CONTINUING EDUCATION

Guideline Implementation: Moderate Sedation/Analgesia 1.5

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JENNIFER L. FENCL, DNP, RN, CNS, CNOR Continuing Education Contact Hours

Accreditation

indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www .aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Event: #16517 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.

Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Conflict-of-Interest Disclosures

The contact hours for this article expire May 31, 2019. Pricing is subject to change.

Jennifer L. Fencl, DNP, RN, CNS, CNOR, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Purpose/Goal

The behavioral objectives for this program were created by Liz Cowperthwaite, BA, senior managing editor, and Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Van Anderson, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

To provide the learner with knowledge specific to implementing the AORN “Guideline for care of the patient receiving moderate sedation/analgesia.”

Objectives 1. Discuss the RN’s scope of practice related to moderate sedation/analgesia. 2. Describe elements of a preoperative assessment for a patient who may receive moderate sedation/analgesia. 3. Discuss monitoring of the patient undergoing moderate sedation/analgesia. 4. Identify steps the RN should take to ensure safe administration of moderate sedation/analgesia medications. 5. Discuss discharge criteria for a patient who has received moderate sedation/analgesia.

Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.

Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2016.03.001 ª AORN, Inc, 2016

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Guideline Implementation: Moderate Sedation/Analgesia 1.5

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JENNIFER L. FENCL, DNP, RN, CNS, CNOR

ABSTRACT Moderate sedation/analgesia is practiced in a variety of settings and delivered by a variety of health care providers, with a goal of reducing the patient’s anxiety and discomfort during diagnostic and therapeutic procedures. The updated AORN “Guideline for care of the patient receiving moderate sedation/analgesia” provides guidance on RN administration of moderate sedation/analgesia within the scope of nursing practice as defined by the state boards of nursing. The guideline addresses patient selection and assessment, staffing for the procedure, patient monitoring, medication administration, and criteria for postoperative discharge. This article focuses on key points of the guideline to promote safe care throughout the perioperative continuum for a patient receiving moderate sedation/ analgesia. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures. AORN J 103 (May 2016) 501-508. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.03.001 Key words: moderate sedation/analgesia, scope of nursing practice, preoperative assessment, medication administration.

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rocedures requiring sedation have historically been performed in the OR by an anesthesia professional (eg, anesthesiologist, certified RN anesthetist),1 but evolution in patient care delivery has resulted in an increased demand for provision of moderate sedation and analgesia by nonanesthesia providers in procedural settings. Moderate sedation/analgesia in today’s health care environment is performed in a variety of settings (eg, minor procedure rooms, cardiac catheterization laboratories, endoscopy suites, emergency rooms, dentist offices)1-3 and delivered by a variety of health care providers (eg, physician, dentist, RN, physician assistant).1,2

Oftentimes, moderate sedation/analgesia is the preferred intervention for patients undergoing diagnostic and therapeutic procedures for which loss of consciousness is not required (eg, cardiac catheterization, dislocation reduction, endoscopy).4-7 Moderate sedation/analgesia is an effective intervention for

providing a patient with pain relief while also decreasing the patient’s level of discomfort and feelings of anxiety during these procedures.3,5,8 Perioperative RNs who administer moderate sedation/analgesia must practice within the RN scope of practice as defined by their state’s board of nursing and should be knowledgeable and skilled in the safe delivery of moderate sedation/analgesia. The AORN “Guideline for care of the patient receiving moderate sedation/analgesia”9 was updated in December 2015. AORN guideline documents provide guidance based on an evaluation of the strength and quality of the available evidence for a specific subject. The guidelines apply to inpatient and ambulatory settings and are adaptable to all areas where operative and other invasive procedures may be performed. This article elaborates on key takeaways from the guideline document; however, perioperative RNs should review the

http://dx.doi.org/10.1016/j.aorn.2016.03.001 ª AORN, Inc, 2016

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complete guideline for additional information and for guidance when writing and updating policies and procedures. Key takeaways from the AORN “Guideline for care of the patient receiving moderate sedation/analgesia” include the following:
The perioperative RN administering moderate sedation/ analgesia must practice within the scope of nursing practice as defined by his or her state board of nursing and should comply with state advisory opinions, declaratory rules, and other regulations that direct the practice of the RN.
The perioperative RN should perform and document a patient nursing assessment before administering moderate sedation/analgesia.
The perioperative RN administering moderate sedation/ analgesia should continuously care for (ie, monitor and assess)

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the patient throughout the procedure and should have no competing responsibilities.
The perioperative RN should know the recommended dose, recommended dilution, onset, duration, effects, potential adverse reactions, medication compatibility, and contraindications for each medication used during moderate sedation.
The perioperative RN should evaluate the patient for discharge readiness based on specific discharge criteria (Figure 1). The following scenario highlights the key takeaways and other aspects of the AORN guideline. Each key takeaway and the nurse’s actions are then discussed in detail after the scenario.

