Mood alteration, in order to allay the€¦ · 14.06.2020 · Mood alteration, in order to allay the patient’s fear and anxiety. Maintenance of consciousness and cooperation for

Mood alteration, in order to allay the patient’s fear and anxiety.

Maintenance of consciousness and cooperation for those patients who must be awake enough to cooperate throughout the procedure.

Elevation of the pain threshold with minimal changes in vital signs, protective reflexes and physiologic response.

Partial amnesia.

Prompt and safe return to activities of daily living.

Pain Management

Anxiety

Pre-operative Medication

Ventilator Management

Control of Seizures

Sleep Induction

Minimal Sedation

Moderate Sedation Analgesia

Deep Sedation Analgesia

General Anesthesia

Drug induced state of light sedation.

Patient responses.

Definition of anxiolytic.

Achieve adequate sedation with minimal risk.

Minimize discomfort and pain.

Minimize negative psychological response by providing anxiolysis, analgesia, and amnesia.

Decrease agitation; improve cooperation.

Provide for rapid recovery and safe discharge.

Facilitate technical performance of the procedure.

Drug-induced depression.

Not easily arousable.

Ventilatory function impaired.

Cardiovascular function usually maintained.

General Anesthesia

Spinal Anesthesia

Major Regional Anesthesia

Patients undergoing painful or difficult procedures where cooperation and/or comfort will be difficult or impossible without pharmacological support.

Procedures requiring immobilization.

Microsoft Office Clipart

Informed consent

Health evaluation (H&P)

ASA classification

NPO status

Patient/family education

Physical assessment

Aldrete score

Equipment and staffing

Adult available to drive home (if out-patient)


Informed consent includes:

Discussion of purpose, benefits and potential risks of sedation and analgesia/procedure.

Documentation of sedation consent may consist of a written progress note if procedure consent is not necessary. Microsoft Office Clipart

Must be within last 30 days and updated with any changes if 24 hours have passed.

For hospitalized patients, the current hospital record will suffice, and must be updated if 24 hours have passed.


Must include:

Age Weight Allergies Medications Relevant systemic diseases/pregnancy status Functional health/cognitive status Previous hospitalizations History of sedation/general anesthesia and

related complications ASA Classification Lab values


ASA Class:

I A healthy patient with no systemic disease.

II A patient with mild systemic disease without functional limitations.

III A patient with severe systemic disease associated with definite functional limitations.

IV A patient with severe systemic disease that is an ongoing threat to life.

V A moribund patient unlikely to survive without surgery.

Moderate Sedation:

Used primarily for ASA classes I and II.

ASA III may require anesthesia consult.

ASA IV and V in adult and peds w/ III MUST have anesthesia consult.

Ingested Material Minimum Fasting Period

Clear liquids (e.g., tea, water, juice without pulp)

2 hours

Non-human milk 6 hours

Light meal (toast and clear liquids—NO FATTY FOODS)

6 hours

Explain the following:

Purpose of sedation/analgesia.

The variable responses of individual patients.

Need for continuous monitoring.

Post sedation behavior changes.

Provide culturally appropriate and age specific proceduraleducation.


•Discharge needs assessment and instructions.

•Assessment of knowledge of procedure and reinforcement of weak points.


Age/Weight

Allergies

Current Medications: Which could increase sedation.

Which could affect organ function. e.g., cardiac medications or MAOI.

Use of herbs and dietary supplements can increase risk of complications. Inhibit coagulation, alter blood pressure, cardiac effect, alter

electrolytes, cause sedation.

Level of consciousness/orientation: Baseline Aldrete Score


Emotional Status: Especially important to know about patient’s spiritual and

cultural habits and beliefs.

Baseline Vital Signs: Temperature

HR

RR/lung sounds/airway status

BP

O2 SAT

Determine if patient has latex sensitivity.

Interview to ascertain significant past medical history.

History of tobacco, alcohol or substance abuse.

Previous analgesia/sedation/anesthesia experience.

NPO status.

IV access status.

Pain assessment.

Provide comfort and reassurance.

