MODERATE SEDATION RECORD (formerly termed Conscious Sedation)

Transcription

1 (POLICY #DOC-051) Page 1 of 6 WELLSPAN HEALTH - YORK HOSPITAL NURSING POLICY AND PROCEDURE Dates: Original Issue: September 1998 Annual Review: March 2012 Revised: March 2010 Submitted by: Brenda Artz Approved by: Practice Council TITLE: MODERATE SEDATION RECORD (formerly termed Conscious Sedation) KEYWORDS: Moderate Sedation Record, Moderate Sedation Form, Moderate Sedation documentation, Moderate Sedation, Conscious Sedation) I. PURPOSE: To provide a consistent documentation record for patients at York Hospital who receives Moderate Sedation. II. POLICY STATEMENT: The Moderate Sedation Record will provide uniform documentation for any area that provides Moderate Sedation. The flowsheet will enhance patient care by enabling the health care team to identify expectations or variations in patient outcomes. III. EQUIPMENT: A. Black or Blue pen B. Moderate Sedation Record (Form # 9017) IV. PROCEDURE: Definitions: Front: The side that is labeled Moderate Sedation Record. This is used for pre-procedure, intra-procedure, and post-procedure documentation. A. Back: References to Aldrete Scoring, NPO requirements, Pain Scales, and Level of Consciousness (LOC) key. Comments section is available for additional documentation if needed. B. Carbon Copy of Moderate Sedation Record (2 nd Sheet) 1 st page goes into Medical Record. 2 nd page sent to Nursing Affairs for Performance Improvement Monitoring. Back of carbon copy gives examples of events to be entered into Online event reporting system. V. DOCUMENTATION PROCEDURE: A. Pre-Procedure General Instructions: 1. Place patient label on the front page and the yellow carbon copy of the Moderate Sedation Record.

2 (POLICY #DOC-051) Page 2 of 6 2. Physician Responsibilities a. Consent b. Pre-procedure assessment - this should include an airway assessment c. Sedation plan d. Patient, procedure, and site verification (MAP 721) e. Time out conducted by all team members (MAP 721) f. Review information in H&P and progress notes g. Re-assess patient prior to procedure and sign section on form 3. Nurse Responsibilities a. Pre-procedure vital signs (HR, BP, RR, O2 sats), Level of Consciousness and Pain Score (reference on back of 1 st page) b. Current medications - if inpatient can refer to medication administration record c. Allergies, ask about latex allergies d. Smoking, ETOH or illicit drug use e. Pre-procedure check list Issues addressed are: consent, IV access (if needed), pregnancy status, dentures and NPO status. f. Assess Aldrete score and mark on pre-sedation section (Reference to scoring back of 1 st page) g. Patient, procedure, and site verified (MAP 721) h. Time out conducted by all team members (MAP 721) i. Reminder to physician to complete his responsibilities (refer to #2 above) j. Sign pre-sedation assessment section B. During Procedure 1. Note time, dosage, and drug when first medication is given. 2. Record fluids infusing 3. Record HR and BP every 5 minutes. Continually monitor RR and O2 sat and record Q 15 minutes. 4. O2 therapy, cardiac rhythm (if indicated) and Level of Consciousness (LOC) and Pain Score are recorded in appropriate boxes. Monitor LOC continuously and document a minimum of every 15 minutes. Document Pain Score minimum of every 15 minutes (If patient is unable to communicate please use an alternative method such as a non-verbal pain scale. 5. Record each additional dosage of medications and record initials of person who gave drug. Remember to put initials and sign signature in appropriate column. 6. Complete top section of form: Physician, Procedure, Area, Start/Stop Time, and Date. C. Post-Procedure General Instructions: 1. Note time procedure ended. 2. If an adverse event happens during a Moderate Sedation procedure or recovery record in progress notes and in on-line event reporting system. An Adverse Event is considered: Use of reversal agent, Severe O2 desaturation (any measurement < 90%