SCENARIO Before making assignments for the next day’s surgical schedule, the charge nurse at City Hospital reviews the

Figure 1. Key takeaways from the AORN “Guideline for care of the patient receiving moderate sedation/ analgesia.” 502 j AORN Journal

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updated list of perioperative RNs who have successfully completed the hospital’s required moderate sedation/analgesia education. According to the hospital’s policy, the moderate sedation/analgesia education includes classroom instruction, a simulation scenario, and a skills competency checklist that is approved by the director of anesthesia. The policy also states that to administer moderate sedation/analgesia, the RN must maintain current advanced cardiac life support certification. After confirming which RNs are eligible to administer moderate sedation/analgesia, the charge nurse assigns Nurse B and Nurse H to OR 1 for several minor procedures. Nurse B is assigned to be the RN circulator, and Nurse H is assigned to administer moderate sedation/analgesia. The next day, Nurse B goes to OR 1 to start reviewing the preference card for her first assignment. Nurse H enters the room at the same time, and both RNs have an opportunity to discuss the plan of care for the first procedure. Nurse B reviews the preference card and starts gathering the necessary supplies and equipment for the procedure, while Nurse H gathers the supplies and equipment she will need to safely administer moderate sedation/analgesia. Before going to the preoperative holding room to perform her patient interview and nursing assessment, Nurse H verifies that oxygen is available; the electrocardiogram pads, a blood pressure cuff, a capnograph to measure end-tidal carbon dioxide (EtCO2), and a pulse oximeter are staged for placement; and the suction is available and working properly. In addition, she verifies that the monitoring equipment is functioning properly and all monitoring alarms are turned on and audible. Nurse B opens the sterile supplies onto the back table and assists the scrub person with gowning and gloving, while Nurse H heads to the preoperative holding room to perform her patient interview and nursing assessment. The patient, Mrs J, is a 54-year-old woman scheduled for a left breast biopsy. After introducing herself and using two patient identifiers to confirm that Mrs J is the correct patient for this procedure, Nurse H begins her patient interview and nursing assessment. Mrs J tells Nurse H that she has no known allergies. She has undergone only one previous surgery, an appendectomy when she was a child, but she does not recall having any adverse reactions to the anesthesia. Mrs J has been NPO since midnight except for a few sips of water to take amlodipine prescribed for mild hypertension. When Nurse H inquires what other medication she is currently taking, Mrs J shares that she just started to wear a nicotine patch. She has been trying to quit smoking intermittently for the past few years and just started in earnest to quit approximately two months ago. She admits to “sneaking” a few cigarettes when she is feeling stress and that she had one last night. Nurse H asks the patient whether she knows what

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Guideline Implementation: Moderate Sedation/Analgesia

