- Email: [email protected]
Conscious sedation: Documenting the procedure
Conscious sedation: Documenting the procedure Authors: Ruth Ringland, RN, a n d Sheila Early, RN, BScN, Surrey, British Columbia
C
o d y T., 4 y e a r s old, h a s fallen out t h e door of a p a r k e d car a n d s o m e h o w m a n a g e d to l a c e r a t e his ear a n d cheek. H e is crying, t r y i n g to g e t away, a n d s a y s h e h a t e s h o s p i t a l s a n d n e e d l e s . T h e ED p h y s i c i a n h a s a s s e s s e d h i m a n d o r d e r e d 50 m g of ket a m i n e i n t r a m u s c u l a r l y for c o n s c i o u s s e d a t i o n . Daniel P., 34 y e a r s old, collided w i t h a n o t h e r p l a y e r d u r i n g a friendly football g a m e . His only injury is a d i s l o c a t e d right shoulder. T h e ED p h y s i c i a n h a s o r d e r e d 2.5 m g of m i d a z o l a m IV a n d 100 g g of fent a n y l IV for c o n s c i o u s s e d a t i o n . W h a t d o e s c o n s c i o u s s e d a t i o n involve, a n d w h a t c a r e do you, t h e nurse, n e e d to p r o v i d e a n d d o c u m e n t to e n s u r e p a t i e n t s a f e t y ? In 1994, t h e E m e r g e n c y D e p a r t m e n t at Surrey M e m o r i a l Hospital* b e g a n u s i n g c o n s c i o u s s e d a t i o n - - a p r o c e d u r e t h a t r a i s e d a n u m b e r of c o n c e r n s for n u r s i n g staff. We h a d no formal policies, a n d s o m e of t h e d r u g s h a d p r e v i o u s l y b e e n u s e d only in t h e ope r a t i n g r o o m for full a n e s t h e s i a , w h i c h is n o t a p p r o priate within the emergency department. As emergency nurses, we were concerned about t h e s a f e t y of our p a t i e n t s , particularly t h e p e d i a t r i c p o p u l a t i o n . This c o n c e r n w a s t h e c a t a l y s t for t h e d e v e l o p m e n t of a f l o w s h e e t 3 W h e n t h e p r o c e d u r e s first b e g a n , e a c h n u r s e h a d definite i d e a s of w h a t h e or s h e t h o u g h t w e r e n e c e s s a r y i t e m s to h a v e at t h e b e d side, a n d w h a t s h o u l d b e d o c u m e n t e d : s p e c i f i c a l l y w e w a n t e d to p r o t e c t t h e p a t i e n t ' s A B C s a n d c h a r t e v e r y detail. We h a d o p e n s u g g e s t i o n lists for i d e a s of w h a t s h o u l d b e i n c l u d e d on t h e flowsheet, p e r u s e d a n d s h a r e d t h e information t h a t w e found, a n d t h e n d r a f t e d a c h e c k l i s t similar to a p r e a n e s t h e t i c or preo p e r a t i v e list. This w a s t e s t e d , t h e n r e v i s e d t w i c e to t h e n b e c o m e t h e f l o w s h e e t w e n o w use, w h i c h prov i d e s g u i d e l i n e s for p a t i e n t t r e a t m e n t a n d t h e d o c u -
m e n t a t i o n of clinical d a t a before, during, a n d after t h e p r o c e d u r e (Figure 1). C o n s c i o u s s e d a t i o n is a p r o c e d u r e in w h i c h analg e s i a a n d a s e d a t i v e s t a t e are a c c o m p l i s h e d - - w i t h out loss of c o n s c i o u s n e s s for t h e p a t i e n t - - f o r t h e p u r p o s e of p e r f o r m i n g difficult or painful p r o c e d u r e s s u c h as c o m p l i c a t e d l a c e r a t i o n repairs, c l o s e d r e d u c tion of s i m p l e fractures, d e b r i d e m e n t of w o u n d s , red u c t i o n of d i s l o c a t e d joints, e l e c t i v e cardioversion, a d j u s t m e n t of e x t e r n a l fixation d e v i c e s , c l e a n s i n g of tar burns, a n d foreign b o d y removal. It is u s e d safely in t h e e m e r g e n c y d e p a r t m e n t for c h i l d r e n a n d adults, w i t h c o n s t a n t m o n i t o r i n g of t h e p a t i e n t before, during, a n d after t h e p r o c e d u r e .
*Surrey Memorial Hospital is a 350-bed facility in southwestern British Columbia serving a community of 500,000. Our 32-bed emergency department treats 78,000 people per year (approximately 215 per day); 25% are pediatric cases.
T h e m e d i c a t i o n is n o t g i v e n u n t i l all r e q u i r e d s t a f f are at t h e b e d s i d e . In our department, required staff include a respiratory t h e r a p i s t to m o n i t o r ventilation respiratory s t a t u s , a n ED p h y s i c i a n , who orders the medication a n d w i l l b e t h e o n e to i n t u b a t e in c a s e of difficulties, the doctor p e r f o r m i n g t h e p r o c e d u r e (if it is n o t t h e ED p h y s i c i a n ) , t h e R N r e s p o n s i b l e for monitoring and documenting patient status a n d , if h e or s h e w i s h e s , a p a r e n t c a n r e m a i n at t h e bedside.
Ruth Ringland and Sheila Early are ED Nurses at Surrey Memorial Hospital, British Columbia, Canada. For reprints write Ruth Ringland, RN, Surrey Memorial Hospital, Emergency Room, 13750 96th Ave., Surrey, BC, Canada V3V 122. J Emerg Nurs 1997;23:611-7. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97/$5.00 + 0 18/1/86666
E x a m p l e s of c o m m o n l y u s e d m e d i c a t i o n s are ket a m i n e , d i a z e p a m , m i d a z o l a m , a n d fentanyl. T h e s e m e d i c a t i o n s p r o d u c e t h e d e s i r e d effects of s e d a t i o n a n d a n a l g e s i a , b u t also m a y c a u s e CNS d e p r e s s i o n , p o t e n t i a l r e s p i r a t o r y d e p r e s s i o n , mild c a r d i a c s t i m u -
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8~[[~
Conscious SedationRecord
8urmy taemorlal HOala~atl Guidelines: Initials 1. 2. 3. 4. 5. 6, 7.
8,
Patient is NPO. Patient's w e i g h t is obtained. Baseline T P R and BP done. Baseline O x y g e n Saturation by Pulse Oxi met e r done. Oral airway, b a g g i n g unit, oxygen, suction, pulse oximeter at bedside. Crash cart with cardiac m o n i t o r is readily available. Vital s i gns post procedure: q 5 minutes for 15 minutes q 15 minutes for 45 m i n u t e s or until patient meets discharge criteria. Discharge criteria arc m e t prior to discharge.
