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Competency verification for conscious sedation
Clinical Articles Competency verificationfor conscious sedation Authors: Maj Mary S. Nelson, USAF NC, Capt Vivene E. Waiters, USAF NC, and Linda M. Watkins, RN, MS, Springfield, Andrews Air Force Base, and Owings, Maryland
m e r g e n c y d e p a r t m e n t s across the n a t i o n are inc r e a s i n g their u s e of c o n s c i o u s s e d a t i o n to decrease the a n x i e t y a n d p a i n of p a t i e n t s w h o require t h e r a p e u t i c i n t e r v e n t i o n s . P r o c e d u r e s for w h i c h conscious s e d a t i o n is u s e d include: c h e s t t u b e insertion, fracture reduction, w o u n d s u t u r i n g (especially in pediatric patients), a m p u t a t i o n of digits, a n d diagn o s t i c p r o c e d u r e s s u c h as c o m p u t e d tomography. T h e s e p r o c e d u r e s often m u s t b e performed on a n e m e r g e n t b a s i s with limited k n o w l e d g e of the pat i e n t ' s m e d i c a l history. 1 N u r s i n g p e r s o n n e l in our d e p a r t m e n t w e r e conc e r n e d a b o u t the specific n u r s i n g care n e e d s of p a t i e n t s w h o receive c o n s c i o u s sedation. No formal t r a i n i n g w a s available to n u r s e s to e n s u r e t h a t the s t a n d a r d of care w a s c o n s i s t e n t l y met, a n d there w a s no clear, c o n c i s e m e t h o d for d o c u m e n t i n g p a t i e n t outcome. The E m e r g e n c y N u r s e s A s s o c i a t i o n ack n o w l e d g e s t h a t c o n s c i o u s s e d a t i o n is w i t h i n the e m e r g e n c y n u r s e ' s s c o p e of p r a c t i c e a n d t h a t a n edu c a t i o n a l / c o m p e t e n c y v a l i d a t i o n m e c h a n i s m should b e in place to e n s u r e safe p r a c t i c e a n d to p r e v e n t adverse o u t c o m e s . 2, 3 With t h e s e c o n c e r n s a n d E N A ' s position in m i n d , the n u r s e s at our level II t r a u m a center developed a c o m p e t e n c y verification r e c o r d / t r a i n i n g guideline. This c o m p e t e n c y verification w a s d e s i g n e d to validate b o t h t h e cognitive a n d p e r f o r m a n c e skills of individuals w h o would perform the procedure. The g u i d e i n c l u d e s a p e r f o r m a n c e checklist that i n d i c a t e s critical b e h a v i o r s in e a c h p h a s e of the p a t i e n t ' s care, for example, p r e p r o c e d u r e a s s e s s m e n t , intraprocedure, p o s t p r o c e d u r e , a n d d i s c h a r g e data (Figure 1).
E
Mary S. Nelson is assistant charge nurse, Emergency Department, and Vivene E. Wakers and Linda M. Watkins are clinical nurses, Emergency Department, Andrews Air Force Base, Maryland. The opinions and assertions contained herein are those of the authors and are not to be construed as reflecting the views of the U.S. Air Force, the Nurse Corps. or the Department of Defense. For reprints, write Linda M. Watkins, RN, MS, 8870 SherbrookCourt, Owings, MD 20736. J Emery Nuts 1996;22:116-9 0099-1767/96 $5.00 + 0 18/1/72031
1 16
Volume 22, Number 2
Furthermore, after r e v i e w i n g the g u i d e l i n e s of the J o i n t C o m m i s s i o n on A c c r e d i t a t i o n of Healthcare O r g a n i z a t i o n s a n d collaborating w i t h the hospital's d e p a r t m e n t of a n e s t h e s i a , w e realized that d o c u m e n tation of p a t i e n t s t a t u s n e e d e d to b e a d d r e s s e d t h r o u g h o u t the specific p h a s e s of the procedure, i, 5 O n e of the m o s t critical 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 t h a t the n u r s e m u s t m o n i t o r is t h e p a t i e n t ' s level of c o n s c i o u s n e s s . We i n c o r p o r a t e d a m e t h o d to m e a s u r e t h e p a t i e n t ' s level of c o n s c i o u s n e s s t h r o u g h o u t the procedure. Until r e c e n t l y the p r e p a r a t i o n for a d m i n i s t e r i n g c o n s c i o u s s e d a t i o n a n d m o n i t o r i n g of the p a t i e n t in our d e p a r t m e n t r e q u i r e d the u s e of several forms, a t t a c h e d slips of paper, a n d e x t e n s i v e writing
D o c u m e n t a t i o n of p a t i e n t s t a t u s n e e d e d to b e addressed throughout the specific p h a s e s of t h e procedure.