procedure she is undergoing today, and Mrs J correctly describes the procedure. She appears to be a little nervous to have the procedure performed and to receive the results. During the patient interview, Nurse H notes that Mrs J’s vital signs are within normal limits except for a slightly elevated blood pressure of 143/92 mm Hg. Nurse H reviews Mrs J’s chart, checking her height, weight, and body mass index. Nurse H also reviews the history and physical, laboratory results, and the obstructive sleep apnea screening tool and notes nothing to cause concern. She assesses the patient for characteristics of difficult mask ventilation and notes no issues. Using the American Society of Anesthesiologists (ASA) Physical Status Classification, Nurse H assigns Mrs J an ASA II (ie, mild systemic disease), reflecting her smoking history and mild hypertension. As they wait for the surgeon to arrive, Nurse H calls the OR to share her nursing assessment and status update with Nurse B. Nurse B responds that they are set up and ready for the patient. Nurse B then comes to the preoperative area to introduce herself and perform her preoperative assessment. Nurse H collects her supplies to start an IV of 0.9% normal saline. As she finishes inserting a peripheral IV in Mrs J’s right hand, the surgeon arrives to talk to the patient and answer her questions. He marks the surgical site and signs the consent. The surgeon is the licensed independent practitioner who will supervise Nurse H during administration of moderate sedation/analgesia. As such, he has completed a formal training program in the safe administration of sedative and analgesic medications and in supervision of moderate sedation/analgesia administration. Nurse H and the surgeon discuss the sedation plan of care. He plans to use midazolam and fentanyl during the procedure, two medications that are within the scope of practice for Nurse H to administer for moderate sedation/analgesia. Nurse H reviews the organization’s pharmacy information regarding midazolam and fentanyl, including the recommended dosing range and maximum amount that should be given. Immediately before returning to OR 1, she retrieves the medication she will be administering during the procedure from the medication dispensing machine. Nurse H brings the patient to OR 1. Nurse B covers the patient with several warm blankets and introduces the scrub person as part of the surgical team that will be providing care to Mrs J during the procedure. Mrs J safely transfers herself to the OR bed, and Nurse B secures the safety strap over Mrs J’s upper thighs. Nurse B then places the patient’s arms on

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padded arm boards while Nurse H is at the head of the bed placing the electrocardiogram leads, pulse oximeter, EtCO2 monitor, blood pressure cuff, and nasal cannula. Nurse H takes and assesses her first set of vital signs, which are automatically pulled into the electronic health record (EHR). She then turns on the oxygen to 2 L/minute through the nasal cannula and documents the start of that intervention. Nurse H also documents Mrs J’s level of consciousness as alert and oriented to time, date, person, and place, and she documents the site of the peripheral IV. Nurse B calls the surgeon to let him know the patient is in the room, the team is ready, and she will be starting the prep. The surgeon enters the room; after he has gowned and gloved, he leads the team in the time out, confirming the correct patient, the correct laterality, and the correct procedure. After the patient is draped, the surgeon asks Nurse H to administer the first dose of midazolam 2 mg and fentanyl 25 mcg. Nurse H notes that both of these amounts are within the pharmacy’s recommendation for initial dosing. Using closed-loop communication, Nurse H repeats to the surgeon that he would like her to administer 2 mg midazolam and 25 mcg fentanyl. The surgeon confirms the order, and Nurse H administers the first dose of medication. She documents the dose, route, and time both medications were administered in the EHR, and she writes a comment on the effect they had on the patient: “airway maintained, gag reflex intact, responds appropriately to verbal comments, denies discomfort.” Because Nurse B is assigned to be the RN circulator, Nurse H is able to devote her full attention to administering moderate sedation/analgesia. Nurse H continuously monitors Mrs J for her response and reaction not only to the medication but also to the procedure stimuli. Every five minutes, Nurse H collects a set of vital signs to assess for changes, and she also verifies that the vital signs are automatically pulled into the EHR. Nurse H validates Mrs J’s depth of sedation using an objective scale. Mrs J then reacts to a stimulus on the field by verbalizing that she feels slight pain, and Nurse H informs the surgeon. The surgeon stops what he is doing and Nurse H tells him that Mrs J’s vital signs have remained stable; her airway, ventilation, and cardiovascular function remain intact; and she has appropriately responded to verbal commands. The surgeon asks Nurse H to administer an additional 2 mg midazolam and 25 mcg fentanyl. Again using closed-loop communication, Nurse H repeats the order and the surgeon confirms it before she administers the second dose of medication. Nurse H documents the dose, route, and time both medications were administered and writes a comment on the effect they had on 504 j AORN Journal

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the patient: “airway maintained, gag reflex intact, responds appropriately to verbal comments, denies discomfort.” As the surgeon is completing the procedure, Nurse B calls the postanesthesia care unit (PACU) phase 2 level of care to give a brief report. Nurse H transports the patient to the PACU and gives a complete hand-over report to Nurse M, who will be caring for Mrs J until she meets the criteria for discharge. Mrs J’s vital signs continue to remain stable throughout her stay in PACU phase 2. After 30 minutes, Mrs J has returned to her preprocedure baseline mental status and says she has no nausea. She has been given acetaminophen and oxycodone for pain, and she has consistently reported her pain level as a 2 out of 10. Mrs J’s husband meets her in the recovery area, where Nurse M reviews all discharge instructions verbally with both of them. The discharge instructions include postdischarge diet and activity level, information on discharge medication, signs and symptoms of an infection, and a telephone number to call in case of an emergency. Nurse M also explains that, according to the organization’s policy, Mrs J will receive a follow-up telephone call to assess her pain level, presence of nausea and vomiting, oral intake and output (ie, that she is voiding without issue), activity level, and presence of bleeding or other discharges. Nurse M prints two copies of all discharge instructions, one for Mrs J and her husband to take home with them and one that will be scanned into the chart at a later time. Nurse M then takes Mrs J via wheelchair to the hospital entrance, where her husband helps her into their car.