Procedure: Time Begin:
End:
PRE-SEDATION ASSESSMENT Airway
Breathing
Colour
Skin
Vital Signs
[] O w n [] M a s k []
[] D [] El
[] N o r m a l [] Pale []
[] [] [] []
BP _ HR
_
RR _
_
Nasal Normal Shallow Rapid
Moist Warm Dry Cool
[] Laboured • Weight
,
T=
-
[] N/A
l.V. Access
[] Cannula
Site
Time mltiated
Size
Time DisContinued -
[] N/A
[] Heparin Lock [] Peripheral I.V.
[] Mask []
02 SAT
kilograms
VITAL SIGNS:
Oxygen Rate
Solution Time initiated _ Time ,th ~ t l , .,~l
'
DURING AND POST PROCEDURE MEDICATION
TIME
TIME
Medication
Dose
Route Initials
BP HR
RR OzSAT DISCHARGE CRITERIA
DISCHARGE CRITERIA KEY 1.
Activity Breathing Circulation
2.
Cousciousuess TOTAL SCORES COMMENTS:
(Document pre-procedure information given to patient/parem)
3.
4.
Activity 0 = Unable to lift head or move extremities voluntarily or on command 1 = Lifts head spontaneously and moves extremities voluntarily or on command 2 = Able to ambulate without a~istatme Breathing 0 = Apneic 1 = Dyspnea or shallow, irregular breathing 2 = Able to breath deeply and cough on command Circulation 0 = Systolic B.P. below 80 mm Hg 1 = Systolic B.P. above 1O0 m m Hg 2 = Systolic B.P. within normal limits for patient Consciousness 0 = Not responding, or responding only to painful stimuli 1 = Responds to verbal stimuli but falls asleep readily 2 = Awake, alert and oriented to time, person, place (child oriented to name, parent).
TOTAL SCORE PRIOR TO DISCHARGE MUST BE SEVEN Verbal and written discharge instructions given to: [] patient [] parent/guardian [] other SMH0725 (05/96)
Signature:
R.N.
Initials:
Signature:
R.N.
I n i f i a l s : ~
Signature: WHITECOPY: CHART
M.D. CANARYCOPY: MEDICALDIRECTOREMERGENCY
Figure 1 Conscious-sedation record. (Courtesy Surrey Memorial Hospital, British Columbia.)
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Drug
Ketamine
Midazolam
Fentanyl
Diazepam
Class
Parenteral a n e s t h e t i c ; produces dissociative a n e s t h e s i a ++
Benzodiazepine sedative/ hypnotic; s h o r t - a c t i n g
Narcotic analgesic; produces sedation, adjunct to a n e s t h e s i a
Benzodiazepine sedative/ hypnotic; l o n g - a c t i n g
Use
Children < 10 yr
U s u a l l y adults ( c o m b i n e d w i t h a narcotic)
U s u a l l y adults ( c o m b i n e d with a benzodiazepine)
U s u a l l y adults ( c o m b i n e d w i t h a narcotic)
Dose
IM 2-4 mg/kg; IV 0.2-0.75 mg/kg over 1~3 min
Adults: u s u a l d o s e is
Adults: 50-150 gg; Peds: up to 3 pg/kg g i v e n over 3-5 min
Adults: 2-20 mg IV Peds: 0.25 mg/kg IV
CNS d e p r e s s i o n ,
0.5-2.5 mg IV slowly over 2-3 min; m a y r e p e a t 3 times; Peds: IV 0.01-0.05 mg/kg if over 2 yr; oral 0.5 mg/kg
Side effects
Tachycardia, delirium, CNS d e p r e s s i o n , h y p o t e n s i o n , hallucinations, vivid tachycardia, tonic/clonic dreams, nystagmus, movements, laryngo/ m i s p e r c e p t i o n of v i s u a l / b r o n c h o s p a s m , lack of auditory stimuli, recall after injection cataleptic m o v e m e n t s , lack of recall after u s e , increased secretions
As with all narcotics,
Antidote
None
Naloxone
Flumazenil
respiratory d e p r e s s i o n , h y p o t e n s i o n , bradycardia, laryngospasm, muscle rigidity w i t h rapid administration
h y p o t e n s i o n , ataxia, syncope, laryngospasm, respiratory depression/apnea
Flumazenil
* *All m e d i c a t i o n s m u s t b e g i v e n u n d e r t h e direct s u p e r v i s i o n of a p h y s i c i a n w i t h t h e ability to intubate.
++Dissociative anesthesia: "Functional dissociation between the thalmic structures and the limbic system. ''4 "Sensory input reaches the cortex, but depression of the brain's association pathway results in a diminished or absent response to stimuli and lack of recall to stimuli.''5 Figure 2
Guidelines for use of medications for sedation and analgesia.
lation, a n d h y p o t e n s i o n . T h e d o s a g e is b a s e d on pat i e n t w e i g h t (Figure 2). T h e u s e of t h e s e m e d i c a t i o n s r a i s e s m a n y q u e s t i o n s t h a t n e e d to b e a d d r e s s e d . W h a t is t h e policy on g i v i n g t h e d r u g a n d m o n i t o r i n g t h e p a t i e n t after it h a s b e e n a d m i n i s t e r e d ? H o w are y o u as t h e n u r s e g o i n g to e n s u r e t h a t i n f o r m e d cons e n t b y t h e p a t i e n t or p a r e n t h a s b e e n elicited, a n d t h a t t h e p a t i e n t or p a r e n t is a w a r e of t h e follow-up c a r e i n v o l v e d ? W h a t t e a c h i n g is this p a t i e n t or p a r e n t g o i n g to n e e d before a n d after t h e p r o c e d u r e ? T h e f l o w s h e e t w e c r e a t e d natural]y ]ends itself to h e l p i n g c r e a t e t h e policies t h a t w e r e d e v e l o p e d for all a s p e c t s of t h e c o n s c i o u s s e d a t i o n p r o c e d u r e . For example, w h e n k e t a m i n e 2 is t h e m e d i c a t i o n of c h o i ce, a n a d d i t i o n a l a s s e s s m e n t is d o n e w i t h u s e of t h e K e t a m i n e E x c l u s i o n C h e c k l i s t (Figure 3) to e n s u r e its appropriateness for t h e p e d i a t r i c p a t i e n t ) Before a d m i n i s t e r i n g t h e m e d i c a t i o n , all r e s u s c i tation e q u i p m e n t - - " c r a s h cart" (i.e., a d v a n c e d airway m a n a g e m e n t , oxygen, suction, c a r d i a c m o n i t o r / d e f i b rillator) m u s t b e at t h e b e d s i d e , a n d t h e p a t i e n t - or p a r e n t - t e a c h i n g c o m p l e t e d by t h e n u r s e a n d doctor. A t this time, w e also g i v e d i s c h a r g e information p a m phlets to t h e p a r e n t (Figure 4) or p e r s o n w h o will b e t e n d i n g t h e adult p a t i e n t after d i s c h a r g e (Figure 5).