for nurses. None of t h e s e forms w a s specifically d e s i g n e d for the n u r s e to m o n i t o r c o n s c i o u s s e d a t i o n in t h e e m e r g e n c y d e p a r t m e n t . A C o n s c i o u s Sedation D o c u m e n t a t i o n Form w a s c r e a t e d to a c c o m p l i s h a clear, c o n c i s e m e t h o d of d o c u m e n t a t i o n (Figure 2). This form i n c l u d e s a n i n - d e p t h a s s e s s m e n t of e a c h p h a s e of s e d a t i o n a n d m i n i m i z e s t h e a m o u n t of writi n g required of the nurse. This flees t h e n u r s e ' s h a n d s to a d m i n i s t e r a d d i t i o n a l m e d i c a t i o n s at appropriate intervals a n d allows the n u r s e to m o n i t o r the p a t i e n t ' s r e s p o n s e (i.e., vital s i g n s a n d modified Aldrete scoresS). The Aldrete scores are o b t a i n e d b y a n objective scori n g s y s t e m in w h i c h t h e p a t i e n t ' s activity, respiration, circulation, level of consciousness, a n d color are assessed. Numeric scores of 0, 1, or 2 are a s s i g n e d in each area, with 2 r e p r e s e n t i n g the h i g h e s t level of function-
Nelson, Walters, and Watkins/JOURNAL OF EMERGENCY NURSING DEPARTMENT
OF EMERGENCY
MEDICINE;
CONSCIOUS
SEDATION
DOCUMENTATION
-
T
I. PRE-PROCEDURE ASSESSMENT
J
Diagnosis:
Last PO Intake:
....
Weight:
Allergies:
Procedure:
Provider: Informed Consent Obtained Yes / No Equipment: Patent IV Oxygen ~ Defibrillator: _ _
Pulse Ox: _ _
A. LOC: Awake and Oriented B. Skin: Warm _
_
C. IV Site: D. Emotional Status:
Cardiac Monitor ~
Suction Apparatus , Confused
, Cool
, Drowsy
, Dry
IVSolution: , Apprehensive
Calm
E. Vital Signs: Temp _ _ ,
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, Restless
, Resp
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B. LOC: Awake and Oriented Lethargic , Unconscious C. E m o t i o n a l S t a t u s : C a l m Crying , Assessed by:
LcR __,
, Crying
Assessed by:
/
, Pulse OX
III. POST-PROCEDURE ASSESSMENT/MONITORING A n c i l l a r y Nurses Notes Yes~No A. L O C : A w a k e a n d Oriented ., Confused
Right __
Lethargic , Uncomcious B. S k i n : W a r m _ _ , Cool , Dry
_ _ , Apprehensive
, Unconscious
_ , Color
, B/P
, Drowsy
, C o n f u s e d
Airway Adjuncts:
Antagonist/Emergency Drugs
, Lethargic
. , Moist
II. INTRA-PROCEDURE ASSESSMENT/NOTES S e d a t i n n Start: A+ P o s i t i o n i n g : S u p i n e _ _ ,
B/P Monitor
Ambu Bag ~
, Restless
,
.....
, Drowsy Moist
, Color
C. I V I n t a k e : Output: Urine D. R e s p S t a t u s : B r e a t h i n g Unassisted , Ventilated
D. N u r s e s N o t e s :
, Emesis
Oxygen per Cannula .... L/rain, Mask L/rain E. M o v e m e n t : M o v i n g U / L E x t r e m i t i e s , Not Moving, Location F. E m o t i o n a l Status: C a m , Al:rpmhemive . , Resdess .
S e d a t i o n Elxl:
Procedttre E n d :
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, Assessed by:
TIME
TIME
f
[ T
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Dose
Route
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1 1
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,
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Modified Aldrete Scoring scoaz =
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L Aatlvity: Abletomovc4ex~miti~ . . . . . . . . . . . . . . . Able to move 2 cttml~Jdr . . . . . Not able to control any extremiti I1. Rta~rl~Ma:
Amto~
,k=#y=ad~ # ,
Limited ~ o r y effort (dysptl~t) . . . . . . . NO $po~tzneolut ~ o r y effort . . . . . . . . .
m. cl,.-,.~m:
B/P +/- 20~ pre-s=tatioa level . . . . . . . . . . .
9t. ~5o,~ ~ . ~ L , , ~ = J~.~ B/P +/.50%orgttaterl~-sedat~oelevel...
IV. DISCHARGE scour
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1 I
to care of:
Admit to hospital: Post Procedure Instrucoons to: Patient . - -
~
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0
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Notes:
~a~s~l N~ms:
89 MDG TEST FORM 20.6, APR 95
Figure 1 C o n s c i o u s s e d a t i o n d o c u m e n t a t i o n form. PQ, Oral; b l o o d p r e s s u r e ; Pulse 9 p u l s e o x i m e t r y ; LOC, l e v e l of c o n s c i o u s n e s s ; Resp, r e s p i r a t i o n s ; U/L
B/P,
Extremities, upper~lower e x t r e m i t i e s .
Used with
permission.