KEY TAKEAWAYS DISCUSSION The key takeaways from the AORN “Guideline for care of the patient receiving moderate sedation/analgesia” address being knowledgeable about RN scope of practice as defined by the applicable state board of nursing, key elements for a thorough patient assessment, roles and responsibilities for the perioperative RN assigned to administer moderate sedation/analgesia during the procedure, the medication being administered, and evaluation of the patient for discharge. These takeaways do not cover the entire guideline. Rather, they help the reader focus on important or new information that should be implemented into perioperative practice.

Scope of Nursing Practice The nurse’s scope of practice is defined by the state nurse practice act and the board of nursing. Every US state and territory has a nurse practice act that establishes a board of nursing. The board of nursing develops the rules and regulations under which a nurse can safely practice nursing, which

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serve a vital role in protecting the public from harm.9,10 Each state board of nursing also regulates which medications nonanesthesia providers can administer. Before administering any type of moderate sedation/analgesia, the perioperative RN should thoroughly review his or her state’s nurse practice act as well as rules, regulations, and guidelines that govern nursing practice related to administering moderate sedation/analgesia.1,9,11 In addition, a qualified licensed independent practitioner should supervise the perioperative RN who is administering moderate sedation/analgesia.1,2,11-14 It is the responsibility of leaders and personnel at each health care organization to develop appropriate policy and procedures, conduct initial and ongoing education, and verify competency for all those who will be administering moderate sedation/analgesia in correlation with the state’s board of nursing and other regulatory bodies (eg, Centers for Medicare & Medicaid Services).1,7,9,15 An interprofessional team should develop and update the policy and procedures on moderate sedation/analgesia for the organization, understanding that the director of anesthesia services is responsible for all anesthesia services provided in an organization.7,9,16 Initial and ongoing education that organizations develop may include didactic content, simulation, validation of skills, and examination.7,9 In the scenario presented, several examples show consideration of the perioperative RN’s scope of practice and evidence of the organization’s policy and procedures, education, and competency verification measures for those who will be administering moderate sedation/analgesia. Before making assignments for the day, the charge nurse reviewed a listing of all the perioperative RNs who were eligible to administer moderate sedation/analgesia because they had successfully completed the hospital education requirement as defined by the policy and procedures. The RNs were also required to maintain current advanced cardiac life support status. In the scenario, the qualified licensed independent practitioner who supervised the perioperative RN administering moderate sedation/analgesia was the surgeon.

Nursing Assessment The perioperative RN should perform a thorough preoperative assessment to determine whether the patient is a good candidate for RN-administered moderate sedation/analgesia and to identify potential risk of adverse outcomes.9,13,17,18 The patient assessment should include a review of the patient’s allergies, age, height, weight, body mass index, history and physical, medication use, test results, vital signs, and NPO status. The assessment should also include specific elements regarding the administration of moderate sedation/ analgesia, such as ASA status, risk of obstructive sleep apnea,

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and characteristics that may indicate difficult mask ventilation.2,9,19,20 The perioperative patient assessment is a means for gathering essential patient information that will not only aid in selecting and implementing appropriate intraoperative interventions but also provide baseline data for evaluating the patient’s response to moderate sedation/analgesia.9 As part of the perioperative patient assessment, if a patient is assessed to have significant comorbidities or an ASA classification of unstable ASA III, ASA IV, or above, the perioperative RN should consult with an anesthesia professional to determine the most appropriate care.9,21-23 In this scenario, Nurse H performed a thorough perioperative patient assessment and determined that the patient was an appropriate candidate for RN-administered moderate sedation/analgesia. Nurse H assigned the patient an ASA II classification, reflecting her mild hypertension and smoking history, which indicates no significant comorbidities that would require consultation with an anesthesia professional. As part of the preoperative assessment, Nurse H collaborated with the surgeon on the sedation plan of care before taking Mrs J to the OR for the procedure.