Suggested patient- or parent-teaching P a r e n t s and, as appropriate, p a t i e n t s are told t h a t t h e patient: • M a y s p e a k or cry out, m a y h a v e r a n d o m limb m o v e ment • M a y still e x p e r i e n c e s o m e discomfort, b u t will not recall t h e p r o c e d u r e • M a y r e s p o n d to w h a t is said a r o u n d h i m or her, b u t not necessarily appropriately • M a y h a v e d r e a m s w h i l e s e d a t e d , s o m e c a n b e v ivi d • After t h e p r o c e d u r e , will b e a s k e d s i m p l e q u e s t i o n s a n d will b e a s k e d to d e e p b r e a t h e a n d c o u g h at intervals • Will r e m a i n in t h e d e p a r t m e n t until d i s c h a r g e criteria h a v e b e e n met. B a s e l i n e vital signs, o x y g e n saturation, ABCs, NPO status, a n d an a c c u r a t e w e i g h t are d o c u m e n t e d , a n d t h e p a t i e n t is a t t a c h e d to a p u l se oximeter, a u t o m a t i c BP m a c h i n e , a n d c a r d i a c monitor. A b a s e l i n e r h y t h m strip is o b t a i n e d a n d p l a c e d in t h e E m e r g e n c y A d m i s s i o n A s s e s s m e n t form t h a t w e u s e in our d e p a r t m e n t for all p at i en t s , or t a p e d to t h e b a c k of t h e flowsheet. T h e m e d i c a t i o n is n o t g i v e n until all r e q u i r e d staff are at t h e b e d s i d e . In our d e p a r t m e n t , r e q u i r e d staff i n c l u d e a r esp i r at o r y t h e r a p i s t to m o n i t o r v e n t i -
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B
8MH V
1
Surrey Memorial Hospital EMERGENCY DEPARTMENT
EXCLUSION CRITERIA FOR THE USE OF ~ T A M I N E
CRITERIA
YES
NO
• age less than 6 months or greater than 12 years • previous adverse reaction or hypersensitivity to Ketamine
• history of psychiatric, opthamologic, CNS, CVS, hepatologic, or other chronic medical disorder(s) • history of hyperactivity • history of vivid dream or night terror • current upper or lower respiratory infection • acute injuries (such as globe, head injury) for which Ketamine is contraindicated
Physician's Signature
Note: This is not an all inclusive list of contraindications of Ketamine use. Figure 3 Ketamine exclusion checklist. (Courtesy Surrey Memorial Hospital, British Columbia.
lation r es p i r at o ry status, an ED p h y s i c i a n , w h o orders t h e m e d i c a t i o n a n d will b e t h e o n e to i n t u b a t e in c a s e of difficulties, t h e d o c t o r p e r f o r m i n g t h e p r o c e d u r e (if it is n o t t h e ED physician), t h e r e g i s t e r e d n u r s e res p o n s i b l e for m o n i t o r i n g a n d d o c u m e n t i n g p a t i e n t
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s t a t u s and, if h e or s h e w i s h e s , a p a r e n t c a n r e m a i n at the bedside. The medication can now be given and t h e p r o c e d u r e c o m m e n c e d . O n e - t o - o n e n u r s i n g care i n v o l v e s o n g o i n g a s s e s s m e n t a n d d o c u m e n t a t i o n of clinical d a t a (vital signs, o x y g e n saturation, p a t i e n t
Ringland and Early/JOURNALOF EMERGENCYNURSING
DISCHARGE INSTRUCTIONS FOR CHILDREN RECEIVING CONSCIOUS SEDATION IN THE EMERGENCY DEPARTMENT Your child has r e c e i v e d m e d i c a t i o n for s e d a t i o n or p a i n relief while in the E m e r g e n c y D e p a r t m e n t . It is i m p o r t a n t t h a t you u n d e r s t a n d w h a t h a s b e e n d o n e for your child a n d w h a t to e x p e c t over the n e x t 24 hours. Please ask the N u r s e or P h y s i c i a n a n y q u e s t i o n s you m a y have before you take your child home. ***Your child's b a l a n c e m a y b e affected over t h e n e x t 24 hours. Your child should b e s u p e r v i s e d for all activities d u r i n g this time.
Example: Your child should n o t play o u t s i d e alone, or b e left alone in a b a t h t u b . ***Wake your child if h e / s h e goes to sleep every two hours at least twice. (If your child goes to sleep at 8:00 PM, yOU w o u l d w a k e h i m / h e r at 10:00 PM a n d 12:00 AM.) C h e c k to see t h a t t h e y r e c o g n i z e y o u or c a n tell you w h e r e t h e y are. If your child is too y o u n g to talk, m a k e sure t h e y are able to r e s p o n d to you w h e n you w a k e t h e m . ***Don't give your child solid foods immediately, your child m a y vomit. Start on clear liquids first, e.g., clear juice, g i n g e r ale, a n d t h e n go to other liquids a n d solids as your child tolerates them. If n a u s e a a n d v o m i t i n g occur, go b a c k to clear fluids. ***Normally, you should n o t give your child a n y m e d i c a t i o n s after t h e y leave t h e E m e r g e n c y Department. If your child is on a n y m e d i c a t i o n routinely, please ask t h e E m e r g e n c y P h y s i c i a n w h e n you should r e s t a r t the m e d i c a t i o n . ***Be a w a r e of a n y c h a n g e s i n your child's b e h a v i o u r or u n u s u a l activities.
Example: Your child is n o t able to tolerate solids. MEDICATIONS GIVEN: PRE CAUTIONS: DATE AND TIME: SIGNATURE:
IF YOU HAVE A N Y PROBLEMS OR QUESTIONS REGARDING YOUR CHILD, PLEASE CALL THE E M E R G E N C Y DEPARTMENT A T 585-5666 local 2662.
Figure 4 Discharge instruction pamphlet for parent/person attending child who has received conscious sedation. (Courtesy Surrey Memorial Hospital, British Columbia.)
response) a n d d i s c h a r g e criteria. In the e v e n t of a n y difficulties, d o c u m e n t a t i o n w o u l d r e t u r n to t h e E m e r g e n c y A d m i s s i o n A s s e s s m e n t (to date, t h a t has n o t b e e n necessary). The d i s c h a r g e criteria reflect t h e resolution of t h e effects of t h e m e d i c a t i o n . W h e n t h e d i s c h a r g e criteria h a v e b e e n met, d i s c h a r g e t e a c h i n g p a m p h l e t s are rev i e w e d a g a i n to reinforce the verbal t e a c h i n g a n d to provide t h e p a t i e n t or p a r e n t w i t h i n f o r m a t i o n for ade q u a t e care or s u p e r v i s i o n at home. If t h e y h a v e a n y c o n c e r n s , t h e y are a d v i s e d to r e t u r n to the emer-
g e n c y d e p a r t m e n t ; w e also provide our d e p a r t m e n t p h o n e n u m b e r a n d e n c o u r a g e t h e p a t i e n t or p a r e n t to call if they h a v e a n y q u e s t i o n s . In 1994, d u r i n g t h e p e r i o d from April to September, our d e p a r t m e n t performed 60 c o n s c i o u s s e d a t i o n procedures. T h r o u g h a follow-up p h o n e survey, 6 w e d e t e r m i n e d t h a t there h a d b e e n no complic a t i o n s or a d v e r s e r e a c t i o n s after t h e c o n s c i o u s s e d a t i o n procedure. Also, of t h e children w h o h a d rec e i v e d c o n s c i o u s sedation, 100% of their p a r e n t s w o u l d choose the p r o c e d u r e again.