April 1996
117
OURNAL OF EMERGENCY NURSING/Nelson, Waiters, and Watkins C o m p e t e n c y Verification R e c o r d : C o n s c i o u s S e d a t i o n / A n a l g e s i a Directive: J C A H O A c c r e d i t a t i o n M a n u a l for H o s p i t a l s D a t e of C h e c k l i s t Creation: M a r c h 1995 T a r g e t Group: All E m e r g e n c y N u r s e s Name I. C o g n i t i v e Objective(s) 1. Define c o n s c i o u s s e d a t i o n a n d its p u r p o s e s , 2. I d e n t i f y t h e d i f f e r e n c e s b e t w e e n c o n s c i o u s s e d a t i o n , d e e p s e d a t i o n , a n d g e n e r a l a n e s t h e s i a . 3. I d e n t i f y s t a f f q u a l i f i c a t i o n s for a d m i n i s t r a t i o n of c o n s c i o u s s e d a t i o n . 4. D e s c r i b e p r e p r o c e d u r e , i n t r a p r o c e d u r e , and p o s t p r o c e d u r e a s s e s s m e n t a n d m o n i t o r i n g . 5, D e m o n s t r a t e k n o w l e d g e of p h a r m a c o l o g i c a l a g e n t s u s e d for c o n s c i o u s s e d a t i o n . 6, A n t i c i p a t e a n d r e c o g n i z e p o t e n t i a l c o m p l i c a t i o n s of IV c o n s c i o u s s e d a t i o n in r e l a t i o n to t h e t y p e of m e d i c a t i o n administered. 7. D e m o n s t r a t e skills in a i r w a y m a n a g e m e n t , c a r d i o p u l m o n a r y r e s u s c i t a t i o n , d y s r h y t h m i a r e c o g n i t i o n , and treatments. Teaching Methodology a. R e a d local policies o n c o n s c i o u s s e d a t i o n / a n a l g e s i a . b. R e a d G a h a r t BL. I n t r a v e n o u s m e d i c a t i o n s . 12th ed. St. Louis: M o s b y - Y e a r Book, 1995. c. R e a d t h e following: G u i d e l i n e s for t h e elective u s e of c o n s c i o u s s e d a t i o n , d e e p s e d a t i o n a n d g e n e r a l a n e s t h e s i a p e d i a t r i c p a t i e n t s . P e d i a t r i c s 1985;76:317-21. d. G a g n o n L. P r e s i d e n t ' s m e s s a g e : a d m i n i s t r a t i o n of i n t r a v e n o u s c o n s c i o u s s e d a t i o n in t h e e m e r g e n c y d e p a r t m e n t . J E m e r g N u r s 1991;17:123. e. Neff JA. P a t i e n t c a r e g u i d e l i n e : c o n s c i o u s s e d a t i o n . J E m e r g M e d 1992;18:170-2. M e t h o d of E v a l u a t i o n / S t a n d a r d : C l o s e d - b o o k w r i t t e n t e s t / 9 0 % . F r e q u e n c y of Reverification: A n n u a l . Reverification Requirements: Retest. Written test passed on w i t h a s c o r e of e q u a l to or g r e a t e r t h a n m i n i m a l p a s s i n g s c o r e of 90%. M e m b e r ' s t e s t s c o r e is m a i n t a i n e d in f o r r e c o r d p u r p o s e s . M e m b e r is proficient in t h e c o g n i t i v e p h a s e of conscious s e d a t i o n . S i g n a t u r e of P r e c e p t o r II, P e r f o r m a n c e Objective(s) 1. U s e s h o s p i t a l g u i d e l i n e s to p r e p a r e p a t i e n t for c o n s c i o u s s e d a t i o n . 2. E n s u r e s c o n s e n t form h a s b e e n s i g n e d . 3. O b t a i n s b a s e l i n e vital s i g n s to i n c l u d e p u l s e o x i m e t r y , l a s t oral i n t a k e , w e i g h t , a n d allergies. 4. I n i t i a t e s a p a t e n t i n t r a v e n o u s a c c e s s . 5. O b t a i n s all d r u g s to b e u s e d a n d t h e i r a n t a g o n i s t s b e f o r e s t a r t of p r o c e d u r e . 6. H a s all e q u i p m e n t for r e s u s c i t a t i o n a v a i l a b l e a n d o p e r a t i o n a l , i n c l u d i n g o x y g e n . 7. M a i n t a i n s all flow s h e e t s a c c o r d i n g to d o c u m e n t a t i o n policies. 8. N e v e r l e a v e s t h e p a t i e n t u n a t t e n d e d . 9. C o m m u n i c a t e s e f f e c t i v e l y w i t h p r o v i d e r s , o t h e r n u r s e s , a n d family o n t h e p a t i e n t ' s condition. 10. I n i t i a t e s a p p r o p r i a t e t r e a t m e n t s in r e s p o n s e to c o m p l i c a t i o n s ; notifies p h y s i c i a n . Teaching Methodology Demonstration, s u p e r v i s e d p r a c t i c e , and record r e v i e w . *NOTE: Stop p r o c e d u r e a n d c o r r e c t d e f i c i e n c i e s if n u r s e is failing to m e e t s t a n d a r d s . M e t h o d of E v a l u a t i o n / S t a n d a r d B a s e d o n t h e f o l l o w i n g criteria: 1. (1) P r o c e d u r e for n u r s e s w i t h prior E D / c o n s c i o u s s e d a t i o n e x p e r i e n c e . 2. (2) P r o c e d u r e s for n u r s e s w i t h o t h e r e x p e r i e n c e . 3. (4) P r o c e d u r e s for n e w n u r s e s . 4, (1) P r o c e d u r e u n d e r s u p e r v i s i o n for reverification. F r e q u e n c y of Reverification: A n n u a l . R e v e r i f i c a t i o n R e q u i r e m e n t s : S a m e a s initial r e q u i r e m e n t s . P e r f o r m a n c e Checklist: Critical B e h a v i o r s P a r t I: P r e p r o c e d u r e A s s e s s m e n t A, P r e p a r e t h e p a t i e n t for c o n s c i o u s s e d a t i o n : 1. C h e c k for allergies. 2. E n s u r e i n f o r m e d c o n s e n t is d o n e . (con tin u ed) Figure 2 C o m p e t e n c y v e r i f i c a t i o n r e c o r d for c o n s c i o u s s e d a t i o n / a n a l g e s i a . JCAHO, J o i n t C o m m i s s i o n o n
1 18
V o l u m e 22, N u m b e r 2
A c c r e d i t a t i o n of H e a l t h c a r e O r g a n i z a t i o n s ; BP, blood p r e s s u r e . U s e d w i t h p e r m i s s i o n .