Continuous Care By continuously monitoring and assessing the patient during moderate sedation/analgesia, the perioperative RN is able to directly observe and evaluate the patient for significant changes to physiological (eg, vital signs, pulse oxygenation) and psychological (eg, level of consciousness, comfort, anxiety level) status and can detect and quickly respond to early complications or an adverse reaction.2,7,9,24 Clinical monitors used to assist in automatic monitoring of the patient during the procedure (eg, pulse oximeter, EtCO2 monitor) should be audible to alert the perioperative RN of significant changes to the patient’s status.9,23,24 To safely and continuously monitor the patient during RN-administered moderate sedation/analgesia, there should be no competing demands on the nurse administering moderate sedation/analgesia.7,9,25 In this scenario, the charge nurse assigned two perioperative RNs to care for Mrs J, one as the RN circulator and one to administer moderate sedation/analgesia. With a second perioperative RN assigned to the room, Nurse H was able to devote her full attention to administering moderate sedation/ analgesia and monitoring the patient without competing demands. As Nurse H prepared the room, she verified that her monitoring equipment was working properly and that the alarms on the monitoring equipment were audible. During the procedure, Nurse H continuously monitored the patient. She took the first set of vital signs before the AORN Journal j 505

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Resources for Implementation AORN Syntegrity. http://www.aorn.org/aorn-org/education/ facility-solutions/aorn-syntegrity. Guideline Implementation Topics: Managing the Patient Receiving Moderate Sedation/Analgesia web page. AORN, Inc. http://www.aorn.org/guidelines/guideline-implementation -topics/patient-care/managing-the-patient-receiving-moderate -sedation-analgesia. ORNurseLink. http://www.ornurselink.org/home. Perioperative Competency Verification Tools and Job Descriptions [USB Drive]. Denver, CO: AORN, Inc; 2016. http://www.aorn.org/guidelines/clinical-resources/publications/ perioperative-competency-verification-tools-and-job-descriptions. Policy and Procedure Templates [CD-ROM]. 4th ed. Denver, CO: AORN, Inc; 2015. http://www.aorn.org/guidelines/clinical -resources/publications/policy-and-procedure-templates/. Editor’s notes: Syntegrity is a registered trademark and ORNurseLink is a trademark of AORN, Inc, Denver, CO.

procedure started as the baseline and then took a set of vital signs every five minutes throughout the procedure to assess for any significant changes. Furthermore, Nurse H validated Mrs J’s depth of sedation using an objective scale during the entire procedure and documented her assessment. Nurse H also monitored Mrs J for changes in her response and reaction to the medication and to the procedure stimuli itself.

Medication Knowledge To safely administer moderate sedation/analgesia, it is important for the perioperative RN to have knowledge of each medication that will be used, including desired effect, recommended doses, duration of action, adverse effects, and contraindications.9,24 Before medication administration, the perioperative RN should verify the medication orders placed by the licensed independent practitioner and ensure supplemental oxygen is immediately available in case the patient experiences oxygen desaturation.2,9,24,26 It is also important that the perioperative RN accurately document any moderate sedation/analgesia administered in the patient’s record, including the name of the medication, strength, dose, route, time, patient response, and any adverse reactions.9,26 In this scenario, before going to the OR, Nurse H and the surgeon, as the licensed independent practitioner supervising her, discussed the sedation plan of care for Mrs J, including the 506 j AORN Journal

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What Else Is in the Guideline?

Read the AORN “Guideline for care of the patient receiving moderate sedation/analgesia”1 to learn what the evidence says about the following:
What screening tools are effective for determining obstructive sleep apnea? (Recommendation II.d.1.)
How does obstructive sleep apnea screening differ for pediatric patients? (Recommendation II.d.2.)
How and why does the perioperative RN’s role change when propofol is administered? (Recommendation III.b.2.)
What are the potential benefits of using bispectral index monitoring to measure the patient’s level of sedation? (Recommendation III.c.8.)
What emergency equipment and supplies should be available in every location where moderate sedation is administered? (Recommendations III.e.1) 1. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:617-648.

medications to be used for moderate sedation/analgesia during the procedure. Nurse H also reviewed the organization’s pharmacy information regarding midazolam and fentanyl, including the recommended dosing range and maximum amount that should be given. During the procedure, Nurse H used closedloop communication by repeating to the surgeon his order for medication before administration, both at the beginning of and during the procedure. After administering the medication for each order, she documented in the patient’s record the medication dose, route, and time it was administered, and she included a comment on the effect it had on the patient. Nurse H proactively provided supplemental oxygen at 2 L/minute via nasal cannula to prevent oxygen desaturation during the procedure.