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DISCHARGE INSTRUCTIONS FOR PATIENTS RECEIVING CONSCIOUS SEDATION IN THE EMERGENCY DEPARTMENT You have r e c e i v e d m e d i c a t i o n for s e d a t i o n or p a i n relief. It is i m p o r t a n t t h a t you are a w a r e of the effects of t h e m e d i c a t i o n . ***Your b a l a n c e a n d c o o r d i n a t i o n will b e affected. Do n o t drive or o p e r a t e m a c h i n e r y u n t i l effects of the m e d i c a t i o n are gone. ***Someone should b e available to c h e c k you every 2 h o u r s for the n e x t 6 hours. If you go to sleep, s o m e o n e should w a k e n y o u in 2 hours a n d in 4 hours. ***You m a y feel n a u s e a t e d . Start t a k i n g clear fluids first, t h e n go to solids as you are able. ***If you are t a k i n g a n y m e d i c a t i o n s , ask t h e E m e r g e n c y P h y s i c i a n w h e n you should r e s t a r t the medication. MEDICATIONS GIVEN: PRE CAUTIONS: TIME AND DATE: SIGNATURE:
IF YOU HAVE A N Y PROBLEMS OR QUESTIONS, PLEASE CALL THE E M E R G E N C Y D E P A R T M E N T A T 585-5666 local 2662.
Figure 5 Discharge instruction pamphlet for patient who has received conscious sedation. (Courtesy Surrey Memorial Hospital, British Columbia.)
We n o w perform a n a v e r a g e of 4 to 6 c o n s c i o u s s e d a t i o n p r o c e d u r e s per week, a n d w e h a v e u s e d this flowsheet for 3 years. It is a t h r e e - p a r t form. T h e original r e m a i n s w i t h the chart, t h e s e c o n d is s e n t to the family doctor for c o n t i n u i t y of care a n d follow-up, a n d the third is s e n t to t h e e m e r g e n c y m e d i c a l director a n d n u r s e c l i n i c i a n a n d u s e d for a u d i t purposes: • Statistics of w h i c h m e d i c a t i o n s are m o s t u s e d (mid a z o l a m a n d fentanyl). • W h i c h p r o c e d u r e s are m o s t f r ~ t l e n t (orthopedics a n d l a c e r a t i o n repairs). This h a s be~ter utilized our hospital's resources, as s h o w n b y a d e c r e a s e in adm i s s i o n a n d o p e r a t i n g room costs. • Are g u i d e l i n e s a n d policies b e i n g followed? The flowsheet should b e fully completed. C o n s c i o u s - s e d a t i o n policies a n d d o c u m e n t a t i o n are a part of t h e o r i e n t a t i o n for n u r s e s n e w to our dep a r t m e n t . Also, on request, our e m e r g e n c y departm e n t m e d i c a l director a n d n u r s e clinician provide e d u c a t i o n a l s e s s i o n s to other hospitals in our region. C h a n g e s to t h e flowsheet, a n d policies t h a t w e are looking at this year, are to u s e a c o n s e n t form for "Conscious Sedation" rather t h a n t h e c o n s e n t for e m e r g e n c y t r e a t m e n t w e currently use. O n t h e flow-
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s h e e t w e w o u l d like to h a v e s p a c e for t h e r h y t h m strips, rather t h a n u s i n g the E m e r g e n c y A d m i s s i o n A s s e s s m e n t form or t a p i n g t h e m on t h e back. In retrospect, the flowsheet h a s h e l p e d alleviate a large part of our a n x i e t y a b o u t c o n s c i o u s - s e d a t i o n proced u r e s a n d has e l i m i n a t e d chaotic s c r a m b l i n g to get set u p for t h e procedure. Virtually all of our staff n u r s e s find it a n i n v a l u a b l e tool to b e r e m i n d e d of t h e clinical a s p e c t s of c o n s c i o u s s e d a t i o n a n d to docum e n t thoroughly.
We now perform an average of 4 to 6 conscious sedation procedures per week, and we have used this flowsheet for 3 y e a r s . Cody received the ketamine. His ear a n d cheek were sutured. Within 2 hours, he w a s ready for discharge, r e m e m b e r i n g n o t h i n g of t h e p r o c e d u r e .
Ringland and Early/JOURNALOF EMERGENCYNURSING
(Cody's m o t h e r verbalized s o m e anxious feelings while h e w a s s e d a t e d , b u t b e l i e v e d t h a t she preferred this m e t h o d of treatment, a n d said it a p p e a r e d as if "The lights w e r e on, b u t no o n e w a s h o m e in his head.")
Conscious-sedation policies and documentation are a p a r t of t h e o r i e n t a t i o n for nurses new to our department. Daniel h a d his s h o u l d e r r e d u c e d w i t h o u t difficulty. W h e n h e b e c a m e m o r e alert, h e told t h e n u r s e h e w a s r e a d y to start. W h e n t h e n u r s e told h i m t h e t r e a t m e n t w a s finished, h e said h e h a d n o t really b el i e v e d it w h e n h e w a s told he w o u l d n o t r e m e m b e r . H e t h e n l a u g h i n g l y a s k e d w h e t h e r h e h a d said or done anything embarrassing.
We acknowledge the support and assistance of Renette Bertholet, Pharmacist, and John Blenkinsopp, RN.
References 1. Ringland R. Creating guidelines for conscious sedation. Can Nurse 1997;93:45-7 2. Green SM, Nakamura R, Johnson N. Eric: ketamine sedation for pediatric procedures: part II--review and implications. Ann Emerg Med Sept 1990;23:131-44. 3. Green SM, Nakamura R, Johnson N. Eric: ketamine sedation for pediatric procedures: part I - - a prospective series. Ann Emerg Med Sept 1990;23:119-27. 4. Glickman A. Ketamine: the dissociative anesthetic and the development of a policy for its safe administration in the pediatric emergency department. J Emerg Nurs 1995;21: 116-24. 5. Groenveld A, Inkson T. Ketamine: a solution to procedural pain in burned children. Can Nurse 1992;88:28-31. 6. Duda J. Drug update: the good, bad and ugly: using ketamine of ED pediatric patients. J Emerg Nuts 1996;22:49. 7. Urbain I. Emergency department conscious sedation audit. In: Internal emergency programme document. Surrey (BC): Surrey Memorial Hospital; 1994.
