FUNCTION: Care of Patients

 

TITLE: Sedation/Analgesia

 

_________________________________________________________________

PURPOSE: 

 

To provide guidelines for the safe and effective care, monitoring, and

discharge of patients receiving sedation/analgesia while undergoing diagnostic

or therapeutic procedures. (NOTE:  This policy does not apply to 

administration of medication for use in the management of pain or 

anxiety or sedation of patients for ventilator management or control of 

seizure activity.)

 

 

POLICY:

 

Sedation/analgesia for the purpose of an elective procedure shall be

administered and patients monitored according to the guidelines specified

below.  These guidelines shall be used for patients of all ages.

 

 

Definition of sedation/analgesia:  A condition produced by the administration

of pharmacological agents where the patient exhibits a decreased level of

consciousness, but retains the ability to independently and continuously

maintain a patent airway and respond appropriately to verbal commands or

physical stimulation. 

 

 

 

Pre-procedure assessment

 

The pre-sedation assessment will be accomplished prior to the start of the

procedure and will include a patient interview to ascertain significant past

medical history, drug history, allergies previous sedation analgesia

experience, NPO status, IV access status, a physical status assessment, airway

assessment, vital signs, and Aldrete score.

 

Medical History and physical examination will be completed in accordance with

Medical staff Rules and regulations.

 

The patient's medical record will include a properly signed consent and

pre-procedure lab results as indicated by physician order.  Any other

pertinent diagnostic results will also be included in the medical record.

 

The Independent Licensed Practitioner will determine that the patient is a

candidate for sedation/analgesia.

 

The patient will be re-evaluated by the Independent Licensed Practitioner

immediately prior to the procedure.

 

 

LOCATIONS FOR ADMINISTRATION

 

Sedation analgesia may be administered in the following areas;

 

- Operation Room

- Critical Care Units

- Radiology department

- Emergency Department (NOT TO INCLUDE AFTER HOURS CLINIC)

- Cardiac Cath/Special procedures Lab

- GI Lab

- Medical/Surgical units

- PACU

- Holding Area

 

 

Equipment Readily available when sedation analgesia is administered

 

- O2 delivery system (wall or portable unit)

- intubation supplies and equipment

- Suction equipment

- Pulse oximeter

- EKG/Defibrillator Unit

- Emergency drugs (to include, but not limited to cardiac and reversal agents)

- Non-invasive BP monitoring unit

- Emergency call system

- Emergency power

 

 

Management and monitoring

 

Monitoring will include assessment of circulation, ventilation, level of

consciousness, and continuous O2 saturation.  Compromised cardiac patients

will have continuous cardiac monitoring.  This determination will be made by

the physician.

 

Stable IV access must be present.

 

The physician must be immediately available throughout the procedure and

during the administration of sedative agents.

 

A qualified Registered Nurse with documented competency in Basic Cardiac Life

Support, airway management, pulse oximetry, and medication administration.

A score of 85% on the sedation analgesia post-test is required for documented

competency.  Documented competency will be kept on the employee's unit. 

 

An ACLS or PALS qualified nurse (appropriate to the patient's age) will

be assigned when continuous ECG monitoring is indicated.

 

 

 

 

 

 

Aldrete Scoring system with sedation analgesia

 

Hospital personnel will use the Aldrete scoring system in all areas of the

hospital where sedation is administered.

 

Pre-sedation scoring:  The patient will be scored utilizing the Aldrete scale

before sedation is given to establish a pre-sedation baseline score. Optimum

score is 10, but initial score will vary depending on patient condition.

Each patient must be treated individually and nursing judgment that considers

the patients present condition must be utilized since this scoring system is

not infallible.