Discharge Readiness Many complications (eg, respiratory depression, aspiration2) can occur during the postoperative phase of care, and many of the medications used for moderate sedation/analgesia affect cognition, memory, and motor function. Therefore, essential care in this phase includes medical supervision, patient monitoring by a qualified provider (eg, the PACU RN), and determining that the patient meets the criteria for discharge.2,9,24 Specific elements signifying that the patient may be ready for discharge should include mental status returned to baseline, stable vital signs, an adequate time interval since administration of the last moderate sedation/ analgesia medication, absence of nausea, sufficient pain

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management, and arrangement of safe transportation with a responsible adult.2,9,24,26-28 All patients and their caregivers must receive both oral and written discharge instructions before discharge.9,26,28 In addition, a copy of the written discharge instructions should be placed in the patient’s chart.9,29 In the scenario, Mrs J was cared for by a PACU RN in the phase 2 area. Mrs J’s vital signs were monitored and remained stable throughout her course of care. After Mrs J returned to her preprocedure baseline mental status and denied any nausea, her pain was assessed to be adequately managed. Nurse M gave Mrs J and her husband oral and written discharge instructions before Mrs J was discharged from the hospital, and her husband drove her home. Not specially mentioned in this scenario and important to consider is that patient discharge could be prolonged or delayed for pediatric patients, patients with obstructive sleep apnea, patients who received morphine or an antagonist during the course of care, or patients who experience prolonged nausea and vomiting.9

CONCLUSION Perioperative RNs who provide moderate sedation/analgesia should proactively pursue information regarding moderate sedation/analgesia to include understanding of the RN’s scope of practice, key elements of the patient assessment, roles and responsibilities for the perioperative RN assigned to administer moderate sedation/analgesia, the medication being administered, and criteria for patient discharge. By having a thorough understanding of moderate sedation, perioperative RNs can deliver exceptional and safe patient care.




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7. Spruce L. Back to basics: procedural sedation. AORN J. 2015; 101(3):346-350. 8. Conway A, Douglas C, Sutherland J. Capnography monitoring during procedural sedation and analgesia: a systematic review protocol. Syst Rev. 2015;4:92. 9. Guideline for care of the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:617-648. 10. Nurse Practice Act, Rules & Regulations: Nurse Practice Acts Guide and Govern Nursing Practice. National Council of State Boards of Nursing. https://www.ncsbn.org/nurse-practice-act.htm. Accessed February 8, 2016. 11. Ketcham E, Ketcham C, Bushnell FL. Patient safety and nurses’ role in procedural sedation. Emerg Nurse. 2013;21(6):20-24. 12. Statement on Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals. American Society of Anesthesiologists; 2011. http://www.asahq .org/w/media/Sites/ASAHQ/Files/Public/Resources/standards -guidelines/statement-on-granting-privileges-for-administration-of -moderate-sedation-to-non-anesthesiologist.pdf. Accessed February 8, 2016. 13. Statement on the Anesthesia Care Team. American Society of Anesthesiologists; 2013. http://www.asahq.org/w/media/Sites/ ASAHQ/Files/Public/Resources/standards-guidelines/statement-on -the-anesthesia-care-team.pdf. Accessed February 8, 2016. 14. Heneghan S, Myers J, Fanelli R, Richardson W; Society of American Gastrointestinal Endoscopic Surgeons. Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for office endoscopic services. Surg Endosc. 2009;23(5):1125-1129. 15. Standards of perioperative nursing. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:693-732. 16. 42 CFR x482.51. Condition of participation: surgical services. 2011. Centers for Medicare & Medicaid Services. http://www.gpo .gov/fdsys/granule/CFR-2011-title42-vol5/CFR-2011-title42-vol5 -sec482-51. Accessed February 8, 2016. 17. Chapman W. Administration of sedation in endoscopy: guidance, risks and skill requirements. Gastrointest Nurs. 2010;8(2):14-17. 18. Gupta A. Preoperative screening and risk assessment in the ambulatory surgery patient. Curr Opin Anaesthesiol. 2009;22(6): 705-711. 19. El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009;109(6):1870-1880. 20. Phero JC, Rosenberg MB, Giovannitti JA Jr. Adult airway evaluation in oral surgery. Oral Maxillofac Surg Clin North Am. 2013; 25(3):385-399. 21. Caperelli-White L, Urman RD. Developing a moderate sedation policy: essential elements and evidence-based considerations. AORN J. 2014;99(3):416-430. 22. Gorospe EC, Oxentenko AS. Preprocedural considerations in gastrointestinal endoscopy. Mayo Clin Proc. 2013;88(9):1010-1016. 23. Lichtenstein DR, Jagannath S, Baron TH, et al; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815-826. 24. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for