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o d y T., 4 y e a r s old, h a s fallen out t h e door of a p a r k e d car a n d s o m e h o w m a n a g e d to l a c e r a t e his ear a n d cheek. H e is crying, t r y i n g to g e t away, a n d s a y s h e h a t e s h o s p i t a l s a n d n e e d l e s . T h e ED p h y s i c i a n h a s a s s e s s e d h i m a n d o r d e r e d 50 m g of ket a m i n e i n t r a m u s c u l a r l y for c o n s c i o u s s e d a t i o n . Daniel P., 34 y e a r s old, collided w i t h a n o t h e r p l a y e r d u r i n g a friendly football g a m e . His only injury is a d i s l o c a t e d right shoulder. T h e ED p h y s i c i a n h a s o r d e r e d 2.5 m g of m i d a z o l a m IV a n d 100 g g of fent a n y l IV for c o n s c i o u s s e d a t i o n . W h a t d o e s c o n s c i o u s s e d a t i o n involve, a n d w h a t c a r e do you, t h e nurse, n e e d to p r o v i d e a n d d o c u m e n t to e n s u r e p a t i e n t s a f e t y ? In 1994, t h e E m e r g e n c y D e p a r t m e n t at Surrey M e m o r i a l Hospital* b e g a n u s i n g c o n s c i o u s s e d a t i o n - - a p r o c e d u r e t h a t r a i s e d a n u m b e r of c o n c e r n s for n u r s i n g staff. We h a d no formal policies, a n d s o m e of t h e d r u g s h a d p r e v i o u s l y b e e n u s e d only in t h e ope r a t i n g r o o m for full a n e s t h e s i a , w h i c h is n o t a p p r o priate within the emergency department. As emergency nurses, we were concerned about t h e s a f e t y of our p a t i e n t s , particularly t h e p e d i a t r i c p o p u l a t i o n . This c o n c e r n w a s t h e c a t a l y s t for t h e d e v e l o p m e n t of a f l o w s h e e t 3 W h e n t h e p r o c e d u r e s first b e g a n , e a c h n u r s e h a d definite i d e a s of w h a t h e or s h e t h o u g h t w e r e n e c e s s a r y i t e m s to h a v e at t h e b e d side, a n d w h a t s h o u l d b e d o c u m e n t e d : s p e c i f i c a l l y w e w a n t e d to p r o t e c t t h e p a t i e n t ' s A B C s a n d c h a r t e v e r y detail. We h a d o p e n s u g g e s t i o n lists for i d e a s of w h a t s h o u l d b e i n c l u d e d on t h e flowsheet, p e r u s e d a n d s h a r e d t h e information t h a t w e found, a n d t h e n d r a f t e d a c h e c k l i s t similar to a p r e a n e s t h e t i c or preo p e r a t i v e list. This w a s t e s t e d , t h e n r e v i s e d t w i c e to t h e n b e c o m e t h e f l o w s h e e t w e n o w use, w h i c h prov i d e s g u i d e l i n e s for p a t i e n t t r e a t m e n t a n d t h e d o c u -
m e n t a t i o n of clinical d a t a before, during, a n d after t h e p r o c e d u r e (Figure 1). C o n s c i o u s s e d a t i o n is a p r o c e d u r e in w h i c h analg e s i a a n d a s e d a t i v e s t a t e are a c c o m p l i s h e d - - w i t h out loss of c o n s c i o u s n e s s for t h e p a t i e n t - - f o r t h e p u r p o s e of p e r f o r m i n g difficult or painful p r o c e d u r e s s u c h as c o m p l i c a t e d l a c e r a t i o n repairs, c l o s e d r e d u c tion of s i m p l e fractures, d e b r i d e m e n t of w o u n d s , red u c t i o n of d i s l o c a t e d joints, e l e c t i v e cardioversion, a d j u s t m e n t of e x t e r n a l fixation d e v i c e s , c l e a n s i n g of tar burns, a n d foreign b o d y removal. It is u s e d safely in t h e e m e r g e n c y d e p a r t m e n t for c h i l d r e n a n d adults, w i t h c o n s t a n t m o n i t o r i n g of t h e p a t i e n t before, during, a n d after t h e p r o c e d u r e .
*Surrey Memorial Hospital is a 350-bed facility in southwestern British Columbia serving a community of 500,000. Our 32-bed emergency department treats 78,000 people per year (approximately 215 per day); 25% are pediatric cases.
T h e m e d i c a t i o n is n o t g i v e n u n t i l all r e q u i r e d s t a f f are at t h e b e d s i d e . In our department, required staff include a respiratory t h e r a p i s t to m o n i t o r ventilation respiratory s t a t u s , a n ED p h y s i c i a n , who orders the medication a n d w i l l b e t h e o n e to i n t u b a t e in c a s e of difficulties, the doctor p e r f o r m i n g t h e p r o c e d u r e (if it is n o t t h e ED p h y s i c i a n ) , t h e R N r e s p o n s i b l e for monitoring and documenting patient status a n d , if h e or s h e w i s h e s , a p a r e n t c a n r e m a i n at t h e bedside.
Ruth Ringland and Sheila Early are ED Nurses at Surrey Memorial Hospital, British Columbia, Canada. For reprints write Ruth Ringland, RN, Surrey Memorial Hospital, Emergency Room, 13750 96th Ave., Surrey, BC, Canada V3V 122. J Emerg Nurs 1997;23:611-7. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97/$5.00 + 0 18/1/86666
E x a m p l e s of c o m m o n l y u s e d m e d i c a t i o n s are ket a m i n e , d i a z e p a m , m i d a z o l a m , a n d fentanyl. T h e s e m e d i c a t i o n s p r o d u c e t h e d e s i r e d effects of s e d a t i o n a n d a n a l g e s i a , b u t also m a y c a u s e CNS d e p r e s s i o n , p o t e n t i a l r e s p i r a t o r y d e p r e s s i o n , mild c a r d i a c s t i m u -
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8~[[~
Conscious SedationRecord
8urmy taemorlal HOala~atl Guidelines: Initials 1. 2. 3. 4. 5. 6, 7.
8,
Patient is NPO. Patient's w e i g h t is obtained. Baseline T P R and BP done. Baseline O x y g e n Saturation by Pulse Oxi met e r done. Oral airway, b a g g i n g unit, oxygen, suction, pulse oximeter at bedside. Crash cart with cardiac m o n i t o r is readily available. Vital s i gns post procedure: q 5 minutes for 15 minutes q 15 minutes for 45 m i n u t e s or until patient meets discharge criteria. Discharge criteria arc m e t prior to discharge.
Procedure: Time Begin:
End:
PRE-SEDATION ASSESSMENT Airway
Breathing
Colour
Skin
Vital Signs
[] O w n [] M a s k []
[] D [] El
[] N o r m a l [] Pale []
[] [] [] []
BP _ HR
_
RR _
_
Nasal Normal Shallow Rapid
Moist Warm Dry Cool
[] Laboured • Weight
,
T=
-
[] N/A
l.V. Access
[] Cannula
Site
Time mltiated
Size
Time DisContinued -
[] N/A
[] Heparin Lock [] Peripheral I.V.