Nelson, Waiters, and Watkins/JOURNAL OF EMERGENCY NURSING (continued) 3. 4. 5. 6.
Establish last oral intake. Obtain weight. Initial vital signs to include pulse oximetry. Establish level of consciousness.
B. A s s e m b l e equipment/supplies: 1. Automatic BP monitor (manual cuff). 2. P a t e n t IV s i t e / e m e r g e n c y drugs. 3. Oxygen 2 L nasal cannula. 4. Functioning suction apparatus. 5. Cardiac monitor w i t h electrodes. 6, Bag-mask-valve device with appropriate size masks. 7, Airway adjuncts. 8. Defibrillator. C. Obtain medications and antagonists: 1. Verify correct medication d o s a g e s with physician's order. 2. Check expiration d a t e s on all medication. 3. Demonstrate knowledge of medication: dosages, route of administration, dilution if n e e d e d , e x p e c t e d actions, and contralndications. 4. Communicate effectively with physicians, nurses, and other m e m b e r s of the care team. Part II: Intraprocedure A s s e s s m e n t / N o t e s 1. Position patient to maintain p a t e n t airway. 2. Monitor vital signs and record every 5 minutes to include pulse oximetry. 3. Document medication dosage, route, and p a t i e n t ' s r e s p o n s e to medication. 4. Constantly monitor p a t i e n t ' s level of consciousness, respiratory status, and r e s p o n s e to procedure. 5. Notify physician if any c h a n g e s occur. Part III: Postprocedure A s s e s s m e n t 1. Monitor vital signs and record every 15 minutes, monitor respiratory effort, level of consciousness, and pulse oximetry. 2. A s s e s s and d o c u m e n t p a t i e n t ' s Aldrete score every 30 minutes. 3. Document p a t i e n t ' s r e s p o n s e to sedation. 4. Remain w i t h the patient at all times. 5. Monitor p a t i e n t for a minimum of 30 minutes. Part IV: Discharge Data 1. Recommend discharge w h e n Aldrete score reaches 10 (after 30 to 60 minutes). 2. Document p a t i e n t ' s condition at discharge. 3. Document p a t i e n t ' s disposition (with whom, where). 4. Ensure follow-up a p p o i n t m e n t is given to patient/escort. 5. Ensure a w r i t t e n instruction s h e e t is given to and reviewed with the patient or accompanying responsible adult. 6. Document time of discharge. 7. Complete all documentation. Checklist completed on w i t h a score of Satisfactory. Member is proficient in the performance p h a s e of conscious sedation. Signature of Preceptor
i n g i n e a c h area. A s c o r e of 10 is t h e h i g h e s t p o s s i b l e s c o r e . T h e A l d r e t e p o s t a n e s t h e s i a s c o r i n g s y s t e m is the most widely accepted scoring system known. Nurses
in our d e p a r t m e n t
g e n e r a l l y like t h i s
f o r m a n d u s e it c o n s i s t e n t l y . M o s t n u r s e s b e l i e v e it has cut documentation
t i m e in half w h i l e i m p r o v i n g
t h e q u a l i t y of d o c u m e n t a t i o n . T h e only i m p r o v e m e n t c u r r e n t l y b e i n g c o n s i d e r e d is e x p a n d i n g t h e n u r s i n g note space change
to i n c l u d e t h e b a c k of t h e form. T h i s
w o u l d r e s o l v e t h e n e e d for a n o c c a s s i o n a l
ancillary n u r s e ' s note on a s e p a r a t e d o c u m e n t .
References
2. E m e r g e n c y Nurses Association. ENA position s t a t e m e n t on conscious sedation. E m e r g e n c y n u r s e s practice (revised S e p t e m b e r 1994). Chicago, 1992. 3. G a g n o n L. P r e s i d e n t ' s m e s s a g e : administration of intravenous c o n s c i o u s s e d a t i o n in the e m e r g e n c y department. J E m e r g Nuts 1991;18:123. 4. Neff J. P a t i e n t care guidelines conscious sedation. J E m e r g M e d 1992;18:170-2. 5. Guidelines for the elective u s e of conscious sedation, d e e p sedation, and general a n e s t h e s i a pediatric patients. Pediatrics 1985;76:317-21. 6. Litwack K. P o s t a n e s t h e s i a care nursing. 2nd ed. St Louis: M o s b y - Y e a r Book, 1995:192-8.