 

Aldrete Scoring System:

                                                               Score

A.   Activity

 

     1. Ability to move all four extremities                      2

     2. Ability to move two extremities                           1

     3. Unable to move any extremity                             0

 

B.   Respiration

 

     1. Ability to deep breathe and cough                        2

     2. Respiratory effort limited and dyspnea present       1

     3. No spontaneous respiratory effort evident              0

 

C.   Circulation

 

     1. Systolic arterial pressure +/- 20mm Hg of            2

        pre-sedation level

     2. Systolic arterial pressure +/- 20 to 50mm Hg        1

        of pre-sedation level

     3. Systolic arterial pressure +/- 50 or higher             0

        of pre-sedation level

 

D.   Level of consciousness

 

     1. Full alertness with ability to answer questions         2

     2. Patient can be aroused by verbal stimuli                 1

     3. Verbal stimuli fails to elicit responses                    0   

 

E.   Color

 

     1. Obviously normal or pink skin color                      2

     2. Alerted skin color, but not cyanotic.                      1    

     3. Cyanotic nailbed, lips, or skin                              0      

 

 

Intra-procedure monitoring:

 

A.   The patient will be continuously monitored for potential adverse

     medication reactions during the procedure.  Signs or symptoms reported to

     the physician include, but not limited to:

     1. Abnormal changes in blood pressure from patient baseline. 

     2. Oxygen saturation drop to 90% or 3% decrease form baseline.

     3. Respiratory depression or distress.

     4. Dysrhythmias.

     5. Interventions and patient response.

B.   The responsible physician will be present and available during the

     administration of sedation/analgesia.

C.   Emergency equipment will be immediately available and will include, but 

     not limited to:

     1. Crash Cart with defibrillator, airways, intubation equipment, and

        emergency medications.

     2. Suction apparatus.

     3. Positive pressure oxygen delivery system.

D.   Venous access will be available and maintained until discharge criteria

     is met.  

E.   Vital signs will be documented a minimum of every 10 minutes or more

     frequently if indicated, and will include, but not limited to:

     1. Heart rate

     2. Blood pressure

     3. Respiratory rate

     4. Oxygen saturation

     5. Level of Consciousness

     6. Cardiac monitoring.

F.   Supplemental oxygen will be available at all times.

G.   Appropriate reversal agents will be available.

H.   Documentation will include medication route, time and incremental doses.

I.   Prior to administration of any medication, the patient will be reassessed

     to determine any changes in condition since initial assessment.

 

Post-procedure assessment and scoring:

 

LVN's with documented competency, under the  direct supervision

of an RN, may monitor the patient post-procedure.

 

A.   Inpatient

     An inpatient will be observed for a minimum of 30 minutes to establish

     that the patient has met criteria for discontinuing the scoring system.

     the Aldrete scoring system will be utilized to measure the patient's

     status at 15 minute intervals.

 

B.   Outpatient

     The out-patient is observed for a minimum of one hour prior to discharge.

     

 

 

Release form observation Criteria; Dismissal/Discharge Criteria

 

A.   Optimum score is 10 by the end of the discharge period. The patient may

     be discharge with a minimum score of 8.  Patients who return to their

     pre-sedation baseline of 8-10 at the end of the required monitoring time

     can be discharged by the RN.

 

B.   Patients who do not meet baseline criteria may need a specialized care

     unit such as PACU or Intensive care unit.

                                           

     Variables which may influence the patient's emergence from

     sedation include:

         1. Type of sedation used

         2. Type of procedure performed

         3. Duration of procedure and sedation 

     

C.   Chronically debilitated, senile, or paralyzed patients may never receive

     an optimum score.  Each patient who does not meet a baseline pre-sedation

     score may be discharged only with an order from the responsible

     physician.

 

 

Home discharge criteria for outpatients

 

Patients must be discharged with a responsible adult.  A physician's order for

discharge is required when no responsible adult is available.  Suitable

arrangements will be made for the patient's safety and care before discharge. 

In addition to meeting the Aldrete criteria, the patient will:

 

     1. Have a minimum of one hour observation prior to discharge.

     2. Be hemodynamically stable

     3. Be clear of secretions

     4. Be oriented to time, person and place and be able to follow

        instructions appropriate to age.

     5. Tolerate post procedure liquid or light food.

     6. Be able to ambulate (unless pre-procedure condition prohibits) with

        no dizziness.  All patients need to return to pre-sedation

        level of gross motor function.   

 

 

______________________________________________________________________________

REFERENCES:

 

Association of Operating Room - 

JCAHO standards - 

 

 

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Administrative Signature                          Approved Date