[] Mask []
02 SAT
kilograms
VITAL SIGNS:
Oxygen Rate
Solution Time initiated _ Time ,th ~ t l , .,~l
'
DURING AND POST PROCEDURE MEDICATION
TIME
TIME
Medication
Dose
Route Initials
BP HR
RR OzSAT DISCHARGE CRITERIA
DISCHARGE CRITERIA KEY 1.
Activity Breathing Circulation
2.
Cousciousuess TOTAL SCORES COMMENTS:
(Document pre-procedure information given to patient/parem)
3.
4.
Activity 0 = Unable to lift head or move extremities voluntarily or on command 1 = Lifts head spontaneously and moves extremities voluntarily or on command 2 = Able to ambulate without a~istatme Breathing 0 = Apneic 1 = Dyspnea or shallow, irregular breathing 2 = Able to breath deeply and cough on command Circulation 0 = Systolic B.P. below 80 mm Hg 1 = Systolic B.P. above 1O0 m m Hg 2 = Systolic B.P. within normal limits for patient Consciousness 0 = Not responding, or responding only to painful stimuli 1 = Responds to verbal stimuli but falls asleep readily 2 = Awake, alert and oriented to time, person, place (child oriented to name, parent).
TOTAL SCORE PRIOR TO DISCHARGE MUST BE SEVEN Verbal and written discharge instructions given to: [] patient [] parent/guardian [] other SMH0725 (05/96)
Signature:
R.N.
Initials:
Signature:
R.N.
I n i f i a l s : ~
Signature: WHITECOPY: CHART
M.D. CANARYCOPY: MEDICALDIRECTOREMERGENCY
Figure 1 Conscious-sedation record. (Courtesy Surrey Memorial Hospital, British Columbia.)
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Drug
Ketamine
Midazolam
Fentanyl
Diazepam
Class
Parenteral a n e s t h e t i c ; produces dissociative a n e s t h e s i a ++
Benzodiazepine sedative/ hypnotic; s h o r t - a c t i n g
Narcotic analgesic; produces sedation, adjunct to a n e s t h e s i a
Benzodiazepine sedative/ hypnotic; l o n g - a c t i n g
Use
Children < 10 yr
U s u a l l y adults ( c o m b i n e d w i t h a narcotic)
U s u a l l y adults ( c o m b i n e d with a benzodiazepine)
U s u a l l y adults ( c o m b i n e d w i t h a narcotic)
Dose
IM 2-4 mg/kg; IV 0.2-0.75 mg/kg over 1~3 min
Adults: u s u a l d o s e is
Adults: 50-150 gg; Peds: up to 3 pg/kg g i v e n over 3-5 min
Adults: 2-20 mg IV Peds: 0.25 mg/kg IV
CNS d e p r e s s i o n ,
0.5-2.5 mg IV slowly over 2-3 min; m a y r e p e a t 3 times; Peds: IV 0.01-0.05 mg/kg if over 2 yr; oral 0.5 mg/kg
Side effects
Tachycardia, delirium, CNS d e p r e s s i o n , h y p o t e n s i o n , hallucinations, vivid tachycardia, tonic/clonic dreams, nystagmus, movements, laryngo/ m i s p e r c e p t i o n of v i s u a l / b r o n c h o s p a s m , lack of auditory stimuli, recall after injection cataleptic m o v e m e n t s , lack of recall after u s e , increased secretions
As with all narcotics,
Antidote
None
Naloxone
Flumazenil
respiratory d e p r e s s i o n , h y p o t e n s i o n , bradycardia, laryngospasm, muscle rigidity w i t h rapid administration
h y p o t e n s i o n , ataxia, syncope, laryngospasm, respiratory depression/apnea
Flumazenil
* *All m e d i c a t i o n s m u s t b e g i v e n u n d e r t h e direct s u p e r v i s i o n of a p h y s i c i a n w i t h t h e ability to intubate.
++Dissociative anesthesia: "Functional dissociation between the thalmic structures and the limbic system. ''4 "Sensory input reaches the cortex, but depression of the brain's association pathway results in a diminished or absent response to stimuli and lack of recall to stimuli.''5 Figure 2
Guidelines for use of medications for sedation and analgesia.
lation, a n d h y p o t e n s i o n . T h e d o s a g e is b a s e d on pat i e n t w e i g h t (Figure 2). T h e u s e of t h e s e m e d i c a t i o n s r a i s e s m a n y q u e s t i o n s t h a t n e e d to b e a d d r e s s e d . W h a t is t h e policy on g i v i n g t h e d r u g a n d m o n i t o r i n g t h e p a t i e n t after it h a s b e e n a d m i n i s t e r e d ? H o w are y o u as t h e n u r s e g o i n g to e n s u r e t h a t i n f o r m e d cons e n t b y t h e p a t i e n t or p a r e n t h a s b e e n elicited, a n d t h a t t h e p a t i e n t or p a r e n t is a w a r e of t h e follow-up c a r e i n v o l v e d ? W h a t t e a c h i n g is this p a t i e n t or p a r e n t g o i n g to n e e d before a n d after t h e p r o c e d u r e ? T h e f l o w s h e e t w e c r e a t e d natural]y ]ends itself to h e l p i n g c r e a t e t h e policies t h a t w e r e d e v e l o p e d for all a s p e c t s of t h e c o n s c i o u s s e d a t i o n p r o c e d u r e . For example, w h e n k e t a m i n e 2 is t h e m e d i c a t i o n of c h o i ce, a n a d d i t i o n a l a s s e s s m e n t is d o n e w i t h u s e of t h e K e t a m i n e E x c l u s i o n C h e c k l i s t (Figure 3) to e n s u r e its appropriateness for t h e p e d i a t r i c p a t i e n t ) Before a d m i n i s t e r i n g t h e m e d i c a t i o n , all r e s u s c i tation e q u i p m e n t - - " c r a s h cart" (i.e., a d v a n c e d airway m a n a g e m e n t , oxygen, suction, c a r d i a c m o n i t o r / d e f i b rillator) m u s t b e at t h e b e d s i d e , a n d t h e p a t i e n t - or p a r e n t - t e a c h i n g c o m p l e t e d by t h e n u r s e a n d doctor. A t this time, w e also g i v e d i s c h a r g e information p a m phlets to t h e p a r e n t (Figure 4) or p e r s o n w h o will b e t e n d i n g t h e adult p a t i e n t after d i s c h a r g e (Figure 5).