1. S o m e r s o n S, H u s t e d C, Scilia M. Insights into conscious sedation. A m J Nurs 1995;6:26-32.
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m e r g e n c y d e p a r t m e n t s across the n a t i o n are inc r e a s i n g their u s e of c o n s c i o u s s e d a t i o n to decrease the a n x i e t y a n d p a i n of p a t i e n t s w h o require t h e r a p e u t i c i n t e r v e n t i o n s . P r o c e d u r e s for w h i c h conscious s e d a t i o n is u s e d include: c h e s t t u b e insertion, fracture reduction, w o u n d s u t u r i n g (especially in pediatric patients), a m p u t a t i o n of digits, a n d diagn o s t i c p r o c e d u r e s s u c h as c o m p u t e d tomography. T h e s e p r o c e d u r e s often m u s t b e performed on a n e m e r g e n t b a s i s with limited k n o w l e d g e of the pat i e n t ' s m e d i c a l history. 1 N u r s i n g p e r s o n n e l in our d e p a r t m e n t w e r e conc e r n e d a b o u t the specific n u r s i n g care n e e d s of p a t i e n t s w h o receive c o n s c i o u s sedation. No formal t r a i n i n g w a s available to n u r s e s to e n s u r e t h a t the s t a n d a r d of care w a s c o n s i s t e n t l y met, a n d there w a s no clear, c o n c i s e m e t h o d for d o c u m e n t i n g p a t i e n t outcome. The E m e r g e n c y N u r s e s A s s o c i a t i o n ack n o w l e d g e s t h a t c o n s c i o u s s e d a t i o n is w i t h i n the e m e r g e n c y n u r s e ' s s c o p e of p r a c t i c e a n d t h a t a n edu c a t i o n a l / c o m p e t e n c y v a l i d a t i o n m e c h a n i s m should b e in place to e n s u r e safe p r a c t i c e a n d to p r e v e n t adverse o u t c o m e s . 2, 3 With t h e s e c o n c e r n s a n d E N A ' s position in m i n d , the n u r s e s at our level II t r a u m a center developed a c o m p e t e n c y verification r e c o r d / t r a i n i n g guideline. This c o m p e t e n c y verification w a s d e s i g n e d to validate b o t h t h e cognitive a n d p e r f o r m a n c e skills of individuals w h o would perform the procedure. The g u i d e i n c l u d e s a p e r f o r m a n c e checklist that i n d i c a t e s critical b e h a v i o r s in e a c h p h a s e of the p a t i e n t ' s care, for example, p r e p r o c e d u r e a s s e s s m e n t , intraprocedure, p o s t p r o c e d u r e , a n d d i s c h a r g e data (Figure 1).
E
Mary S. Nelson is assistant charge nurse, Emergency Department, and Vivene E. Wakers and Linda M. Watkins are clinical nurses, Emergency Department, Andrews Air Force Base, Maryland. The opinions and assertions contained herein are those of the authors and are not to be construed as reflecting the views of the U.S. Air Force, the Nurse Corps. or the Department of Defense. For reprints, write Linda M. Watkins, RN, MS, 8870 SherbrookCourt, Owings, MD 20736. J Emery Nuts 1996;22:116-9 0099-1767/96 $5.00 + 0 18/1/72031
1 16
Volume 22, Number 2
Furthermore, after r e v i e w i n g the g u i d e l i n e s of the J o i n t C o m m i s s i o n on A c c r e d i t a t i o n of Healthcare O r g a n i z a t i o n s a n d collaborating w i t h the hospital's d e p a r t m e n t of a n e s t h e s i a , w e realized that d o c u m e n tation of p a t i e n t s t a t u s n e e d e d to b e a d d r e s s e d t h r o u g h o u t the specific p h a s e s of the procedure, i, 5 O n e of the m o s t critical 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 t h a t the n u r s e m u s t m o n i t o r is t h e p a t i e n t ' s level of c o n s c i o u s n e s s . We i n c o r p o r a t e d a m e t h o d to m e a s u r e t h e p a t i e n t ' s level of c o n s c i o u s n e s s t h r o u g h o u t the procedure. Until r e c e n t l y the p r e p a r a t i o n for a d m i n i s t e r i n g c o n s c i o u s s e d a t i o n a n d m o n i t o r i n g of the p a t i e n t in our d e p a r t m e n t r e q u i r e d the u s e of several forms, a t t a c h e d slips of paper, a n d e x t e n s i v e writing
D o c u m e n t a t i o n of p a t i e n t s t a t u s n e e d e d to b e addressed throughout the specific p h a s e s of t h e procedure.
for nurses. None of t h e s e forms w a s specifically d e s i g n e d for the n u r s e to m o n i t o r c o n s c i o u s s e d a t i o n in t h e e m e r g e n c y d e p a r t m e n t . A C o n s c i o u s Sedation D o c u m e n t a t i o n Form w a s c r e a t e d to a c c o m p l i s h a clear, c o n c i s e m e t h o d of d o c u m e n t a t i o n (Figure 2). This form i n c l u d e s a n i n - d e p t h a s s e s s m e n t of e a c h p h a s e of s e d a t i o n a n d m i n i m i z e s t h e a m o u n t of writi n g required of the nurse. This flees t h e n u r s e ' s h a n d s to a d m i n i s t e r a d d i t i o n a l m e d i c a t i o n s at appropriate intervals a n d allows the n u r s e to m o n i t o r the p a t i e n t ' s r e s p o n s e (i.e., vital s i g n s a n d modified Aldrete scoresS). The Aldrete scores are o b t a i n e d b y a n objective scori n g s y s t e m in w h i c h t h e p a t i e n t ' s activity, respiration, circulation, level of consciousness, a n d color are assessed. Numeric scores of 0, 1, or 2 are a s s i g n e d in each area, with 2 r e p r e s e n t i n g the h i g h e s t level of function-
Nelson, Walters, and Watkins/JOURNAL OF EMERGENCY NURSING DEPARTMENT
OF EMERGENCY
MEDICINE;
CONSCIOUS
SEDATION
DOCUMENTATION
-
T
I. PRE-PROCEDURE ASSESSMENT
J
Diagnosis:
Last PO Intake:
....