3 (POLICY #DOC-051) Page 3 of 6 or a measurement >5% less than the pre-procedure score), Airway rescue (oral airway, jaw thrust, need for Anesthesia Department assistance or intervention), Mortality, Known or Suspected Gastric Content Aspiration. 3. Physician completes post-procedure assessment and signs form (Moderate Sedation Post-procedure Record). 4. Continue to monitor HR and BP Q 5 minutes, continual monitoring of RR and O2 saturation with recording Q 15 minutes, continual monitoring of LOC and Pain Score (if appropriate) with recording Q 15 minutes. 5. Once V.S. has stabilized record every 15 minutes until the patient is easily arousable and V.S. return to within 20% of pre-procedural level. 6. Aldrete score needs to be >/= 8 or a score equal to the pre-procedure score is required before patient can be discharged or transferred. 7. Discharge/Transfer Aldrete Score needs to be written on Post-Sedation Section 8. If a reversal agent is used, patient must be monitored for a minimum of 90 minutes after the last reversal agent is given. 9. Discharge/Transfer criteria must be met: (In addition to above) a. Outpatients need to have 24 hour supervision from a responsible adult. b. Discharge instructions should include name and number of who to call if any questions or problems. c. Outpatients should have: Minimal to no pain Be able to stand up and walk straight or pre-anesthesia level Minimal to no nausea and no vomiting d. If recovery is completed in another department discharge/transfer criteria must be met, and report given to unit. e. Make sure all sections are completed and appropriate signatures are obtained. f. Tear off carbon copy and send to Nursing Affairs, Put Original Copy on chart. Make sure carbon copy has a patient label. g. If any adverse reactions occur as a result of Moderate Sedation (refer to back of 2 nd sheet of record) record in on-line reporting system Use of reversal agent Severe O2 desaturation Airway Rescue Mortality Known or Suspected Gastric Content Aspiration VI. APPLIES TO: PERSONS PERMITTED TO PERFORM: RN x (who is ACLS or PALS and who has completed the Moderate Sedation competency yearly) Physician x (who has passed the physician credentialing process) VII. AREA PERFORMED: This form or a version of this form is used for everyone receiving moderate

4 (POLICY #DOC-051) Page 4 of 6 sedation within the WellSpan York Hospital System. VIII. REFERENCES/RESOURCES: 1. WellSpan Moderate Sedation Record - Form # Comprehensive Accreditation Manual for Hospitals The Official Handbook Provision of Care PC Operative/Moderate & Deep Sedation, Provision of Care 8.10 Pain Standard 4. York Hospital Moderate Sedation Policy Administrative Manual (711). 5. York Hospital Guidelines for Moderate Sedation (revised 9/08) 6. York Hospital Identification of Patient/Site for Procedures Manual of Administrative Policy (721) 7. York Hospital Nursing Policy and Procedure (N-070) Odom-Forren, Watson (2005). Practical Guide to Moderate Sedation/Analgesia 2 nd Edition. Mosby

5 (POLICY #DOC-051) Page 5 of 6 Guidelines for Moderate Sedation (Previous title: Guidelines for Conscious Sedation) Dosage requirements for sedation generally decrease in elderly, pediatric, debilitated patients and in patients with significant cardiac, pulmonary, hepatic, renal, or CNS disease. Allow sufficient time for drugs to take effect before redosing. Particular care should be exercised with morbidly obese patients due to the increased risk of airway obstruction with rapid oxygen desaturation. Dose recommendations for IM and PO are for single doses only. Do not repeat by this route. Additional sedation should be given I.V. Doses given below can be modified according to the judgment and practice of the prescribing physician. Adult Sedation Drug Route Suggested Dose Onset of Effect Duration Midazolam IV Incremental dose: 1-2 mg min 1-2 hours Total cumulative dose: 5 mg Morphine IV Incremental dose: mg/kg 5-10 min 3-4 hours Total cumulative dose: 0.2 mg/kg IM 0.1 mg/kg min 4-5 hours Fentanyl IV Incremental dose: micrograms 1-3 min min Total cumulative dose: 3 micrograms/kg Ketamine IV 1 2mg/kg 30 seconds min IM 2-4mg/kg x1 dose (use 100mg/ml solution 4 min min to limit pain on injection) Naloxone IV 0.4 mg/ml added to 9ml NSS 1-2 min min 1-2 ml Q 2-3 min Flumazenil IV 0.2 mg x1 then 0.1 mg Q 1 min 2 min min Total cumulative dose: 1 mg Pediatric Sedation (12 years or under) Drug Route Suggested Dose Onset of Effect Duration Midazolam PO Single dose: 0.5 mg/kg (maximum dose 10mg) min 45 min IV Incremental dose: 0.05 mg/kg min 1-2 hours Single dose: 1 mg Total cumulative dose: 5 mg Morphine IV Incremental dose: 0.05 mg/kg 5-10 min 3-4 hours Total cumulative dose: 0.2 mg/kg IM 0.1 mg/kg min 4-5 hours

6 (POLICY #DOC-051) Page 6 of 6 Fentanyl IV Initial dose: 1 microgram/kg 1-3 min min Repeat dose: 0.5 micrograms/kg Q 10 min Total cumulative dose: 2 micrograms/kg (For children < 6 months, use 0.5 micrograms/kg and titrate upward in 0.5 micrograms/kg increments) Ketamine IV 1 2mg/kg 30 seconds min IM 2-4mg/kg x1 dose (use 100mg/ml solution 4 min min to limit pain on injection) Naloxone IV 0.4 mg/ml added to 9ml NSS 1-2 min min 1-2 ml Q 2-3 min Flumazenil IV 0.02 mg/kg, repeat Q 2 min 2 min min Total cumulative dose: 1 mg Date: 9/2008