Suggested patient- or parent-teaching P a r e n t s and, as appropriate, p a t i e n t s are told t h a t t h e patient: • M a y s p e a k or cry out, m a y h a v e r a n d o m limb m o v e ment • M a y still e x p e r i e n c e s o m e discomfort, b u t will not recall t h e p r o c e d u r e • M a y r e s p o n d to w h a t is said a r o u n d h i m or her, b u t not necessarily appropriately • M a y h a v e d r e a m s w h i l e s e d a t e d , s o m e c a n b e v ivi d • After t h e p r o c e d u r e , will b e a s k e d s i m p l e q u e s t i o n s a n d will b e a s k e d to d e e p b r e a t h e a n d c o u g h at intervals • Will r e m a i n in t h e d e p a r t m e n t until d i s c h a r g e criteria h a v e b e e n met. B a s e l i n e vital signs, o x y g e n saturation, ABCs, NPO status, a n d an a c c u r a t e w e i g h t are d o c u m e n t e d , a n d t h e p a t i e n t is a t t a c h e d to a p u l se oximeter, a u t o m a t i c BP m a c h i n e , a n d c a r d i a c monitor. A b a s e l i n e r h y t h m strip is o b t a i n e d a n d p l a c e d in t h e E m e r g e n c y A d m i s s i o n A s s e s s m e n t form t h a t w e u s e in our d e p a r t m e n t for all p at i en t s , or t a p e d to t h e b a c k of t h e flowsheet. T h e m e d i c a t i o n is n o t g i v e n until all r e q u i r e d staff are at t h e b e d s i d e . In our d e p a r t m e n t , r e q u i r e d staff i n c l u d e a r esp i r at o r y t h e r a p i s t to m o n i t o r v e n t i -
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JOURNAL OF EMERGENCYNURSING/Ringlandand Early
B
8MH V
1
Surrey Memorial Hospital EMERGENCY DEPARTMENT
EXCLUSION CRITERIA FOR THE USE OF ~ T A M I N E
CRITERIA
YES
NO
• age less than 6 months or greater than 12 years • previous adverse reaction or hypersensitivity to Ketamine
• history of psychiatric, opthamologic, CNS, CVS, hepatologic, or other chronic medical disorder(s) • history of hyperactivity • history of vivid dream or night terror • current upper or lower respiratory infection • acute injuries (such as globe, head injury) for which Ketamine is contraindicated
Physician's Signature
Note: This is not an all inclusive list of contraindications of Ketamine use. Figure 3 Ketamine exclusion checklist. (Courtesy Surrey Memorial Hospital, British Columbia.
lation r es p i r at o ry status, an ED p h y s i c i a n , w h o orders t h e m e d i c a t i o n a n d will b e t h e o n e to i n t u b a t e in c a s e of difficulties, t h e d o c t o r p e r f o r m i n g t h e p r o c e d u r e (if it is n o t t h e ED physician), t h e r e g i s t e r e d n u r s e res p o n s i b l e for m o n i t o r i n g a n d d o c u m e n t i n g p a t i e n t
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s t a t u s and, if h e or s h e w i s h e s , a p a r e n t c a n r e m a i n at the bedside. The medication can now be given and t h e p r o c e d u r e c o m m e n c e d . O n e - t o - o n e n u r s i n g care i n v o l v e s o n g o i n g a s s e s s m e n t a n d d o c u m e n t a t i o n of clinical d a t a (vital signs, o x y g e n saturation, p a t i e n t
Ringland and Early/JOURNALOF EMERGENCYNURSING
DISCHARGE INSTRUCTIONS FOR CHILDREN RECEIVING CONSCIOUS SEDATION IN THE EMERGENCY DEPARTMENT Your child has r e c e i v e d m e d i c a t i o n for s e d a t i o n or p a i n relief while in the E m e r g e n c y D e p a r t m e n t . It is i m p o r t a n t t h a t you u n d e r s t a n d w h a t h a s b e e n d o n e for your child a n d w h a t to e x p e c t over the n e x t 24 hours. Please ask the N u r s e or P h y s i c i a n a n y q u e s t i o n s you m a y have before you take your child home. ***Your child's b a l a n c e m a y b e affected over t h e n e x t 24 hours. Your child should b e s u p e r v i s e d for all activities d u r i n g this time.
Example: Your child should n o t play o u t s i d e alone, or b e left alone in a b a t h t u b . ***Wake your child if h e / s h e goes to sleep every two hours at least twice. (If your child goes to sleep at 8:00 PM, yOU w o u l d w a k e h i m / h e r at 10:00 PM a n d 12:00 AM.) C h e c k to see t h a t t h e y r e c o g n i z e y o u or c a n tell you w h e r e t h e y are. If your child is too y o u n g to talk, m a k e sure t h e y are able to r e s p o n d to you w h e n you w a k e t h e m . ***Don't give your child solid foods immediately, your child m a y vomit. Start on clear liquids first, e.g., clear juice, g i n g e r ale, a n d t h e n go to other liquids a n d solids as your child tolerates them. If n a u s e a a n d v o m i t i n g occur, go b a c k to clear fluids. ***Normally, you should n o t give your child a n y m e d i c a t i o n s after t h e y leave t h e E m e r g e n c y Department. If your child is on a n y m e d i c a t i o n routinely, please ask t h e E m e r g e n c y P h y s i c i a n w h e n you should r e s t a r t the m e d i c a t i o n . ***Be a w a r e of a n y c h a n g e s i n your child's b e h a v i o u r or u n u s u a l activities.
Example: Your child is n o t able to tolerate solids. MEDICATIONS GIVEN: PRE CAUTIONS: DATE AND TIME: SIGNATURE:
IF YOU HAVE A N Y PROBLEMS OR QUESTIONS REGARDING YOUR CHILD, PLEASE CALL THE E M E R G E N C Y DEPARTMENT A T 585-5666 local 2662.
Figure 4 Discharge instruction pamphlet for parent/person attending child who has received conscious sedation. (Courtesy Surrey Memorial Hospital, British Columbia.)
response) a n d d i s c h a r g e criteria. In the e v e n t of a n y difficulties, d o c u m e n t a t i o n w o u l d r e t u r n to t h e E m e r g e n c y A d m i s s i o n A s s e s s m e n t (to date, t h a t has n o t b e e n necessary). The d i s c h a r g e criteria reflect t h e resolution of t h e effects of t h e m e d i c a t i o n . W h e n t h e d i s c h a r g e criteria h a v e b e e n met, d i s c h a r g e t e a c h i n g p a m p h l e t s are rev i e w e d a g a i n to reinforce the verbal t e a c h i n g a n d to provide t h e p a t i e n t or p a r e n t w i t h i n f o r m a t i o n for ade q u a t e care or s u p e r v i s i o n at home. If t h e y h a v e a n y c o n c e r n s , t h e y are a d v i s e d to r e t u r n to the emer-
g e n c y d e p a r t m e n t ; w e also provide our d e p a r t m e n t p h o n e n u m b e r a n d e n c o u r a g e t h e p a t i e n t or p a r e n t to call if they h a v e a n y q u e s t i o n s . In 1994, d u r i n g t h e p e r i o d from April to September, our d e p a r t m e n t performed 60 c o n s c i o u s s e d a t i o n procedures. T h r o u g h a follow-up p h o n e survey, 6 w e d e t e r m i n e d t h a t there h a d b e e n no complic a t i o n s or a d v e r s e r e a c t i o n s after t h e c o n s c i o u s s e d a t i o n procedure. Also, of t h e children w h o h a d rec e i v e d c o n s c i o u s sedation, 100% of their p a r e n t s w o u l d choose the p r o c e d u r e again.
