderate sedation.
10. Consults with an anesthesia professional and develops a perioperative plan of care if the patient presents with any of the following:
a. known history of respiratory or hemodynamic instability,
b. history of coagulation abnormality,
c. history of neurologic or cardiac disease that may be affected by medications administered for moderate sedation/analgesia,
d. previous difficulties with anesthesia or sedation,
e. severe sleep apnea or other airway-related issues,
f. one or more significant comorbidities,
g. pregnancy,
h. inability to communicate (eg, aphasic),
i. inability to cooperate,
j. multiple drug allergies,
k. multiple medications with potential for drug interaction with sedative analgesics,
l. current substance use (eg, street drugs, herbal supplements, nonprescribed prescription drugs),
m. ASA physical classification of unstable ASA III, or
n. ASA physical classification of ASA IV or above.
Patient Monitoring
11. Collaborates with the licensed independent practitioner (eg, physician, podiatrist, dentist) in developing and documenting the sedation/analgesia plan of care that includes the
a. medications and route of administration,
b. predetermined depth of sedation to complete the procedure,
c. length of the procedure and sedation, and
d. recovery time.
12. Recognizes that the perioperative RN monitors the patient and administers medications under the direct supervision of a licensed independent practitioner.
13. Recognizes that the supervising licensed independent practitioner is to be physically present and immediately available in the procedure suite for diagnosis, treatment, and management of complications while the patient is sedated.
14. Verbalizes the location of emergency resuscitation equipment and supplies and recognizes that emergency resuscitation equipment and supplies are to be immediately available in every location in which moderate sedation is administered.
15. Verbalizes the location of oxygen sources and recognizes that supplemental oxygen is to be immediately available for the patient receiving moderate sedation/analgesia.
16. Identifies opioid antagonists (ie, naloxone) and benzodiazepine antagonists (ie, flumazenil) and recognizes they are to be readily available whenever opioids and benzodiazepines are administered.
17. Verifies that emergency equipment and supplies are age- and size-appropriate.
18. Administers moderate sedation/analgesia within the scope of nursing practice.
19. Verbalizes the recommended dose, recommended dilution, onset, duration, effects, potential adverse reactions, drug compatibility, and contraindications for each medication used during moderate sedation.
20. Recognizes that 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 circulating role.
21. Recognizes that the perioperative RN monitoring the patient is to have no competing responsibilities that would compromise continuous monitoring assessment of the patient during the administration of moderate sedation.
22. Recognizes that the perioperative RN providing moderate sedation/analgesia is to be in constant attendance with unrestricted immediate visual and physical access to the patient.
23. Recognizes that 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.
24. Recognizes that the perioperative RN providing moderate sedation/analgesia will not perform short interruptible tasks when propofol is used, and that the RN is to monitor the patient without interruption.
26. Monitors and documents the patient’s physiological and psychological responses, identifies nursing diagnoses based on assessment of the data, and implements the plan of care.
27. Obtains and documents baseline patient monitoring of
a. pulse,
b. blood pressure,
c. respiratory rate,
d. SpO2 by pulse oximetry,
e. end-tidal carbon dioxide by capnography,
f. pain level,
g. anxiety level, and
h. level of consciousness.
28. Obtains and documents intraoperative patient monitoring of
a. cardiac rate and rhythm,
b. blood pressure,
c. respiratory rate,
d. SpO2 by pulse oximetry,
e. end-tidal carbon dioxide by capnography,
f. depth of sedation assessment,
g. pain level,
h. anxiety level, and
i. level of consciousness.
29. Obtains and documents postoperative patient monitoring of
a. cardiac rate and rhythm,
b. blood pressure,
c. respiratory rate,
d. SpO2 by pulse oximetry,
e. pain level,
f. sedation level,
g. level of consciousness,
h. intravenous line (eg, patency, site, type of fluid),
i. condition of dressing and wound, and
j. type and patency of drainage tubes.