Pre-sedation airway assessment should include:

1. History of snoring, sleep apnea.

2. History of difficulty with sedation analgesia.

3. Short neck, tracheal deviation.

4. Tracheostomy.

5. Loose teeth, crowns, partials, dentures.

Pre-Procedure Post-Procedure

1. Communication Ability

Normal for age: 2 2

Responds somewhat: 1 1

Does not communicate 0 0

verbally:


2. Activity

Voluntary movement, sits

unaided if appropriate: 2 2

Moves to command only: 1 1

Unable to move: 0 0


3. LOC

Fully awake: 2 2

Arousable: 1 1

Unresponsive: 0 0


4. Pain

Mild or No Pain (r/t procedure): 2 2

Moderate Pain (r/t procedure): 1 1

Severe Pain (r/t procedure): 0 0


5. Color

Pink: 2 2

Pale, Blotchy: 1 1

Cyanotic: 0 0


6. Hydration

Adequate: 2 2

Able to take fluids: 1 1

Unable to take fluids: 0 0

7. Circulation

Pre-Procedure

HR WNL for age: 2

HR outside age-related parameters

but normal for this patient: 1

N/A: 0

Post-Procedural

HR within 20% of pre-sedation level: 2

HR within 50% of pre-sedation level: 1

HR >50% variation from pre-sedation level: 0

8. Respiration

Pre-Procedure

Airway patency satisfactory and

stable, O2 Sat 96-100%: 2

Airway patency somewhat compromised

by systemic disease, O2 Sat at baseline: 1

Respirations severely compromised: 0

8. RespiratoryPost-ProceduralAirway patency satisfactory and stable,able to breathe and cough freely,

O2 Sat within 4% of pre-sedation: 2

Dyspnea, hypoventilation, O2 Satbelow 4% of pre-sedation: 1

Apneic: 0


Total Aldrete Score:

/16 /16

Refer to Aldrete score sheet on how to score.

Document per facility’s policies and protocols.


Determining patient’s candidacy for sedation: H & P, Aldrete and ASA classifications are used to

help determine sedation/anesthesia risks.

The anesthetic technique and agents are chosen by the anesthesia care provider with the physician and the patient .

Medically controlled state of depressed consciousness.

Minimally depressed level of consciousness that maintains patient’s protective airway reflexes.

Primary goals are to: Reduce anxiety and discomfort.

Facilitate the procedure.

Allows patient to maintain airway.

Allows patient to respond appropriately to verbal commands.

Provides level of emotional and physical acceptance of painful procedure.

Moderate sedation is extremely safe when administered by qualified providers. Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, physicians, dentists, and oral surgeons are qualified providers of conscious sedation. Specifically trained Registered Nurses may assist in the administration of moderate sedation.

Moderate sedation is administered in hospitals and outpatient facilities (e.g., ambulatory surgery centers, doctors offices, etc.) to facilitate procedures such as the following: Breast biopsy

Vasectomy

Minor foot surgery

Minor bone fracture repair

Plastic/reconstructive surgery

Dental prosthetic/reconstructive surgery

Endoscopy

Diagnostic studies and treatment of stomach, colon and bladder.

Pre-procedure sedation assessment.

Consent for the procedure.

Consent for sedation analgesia.

Pre-sedation scoring.

Procedure/site verification and Time Out.

Intra-procedure sedation monitoring.

Post-procedure sedation assessment.

Release from observation/dismissal/discharge criteria.

Patient education and discharge instructions.

1. Pre-op verification process:

Identification of all relevant documents and studies reviewed prior to start of procedure.

Verify that all documents and studies are consistent with each other, with patient’s expectations and with team’s understanding of intended patient, procedure, site, implants and any special equipment.

2. Marking the operative site

• The intended operative/invasive site is marked, but not immediately over the puncture or incision site.

3. “Time Out”

• Immediately prior to induction, conduct a final verification of the patient, procedure and site as applicable with the entire team.

ASA recommends Ramsay Scale be used for intra-procedure scoring.

The patient should be scored immediately prior to giving sedation, and at 5-minute intervals throughout the procedure.

Response Level

Awake, anxious, & agitated 1

Awake, cooperative, oriented

& tranquil

2

Awake, responds to commands

only

3

Asleep, brisk response to stimuli 4

Asleep, sluggish response 5

Asleep, no response 6

Because patients can slip into a deep sleep, proper

monitoring of moderate sedation is necessary.

Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout the procedure, and after.

The provider who monitors the patient receiving moderate sedation should have no other responsibilities and should remain with the patient at all times during the procedure.

Oxygen saturation less than 90%, or 3% decrease from baseline.

Change in vital signs of 20% or more.

Respiratory depression or distress.

Cardiac dysrhythmias.

Deep sedation or loss of consciousness.

Inadequate sedation and/or analgesic effect.

Interventions and patient response.

Failure to return to baseline status within one hour.

A brief period of amnesia may follow the procedure.

Occasional side effects may include:

Headache, hangover, nausea and vomiting, or unpleasant memories of the surgical experience.