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JOURNAL OF EMERGENCYNURSING/RingIandand Early
DISCHARGE INSTRUCTIONS FOR PATIENTS RECEIVING CONSCIOUS SEDATION IN THE EMERGENCY DEPARTMENT You have r e c e i v e d m e d i c a t i o n for s e d a t i o n or p a i n relief. It is i m p o r t a n t t h a t you are a w a r e of the effects of t h e m e d i c a t i o n . ***Your b a l a n c e a n d c o o r d i n a t i o n will b e affected. Do n o t drive or o p e r a t e m a c h i n e r y u n t i l effects of the m e d i c a t i o n are gone. ***Someone should b e available to c h e c k you every 2 h o u r s for the n e x t 6 hours. If you go to sleep, s o m e o n e should w a k e n y o u in 2 hours a n d in 4 hours. ***You m a y feel n a u s e a t e d . Start t a k i n g clear fluids first, t h e n go to solids as you are able. ***If you are t a k i n g a n y m e d i c a t i o n s , ask t h e E m e r g e n c y P h y s i c i a n w h e n you should r e s t a r t the medication. MEDICATIONS GIVEN: PRE CAUTIONS: TIME AND DATE: SIGNATURE:
IF YOU HAVE A N Y PROBLEMS OR QUESTIONS, PLEASE CALL THE E M E R G E N C Y D E P A R T M E N T A T 585-5666 local 2662.
Figure 5 Discharge instruction pamphlet for patient who has received conscious sedation. (Courtesy Surrey Memorial Hospital, British Columbia.)
We n o w perform a n a v e r a g e of 4 to 6 c o n s c i o u s s e d a t i o n p r o c e d u r e s per week, a n d w e h a v e u s e d this flowsheet for 3 years. It is a t h r e e - p a r t form. T h e original r e m a i n s w i t h the chart, t h e s e c o n d is s e n t to the family doctor for c o n t i n u i t y of care a n d follow-up, a n d the third is s e n t to t h e e m e r g e n c y m e d i c a l director a n d n u r s e c l i n i c i a n a n d u s e d for a u d i t purposes: • Statistics of w h i c h m e d i c a t i o n s are m o s t u s e d (mid a z o l a m a n d fentanyl). • W h i c h p r o c e d u r e s are m o s t f r ~ t l e n t (orthopedics a n d l a c e r a t i o n repairs). This h a s be~ter utilized our hospital's resources, as s h o w n b y a d e c r e a s e in adm i s s i o n a n d o p e r a t i n g room costs. • Are g u i d e l i n e s a n d policies b e i n g followed? The flowsheet should b e fully completed. C o n s c i o u s - s e d a t i o n policies a n d d o c u m e n t a t i o n are a part of t h e o r i e n t a t i o n for n u r s e s n e w to our dep a r t m e n t . Also, on request, our e m e r g e n c y departm e n t m e d i c a l director a n d n u r s e clinician provide e d u c a t i o n a l s e s s i o n s to other hospitals in our region. C h a n g e s to t h e flowsheet, a n d policies t h a t w e are looking at this year, are to u s e a c o n s e n t form for "Conscious Sedation" rather t h a n t h e c o n s e n t for e m e r g e n c y t r e a t m e n t w e currently use. O n t h e flow-
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s h e e t w e w o u l d like to h a v e s p a c e for t h e r h y t h m strips, rather t h a n u s i n g the E m e r g e n c y A d m i s s i o n A s s e s s m e n t form or t a p i n g t h e m on t h e back. In retrospect, the flowsheet h a s h e l p e d alleviate a large part of our a n x i e t y a b o u t c o n s c i o u s - s e d a t i o n proced u r e s a n d has e l i m i n a t e d chaotic s c r a m b l i n g to get set u p for t h e procedure. Virtually all of our staff n u r s e s find it a n i n v a l u a b l e tool to b e r e m i n d e d of t h e clinical a s p e c t s of c o n s c i o u s s e d a t i o n a n d to docum e n t thoroughly.
We now perform an average of 4 to 6 conscious sedation procedures per week, and we have used this flowsheet for 3 y e a r s . Cody received the ketamine. His ear a n d cheek were sutured. Within 2 hours, he w a s ready for discharge, r e m e m b e r i n g n o t h i n g of t h e p r o c e d u r e .
Ringland and Early/JOURNALOF EMERGENCYNURSING
(Cody's m o t h e r verbalized s o m e anxious feelings while h e w a s s e d a t e d , b u t b e l i e v e d t h a t she preferred this m e t h o d of treatment, a n d said it a p p e a r e d as if "The lights w e r e on, b u t no o n e w a s h o m e in his head.")
Conscious-sedation policies and documentation are a p a r t of t h e o r i e n t a t i o n for nurses new to our department. Daniel h a d his s h o u l d e r r e d u c e d w i t h o u t difficulty. W h e n h e b e c a m e m o r e alert, h e told t h e n u r s e h e w a s r e a d y to start. W h e n t h e n u r s e told h i m t h e t r e a t m e n t w a s finished, h e said h e h a d n o t really b el i e v e d it w h e n h e w a s told he w o u l d n o t r e m e m b e r . H e t h e n l a u g h i n g l y a s k e d w h e t h e r h e h a d said or done anything embarrassing.
We acknowledge the support and assistance of Renette Bertholet, Pharmacist, and John Blenkinsopp, RN.
References 1. Ringland R. Creating guidelines for conscious sedation. Can Nurse 1997;93:45-7 2. Green SM, Nakamura R, Johnson N. Eric: ketamine sedation for pediatric procedures: part II--review and implications. Ann Emerg Med Sept 1990;23:131-44. 3. Green SM, Nakamura R, Johnson N. Eric: ketamine sedation for pediatric procedures: part I - - a prospective series. Ann Emerg Med Sept 1990;23:119-27. 4. Glickman A. Ketamine: the dissociative anesthetic and the development of a policy for its safe administration in the pediatric emergency department. J Emerg Nurs 1995;21: 116-24. 5. Groenveld A, Inkson T. Ketamine: a solution to procedural pain in burned children. Can Nurse 1992;88:28-31. 6. Duda J. Drug update: the good, bad and ugly: using ketamine of ED pediatric patients. J Emerg Nuts 1996;22:49. 7. Urbain I. Emergency department conscious sedation audit. In: Internal emergency programme document. Surrey (BC): Surrey Memorial Hospital; 1994.
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