30. Verifies 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.
31. Verifies that clinical alarms are audible and set to alert for critical changes in the patient’s status.
32. Verifies that the emergency resuscitation cart is immediately available in the location where moderate sedation will be administered.
33. Verifies that opioid antagonists (ie, naloxone) and benzodiazepine antagonists (ie, flumazenil) are readily available when administering opioids and benzodiazepines.
34. Before administering medications,
a. verifies the licensed independent practitioner’s order,
b. verifies the correct dosing parameters, and
c. identifies 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.
35. Administers 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).
36. Adjusts doses of sedatives and analgesics when caring for an older adult, as directed by the licensed independent practitioner.
37. Allows sufficient time for drug absorption and onset before considering additional medications when administering medications by a non-intravenous route (eg, oral, rectal, intramuscular, intranasal, transmucosal).
38. Assesses 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.
39. Assesses and documents the depth of sedation using the [facility-specific objective scale].
40. Determines 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.
41. Documents the moderate sedation/analgesia medications administered, including the
a. medication,
b. strength,
c. total amount administered,
d. route,
e. time,
f. patient response, and
g. adverse reactions.
Patient Discharge
42. Recognizes that medical supervision of patient recovery and discharge after moderate sedation/analgesia is the responsibility of the operating practitioner or licensed independent practitioner.
43. Recognizes that a qualified provider defined by [facility-specific policy] will be available in the facility to discharge the patient in accordance with established discharge criteria.
44. Recognizes that discharge criteria is established by a multidisciplinary team.
45. Evaluates the patient for discharge readiness based on established discharge criteria that includes
a. return to baseline mental status (eg, alert and oriented),
b. stable vital signs,
c. sufficient time interval (eg, two hours) since the last administration of an antagonist (eg, naloxone, flumazenil),
d. use of an objective patient assessment discharge scoring system (eg, Aldrete Recovery Score, Post-Anesthetic Discharge Scoring System),
e. absence of protracted nausea,
f. intact protective reflexes,
g. adequate pain control,
h. return of motor/sensory control,
i. ability to remain awake for at least 20 minutes, and
j. arrangement for safe transport from the facility.
46. Evaluates the need for delaying discharge when the patient
a. has obstructive sleep apnea,
b. receives morphine,
c. receives dexmedetomidine,
d. receives an antagonist, or
e. experiences postoperative nausea and vomiting.
47. Evaluates the need for prolonged pediatric patient discharge when
a. the child receives a medication with a long half-life (eg, chloral hydrate) and
b. only one responsible adult is accompanying a child recovering from moderate sedation/analgesia.
48. Provides additional discharge instruction for the adult responsible for care of an infant or toddler riding home in a car seat, including the need for
a. careful observation of the child’s position to avoid airway obstruction and
b. care by two responsible adults (ie, driver and observer).
49. Verifies that the patient or a responsible adult is able to verbalize an understanding of the discharge instructions.
50. Gives the patient and his or her caregiver verbal and written discharge instructions.
51. Places a copy of the written discharge instructions in the patient’s medical record.
52. Documents care of the patient receiving moderate sedation/analgesia accurately, completely, and legibly according to the facility or health care organization policies and procedures throughout the continuum of care.
53. Verbalizes a review of facility or health care organization policies and procedures related to care of the patient receiving moderate sedation/analgesia.
54. Participates in assigned quality improvement activities related to care of the patient receiving moderate sedation/analgesia.
Concurrent competency verification of the following is recommended
· [Additional competencies related to care of the patient receiving moderate sedation/analgesia as determined as determined by the facility or health care organization.] / ·
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DEM/DO/DA = Demonstration/Direct Observation/Documentation Audit KAT = Knowledge Assessment Test

S/SBT/CS = Skills Laboratory/Scenario-based Training/Controlled Simulation V = Verbalization

RWM/P&P = Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s ______) O = Other: ______