Weight:
Allergies:
Procedure:
Provider: Informed Consent Obtained Yes / No Equipment: Patent IV Oxygen ~ Defibrillator: _ _
Pulse Ox: _ _
A. LOC: Awake and Oriented B. Skin: Warm _
_
C. IV Site: D. Emotional Status:
Cardiac Monitor ~
Suction Apparatus , Confused
, Cool
, Drowsy
, Dry
IVSolution: , Apprehensive
Calm
E. Vital Signs: Temp _ _ ,
Pulse
, Restless
, Resp
Prtx:cdureStaR: Prone ~ , Lateral ~ ,
B. LOC: Awake and Oriented Lethargic , Unconscious C. E m o t i o n a l S t a t u s : C a l m Crying , Assessed by:
LcR __,
, Crying
Assessed by:
/
, Pulse OX
III. POST-PROCEDURE ASSESSMENT/MONITORING A n c i l l a r y Nurses Notes Yes~No A. L O C : A w a k e a n d Oriented ., Confused
Right __
Lethargic , Uncomcious B. S k i n : W a r m _ _ , Cool , Dry
_ _ , Apprehensive
, Unconscious
_ , Color
, B/P
, Drowsy
, C o n f u s e d
Airway Adjuncts:
Antagonist/Emergency Drugs
, Lethargic
. , Moist
II. INTRA-PROCEDURE ASSESSMENT/NOTES S e d a t i n n Start: A+ P o s i t i o n i n g : S u p i n e _ _ ,
B/P Monitor
Ambu Bag ~
, Restless
,
.....
, Drowsy Moist
, Color
C. I V I n t a k e : Output: Urine D. R e s p S t a t u s : B r e a t h i n g Unassisted , Ventilated
D. N u r s e s N o t e s :
, Emesis
Oxygen per Cannula .... L/rain, Mask L/rain E. M o v e m e n t : M o v i n g U / L E x t r e m i t i e s , Not Moving, Location F. E m o t i o n a l Status: C a m , Al:rpmhemive . , Resdess .
S e d a t i o n Elxl:
Procedttre E n d :
Crying
, Assessed by:
TIME
TIME
f
[ T
! i
Dose
Route
Pulse Resp Pulse Ox Alclrr
1 1
[
Score
i
,
I
Modified Aldrete Scoring scoaz =
| l
L Aatlvity: Abletomovc4ex~miti~ . . . . . . . . . . . . . . . Able to move 2 cttml~Jdr . . . . . Not able to control any extremiti I1. Rta~rl~Ma:
Amto~
,k=#y=ad~ # ,
Limited ~ o r y effort (dysptl~t) . . . . . . . NO $po~tzneolut ~ o r y effort . . . . . . . . .
m. cl,.-,.~m:
B/P +/- 20~ pre-s=tatioa level . . . . . . . . . . .
9t. ~5o,~ ~ . ~ L , , ~ = J~.~ B/P +/.50%orgttaterl~-sedat~oelevel...
IV. DISCHARGE scour
Alert/Reactive
Condition at release: Y/N
IV. ComcimLsnr 2 } 0
.' [ 0
FmlyalertandaNeto attswef q ucstlol~.,. Aroutable Failerr to eli"it response
v. cao~
XotraR r ............ . Pale, dtmky. Motchy . . . . .
2 I
0
Aldrete Score Discharge
1 I
to care of:
Admit to hospital: Post Procedure Instrucoons to: Patient . - -
~
Follow-up appffdate/time: Time Released _ _
0
Nurses
2
Fr~k~a,o
,
2 l 0
Escort
Notes:
~a~s~l N~ms:
89 MDG TEST FORM 20.6, APR 95
Figure 1 C o n s c i o u s s e d a t i o n d o c u m e n t a t i o n form. PQ, Oral; b l o o d p r e s s u r e ; Pulse 9 p u l s e o x i m e t r y ; LOC, l e v e l of c o n s c i o u s n e s s ; Resp, r e s p i r a t i o n s ; U/L
B/P,
Extremities, upper~lower e x t r e m i t i e s .
Used with
permission.