Moderate sedation provides a safe and effective option for patients undergoing minor surgeries or diagnostic procedures. Number and type of procedures that can be

performed using moderate sedation have increased significantly as a result of new technology and state of the art drugs.

Moderate sedation allows patients to recover quickly and resume normal daily activities in a short period of time.

Prior to administration the RN must:

Understand common dosing.

Understand IV sedation medications, doses & evaluation of effect.

Understand contraindications, precautions, side effects and special considerations.

Be able to anticipate complications and intervene when necessary.

Rash

Redness

Respiratory Arrest

images.MD, 2005

Pulse oximeter

Cardiac monitor (if CV disease or arrhythmias detected or anticipated)

Blood pressure cuff

Crash cart in vicinity

Defibrillator

Suction

Emergency drugs and resuscitation equipment

Ambu bag & mask

Suction (device and Yaunker catheter)

O2 tubing & mask

Patent IV site

Reversal agents (***at bedside)

Oral/nasal airway and ET tube of appropriate size

Minimal personnel for IV sedation: Practitioner performing

procedure.

Registered Nurse or physician assistant monitoring the patient.

ACLS certified healthcare professional must be present nearby.


Benzodiazepines

Diazepam (Valium)

Midazolam (Versed)

Narcotics:

Meperidine (Demerol)

Morphine

Fentanyl (Sublimaze)

*** There are other medications not mentioned in this presentation—those addressed are the most commonly given for Sedation Analgesia.

Narcan (Naloxone)

Flumazenil (Romazicon)

Parameters and accompanying time frames:

Every five minutes: Heart rate

Oxygen saturation

Every fifteen minutes and PRN: Blood pressure

LOC (level of consciousness)

Respiratory rate


Respiratory Depression.

Cardiac dysfunction.

Neurologic effects.

Complications related to the procedure.

Non-invasive automatic blood pressure machine

Cardiac monitor

Pulse oximeter

images.MD, 2005

Establish Baseline

Alarms

Sensor Selection

Reassessment

Interveneimages.MD, 2005

There are many sites that provide accurate monitoring.

images.MD, 2005

General

Neurologic

Cardiac

Pulmonary

Other Assessments

Supplemental oxygen.

Airway management.

Adequate ventilation.

Adequate cardiac output and tissue perfusion.

Administration of reversal agents.

BLS and ACLS protocols.

Oropharyngeal (Oral) Airway

Nasopharyngeal (Nasal) Airway

Resuscitation Bag (Ambu bag, Bag-Valve Mask or BVM bag, Anesthesia bag)

Several Sizes

Advantages

Disadvantages

Insertion TechniquePicture used with permission from http://www.aic.cuhk.edu.hk/web8/index. htm

Kathy Mak June 2004

http://www.aic.cuhk.edu.hk/web8/index

Advantages

Disadvantages

Contraindications

Sizing

Insertion TechniquePicture used with permission from

http://www.aiccuhk.edu.hk/web8/index.htmSally Fong 2004

http://www.aiccuhk.edu.hk/web8/index.htm

Use:

•Picture tused with permission from http://www.aic.cuhk.edu.hk/web8/bag%20 mask%20ventilation•Kathy Mak June 2004

http://www.aic.cuhk.edu.hk/web8/bag

• What if the patient can’t be disturbed during a procedure? Does blood pressure still need to be checked every 15 minutes? If the procedure is non-invasive, then

blood pressure can be deferred; however this needs to be individualized to a case-by-case judgment.

Use automatic equipment if available.


Personnel allowed to monitor patient after procedure:

RN

LVN (under direct RN supervision)Microsoft Office Clipart

Observed for 30 minutes from the last administration of sedation analgesia medication.

Vital signs.

Aldrete scoring.

Assessment of pain level.

Reversal Agents (if applicable).

Parameters and accompanying timeframes:

Monitor every 15 minutes post-procedure until:

Patient is within 2 points of pre-procedure Aldrete score.

Patient sips clear fluids.

Patient returns to prior mobility/cognitive status.

Parameters and accompanying timeframes:

Monitor continuously if: Patient has history of cardiac or respiratory disease.

Excessive sedation used.

Vital sign instability.

O2 desaturation during procedure.

If reversal agent used: Recovery assessment must continue for 2 hours following

the final dose.

Returning to pre-sedation diet:

If NPO only for the procedure, patient needs to take fluids (ice chips).

If NPO pre-procedure, patient then remains NPO.


Aldrete Score is within 2 points of prior Aldrete.

Patient returns to pre-procedural level of mobility.

Patient demonstrates ability to take fluid.