April 1996
117
OURNAL OF EMERGENCY NURSING/Nelson, Waiters, and Watkins C o m p e t e n c y Verification R e c o r d : C o n s c i o u s S e d a t i o n / A n a l g e s i a Directive: J C A H O A c c r e d i t a t i o n M a n u a l for H o s p i t a l s D a t e of C h e c k l i s t Creation: M a r c h 1995 T a r g e t Group: All E m e r g e n c y N u r s e s Name I. C o g n i t i v e Objective(s) 1. Define c o n s c i o u s s e d a t i o n a n d its p u r p o s e s , 2. I d e n t i f y t h e d i f f e r e n c e s b e t w e e n c o n s c i o u s s e d a t i o n , d e e p s e d a t i o n , a n d g e n e r a l a n e s t h e s i a . 3. I d e n t i f y s t a f f q u a l i f i c a t i o n s for a d m i n i s t r a t i o n of c o n s c i o u s s e d a t i o n . 4. D e s c r i b e p r e p r o c e d u r e , i n t r a p r o c e d u r e , and p o s t p r o c e d u r e a s s e s s m e n t a n d m o n i t o r i n g . 5, D e m o n s t r a t e k n o w l e d g e of p h a r m a c o l o g i c a l a g e n t s u s e d for c o n s c i o u s s e d a t i o n . 6, A n t i c i p a t e a n d r e c o g n i z e p o t e n t i a l c o m p l i c a t i o n s of IV c o n s c i o u s s e d a t i o n in r e l a t i o n to t h e t y p e of m e d i c a t i o n administered. 7. D e m o n s t r a t e skills in a i r w a y m a n a g e m e n t , c a r d i o p u l m o n a r y r e s u s c i t a t i o n , d y s r h y t h m i a r e c o g n i t i o n , and treatments. Teaching Methodology a. R e a d local policies o n c o n s c i o u s s e d a t i o n / a n a l g e s i a . b. R e a d G a h a r t BL. I n t r a v e n o u s m e d i c a t i o n s . 12th ed. St. Louis: M o s b y - Y e a r Book, 1995. c. R e a d t h e following: G u i d e l i n e s for t h e elective u s e of c o n s c i o u s s e d a t i o n , d e e p s e d a t i o n a n d g e n e r a l a n e s t h e s i a p e d i a t r i c p a t i e n t s . P e d i a t r i c s 1985;76:317-21. d. G a g n o n L. P r e s i d e n t ' s m e s s a g e : a d m i n i s t r a t i o n of i n t r a v e n o u s c o n s c i o u s s e d a t i o n in t h e e m e r g e n c y d e p a r t m e n t . J E m e r g N u r s 1991;17:123. e. Neff JA. P a t i e n t c a r e g u i d e l i n e : c o n s c i o u s s e d a t i o n . J E m e r g M e d 1992;18:170-2. M e t h o d of E v a l u a t i o n / S t a n d a r d : C l o s e d - b o o k w r i t t e n t e s t / 9 0 % . F r e q u e n c y of Reverification: A n n u a l . Reverification Requirements: Retest. Written test passed on w i t h a s c o r e of e q u a l to or g r e a t e r t h a n m i n i m a l p a s s i n g s c o r e of 90%. M e m b e r ' s t e s t s c o r e is m a i n t a i n e d in f o r r e c o r d p u r p o s e s . M e m b e r is proficient in t h e c o g n i t i v e p h a s e of conscious s e d a t i o n . S i g n a t u r e of P r e c e p t o r II, P e r f o r m a n c e Objective(s) 1. U s e s h o s p i t a l g u i d e l i n e s to p r e p a r e p a t i e n t for c o n s c i o u s s e d a t i o n . 2. E n s u r e s c o n s e n t form h a s b e e n s i g n e d . 3. O b t a i n s b a s e l i n e vital s i g n s to i n c l u d e p u l s e o x i m e t r y , l a s t oral i n t a k e , w e i g h t , a n d allergies. 4. I n i t i a t e s a p a t e n t i n t r a v e n o u s a c c e s s . 5. O b t a i n s all d r u g s to b e u s e d a n d t h e i r a n t a g o n i s t s b e f o r e s t a r t of p r o c e d u r e . 6. H a s all e q u i p m e n t for r e s u s c i t a t i o n a v a i l a b l e a n d o p e r a t i o n a l , i n c l u d i n g o x y g e n . 7. M a i n t a i n s all flow s h e e t s a c c o r d i n g to d o c u m e n t a t i o n policies. 8. N e v e r l e a v e s t h e p a t i e n t u n a t t e n d e d . 9. C o m m u n i c a t e s e f f e c t i v e l y w i t h p r o v i d e r s , o t h e r n u r s e s , a n d family o n t h e p a t i e n t ' s condition. 10. I n i t i a t e s a p p r o p r i a t e t r e a t m e n t s in r e s p o n s e to c o m p l i c a t i o n s ; notifies p h y s i c i a n . Teaching Methodology Demonstration, s u p e r v i s e d p r a c t i c e , and record r e v i e w . *NOTE: Stop p r o c e d u r e a n d c o r r e c t d e f i c i e n c i e s if n u r s e is failing to m e e t s t a n d a r d s . M e t h o d of E v a l u a t i o n / S t a n d a r d B a s e d o n t h e f o l l o w i n g criteria: 1. (1) P r o c e d u r e for n u r s e s w i t h prior E D / c o n s c i o u s s e d a t i o n e x p e r i e n c e . 2. (2) P r o c e d u r e s for n u r s e s w i t h o t h e r e x p e r i e n c e . 3. (4) P r o c e d u r e s for n e w n u r s e s . 4, (1) P r o c e d u r e u n d e r s u p e r v i s i o n for reverification. F r e q u e n c y of Reverification: A n n u a l . R e v e r i f i c a t i o n R e q u i r e m e n t s : S a m e a s initial r e q u i r e m e n t s . P e r f o r m a n c e Checklist: Critical B e h a v i o r s P a r t I: P r e p r o c e d u r e A s s e s s m e n t A, P r e p a r e t h e p a t i e n t for c o n s c i o u s s e d a t i o n : 1. C h e c k for allergies. 2. E n s u r e i n f o r m e d c o n s e n t is d o n e . (con tin u ed) Figure 2 C o m p e t e n c y v e r i f i c a t i o n r e c o r d for c o n s c i o u s s e d a t i o n / a n a l g e s i a . JCAHO, J o i n t C o m m i s s i o n o n
1 18
V o l u m e 22, N u m b e r 2
A c c r e d i t a t i o n of H e a l t h c a r e O r g a n i z a t i o n s ; BP, blood p r e s s u r e . U s e d w i t h p e r m i s s i o n .