All outpatients must receive post-sedation precautions and be discharged from the area.

Written instructions must include: Post procedural complications.

Activity limitations.

Bathing instructions.

Plan for follow-up care: Emergency numbers.

Next physician appointment date.

Remains awake with stimulus for 30 minutes.

Oriented.

Vital signs stable.

Maintain pre-procedure mobility.

No nausea/vomiting.

Satisfactory transportation.

Information about behavior, rest, activity.

Consuming liquids and food.

Side effects.

Warning signs of complications.

What to do in case of emergency.

Telephone number to contact medical service.

Recommended Practice I: “Registered nurses should understand the goals and objectives of moderate sedation/analgesia.”

Recommended Practice II: “The RN managing the nursing care of the patient receiving moderate sedation/analgesia should have no other responsibilities that would require leaving the patient unattended or compromising continuous patient monitoring during the procedure.”

Recommended Practice III: “The RN should be clinically competent, possessing the skills necessary to manage the nursing care of the patient receiving moderate sedation/analgesia.”

Recommended Practice IV: “Each patient receiving moderate sedation/analgesia should be assessed physiologically and psychologically before the procedure. The assessment should be documented in the patient’s record.”

Recommended Practice V: “The RN managing the nursing care of the patient receiving moderate sedation/analgesia should be proficient in equipment selection and use and should ensure that the necessary equipment is available and working properly.”

Recommended Practice VI: “Each patient who receives moderate sedation/analgesia should be monitored for adverse reactions to medications and for physiological and psychological changes.”

Recommended Practice VII: “Documentation of patient’s care moderate sedation/analgesia should be consistent with AORN’s Recommended Practices for documentation of perioperative nursing care.”

Recommended Practice VIII: “Patients receiving moderate sedation/analgesia should be monitored postoperatively, receive verbal and written discharge instructions, and meet specified criteria before discharge.”

Sedation/Analgesia�Moderate Sedation�(Adult)Goals of SedationGoals of Sedation (continued)Non-invasive Reasons for Sedation AnalgesiaSedation ContinuumMinimal Sedation (Anxiolysis)Moderate Sedation GoalsModerate Sedation GoalsDeep Sedation AnalgesiaGeneral AnesthesiaModerate Sedation CandidatesPre-Procedural CriteriaInformed ConsentHealth Evaluation (H & P)Health Evaluation (H & P)ASA ClassificationsASA GuidelinesNPO Status�Fasting Guidelines� (for the healthy patient undergoing elective procedures)�Patient/Family EducationPatient/Family EducationPre-Procedural Physical AssessmentPre-Procedural Physical AssessmentPre-Procedural Physical AssessmentPre-Procedural Physical AssessmentAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete Scoring SheetAldrete ScoringChoice Of Sedation Moderate SedationModerate SedationWho Can Administer �Moderate Sedation?Use Of Moderate SedationMonitoring and Assessment�Key ElementsMonitoring and Assessment�Key ElementsProcedure/Site Verification and Time OutProcedure/Site Verification and Time OutProcedure/Site Verification and Time OutRamsay Sedation ScaleRamsay Sedation ScaleMonitoring During Moderate SedationReportable Conditions�The Side Effects of Moderate Sedation�BenefitsMedication AdministrationAllergic Reaction: 3 R’sNursing Management:�Key PointsEquipment/Supplies Needed for SedationSedation PersonnelMedicationsMedicationsMedications—Reversal AgentsIntraprocedural MonitoringComplicationsMonitoringPulse Oximetry MonitoringPulse Oximetry Sensor SelectionAssessmentEmergency ManagementAirway ManagementOropharyngeal AirwayNasopharyngeal AirwayResuscitation BagNursing Management: �Key PointsPost Procedural PersonnelPost Procedure ObservationPost-Procedural MonitoringPost-Procedural MonitoringNursing Management: �Key PointsMonitoring Discharge CriteriaOutpatient ConsiderationsDischarge from Facility CriteriaDischarge InstructionsAORN Recommended Practices for Managing the Patient Receiving Moderate Sedation/AnalgesiaAORN Recommended Practices for Managing the Patient Receiving Moderate Sedation/AnalgesiaAORN Recommended Practices for Managing the Patient Receiving Moderate Sedation/AnalgesiaAORN Recommended Practices for Managing the Patient Receiving Moderate Sedation/AnalgesiaAORN Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia

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Mood alteration, in order to allay the€¦ · 14.06.2020 · Mood alteration, in order to allay the patient’s fear and anxiety. Maintenance of consciousness and cooperation for