Nelson, Waiters, and Watkins/JOURNAL OF EMERGENCY NURSING (continued) 3. 4. 5. 6.
Establish last oral intake. Obtain weight. Initial vital signs to include pulse oximetry. Establish level of consciousness.
B. A s s e m b l e equipment/supplies: 1. Automatic BP monitor (manual cuff). 2. P a t e n t IV s i t e / e m e r g e n c y drugs. 3. Oxygen 2 L nasal cannula. 4. Functioning suction apparatus. 5. Cardiac monitor w i t h electrodes. 6, Bag-mask-valve device with appropriate size masks. 7, Airway adjuncts. 8. Defibrillator. C. Obtain medications and antagonists: 1. Verify correct medication d o s a g e s with physician's order. 2. Check expiration d a t e s on all medication. 3. Demonstrate knowledge of medication: dosages, route of administration, dilution if n e e d e d , e x p e c t e d actions, and contralndications. 4. Communicate effectively with physicians, nurses, and other m e m b e r s of the care team. Part II: Intraprocedure A s s e s s m e n t / N o t e s 1. Position patient to maintain p a t e n t airway. 2. Monitor vital signs and record every 5 minutes to include pulse oximetry. 3. Document medication dosage, route, and p a t i e n t ' s r e s p o n s e to medication. 4. Constantly monitor p a t i e n t ' s level of consciousness, respiratory status, and r e s p o n s e to procedure. 5. Notify physician if any c h a n g e s occur. Part III: Postprocedure A s s e s s m e n t 1. Monitor vital signs and record every 15 minutes, monitor respiratory effort, level of consciousness, and pulse oximetry. 2. A s s e s s and d o c u m e n t p a t i e n t ' s Aldrete score every 30 minutes. 3. Document p a t i e n t ' s r e s p o n s e to sedation. 4. Remain w i t h the patient at all times. 5. Monitor p a t i e n t for a minimum of 30 minutes. Part IV: Discharge Data 1. Recommend discharge w h e n Aldrete score reaches 10 (after 30 to 60 minutes). 2. Document p a t i e n t ' s condition at discharge. 3. Document p a t i e n t ' s disposition (with whom, where). 4. Ensure follow-up a p p o i n t m e n t is given to patient/escort. 5. Ensure a w r i t t e n instruction s h e e t is given to and reviewed with the patient or accompanying responsible adult. 6. Document time of discharge. 7. Complete all documentation. Checklist completed on w i t h a score of Satisfactory. Member is proficient in the performance p h a s e of conscious sedation. Signature of Preceptor
i n g i n e a c h area. A s c o r e of 10 is t h e h i g h e s t p o s s i b l e s c o r e . T h e A l d r e t e p o s t a n e s t h e s i a s c o r i n g s y s t e m is the most widely accepted scoring system known. Nurses
in our d e p a r t m e n t
g e n e r a l l y like t h i s
f o r m a n d u s e it c o n s i s t e n t l y . M o s t n u r s e s b e l i e v e it has cut documentation
t i m e in half w h i l e i m p r o v i n g
t h e q u a l i t y of d o c u m e n t a t i o n . T h e only i m p r o v e m e n t c u r r e n t l y b e i n g c o n s i d e r e d is e x p a n d i n g t h e n u r s i n g note space change
to i n c l u d e t h e b a c k of t h e form. T h i s
w o u l d r e s o l v e t h e n e e d for a n o c c a s s i o n a l
ancillary n u r s e ' s note on a s e p a r a t e d o c u m e n t .
References
2. E m e r g e n c y Nurses Association. ENA position s t a t e m e n t on conscious sedation. E m e r g e n c y n u r s e s practice (revised S e p t e m b e r 1994). Chicago, 1992. 3. G a g n o n L. P r e s i d e n t ' s m e s s a g e : administration of intravenous c o n s c i o u s s e d a t i o n in the e m e r g e n c y department. J E m e r g Nuts 1991;18:123. 4. Neff J. P a t i e n t care guidelines conscious sedation. J E m e r g M e d 1992;18:170-2. 5. Guidelines for the elective u s e of conscious sedation, d e e p sedation, and general a n e s t h e s i a pediatric patients. Pediatrics 1985;76:317-21. 6. Litwack K. P o s t a n e s t h e s i a care nursing. 2nd ed. St Louis: M o s b y - Y e a r Book, 1995:192-8.
1. S o m e r s o n S, H u s t e d C, Scilia M. Insights into conscious sedation. A m J Nurs 1995;6:26-32.
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