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sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. Hurford WE, Staubach KC. A hospital policy for procedural sedation in the nonintubated patient. Int Anesthesiol Clin. 2013;51(2): 1-22. Cote CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587-2602. Sury M, Bullock I, Rabar S, DeMott K; Guideline Development Group. Sedation for diagnostic and therapeutic procedures in children and young people: summary of NICE guidance. BMJ. 2010;341:c6819. Voynarovska M, Cohen LB. The role of the endoscopy nurse or assistant in endoscopic sedation. Gastrointest Endosc Clin North Am. 2008;18(4):695-705.

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May 2016, Vol. 103, No. 5 29. 42 CFR x416: Ambulatory surgical services. 2011. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations -and-Guidance/Legislation/CFCsAndCoPs/ASC.html. Accessed February 8, 2016.

Jennifer L. Fencl, DNP, RN, CNS, CNOR, is a clinical nurse specialist, Operative Services, and the interim executive director of clinical support and research, Cone Health, Greensboro, North Carolina. Dr Fencl has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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EXAMINATION

Continuing Education: Guideline Implementation: Moderate Sedation/Analgesia 1.5

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PURPOSE/GOAL To provide the learner with knowledge specific to implementing the AORN “Guideline for care of the patient receiving moderate sedation/analgesia.”

OBJECTIVES 1. 2. 3. 4. 5.

Discuss the RN’s scope of practice related to moderate sedation/analgesia. Describe elements of a preoperative assessment for a patient who may receive moderate sedation/analgesia. Discuss monitoring of the patient undergoing moderate sedation/analgesia. Identify steps the RN should take to ensure safe administration of moderate sedation/analgesia medications. Discuss discharge criteria for a patient who has received moderate sedation/analgesia.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.

QUESTIONS 1. The RN’s scope of practice is determined by the state’s nurse practice act and rules and regulations developed by the state’s board of nursing. a. true b. false 2. The perioperative RN who is administering moderate sedation/analgesia should be supervised by a. an RN circulator. b. a nurse manager. c. a qualified licensed independent practitioner. d. a surgeon. 3. Specific preoperative assessment elements for determining whether a patient is a good candidate for moderate sedation/analgesia include the patient’s 1. American Society of Anesthesiologists (ASA) Physical Status Classification. 2. reaction to procedure stimuli. 3. risk for difficult mask ventilation. 4. risk for obstructive sleep apnea. a. 1 and 2 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

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4. The perioperative RN should consult with an anesthesia professional to determine the most appropriate care for a patient with a classification of 1. ASA III. 2. unstable ASA III. 3. ASA IV. 4. ASA V. a. 1 and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 5. The perioperative RN providing care to the patient during moderate sedation/analgesia should directly observe and evaluate the patient for psychological status changes, including 1. anxiety level. 2. comfort. 3. level of consciousness. 4. pulse oxygenation. 5. vital signs. a. 4 and 5 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, 4, and 5

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6. Two RNs are assigned to the OR for moderate sedation/ analgesia procedures so that a. one nurse can circulate and one can scrub. b. one nurse can administer moderate sedation/analgesia and one can circulate. c. one nurse can both administer moderate sedation/ analgesia and circulate and one nurse can scrub. d. one nurse can administer moderate sedation/analgesia and scrub and one can circulate. 7. Before administering moderate sedation/analgesia medications, the perioperative RN should 1. ensure supplemental oxygen is immediately available. 2. know the adverse effects and contraindications of each medication. 3. know the desired effect, dose, and duration of action of each medication. 4. verify the medication orders placed by the licensed independent practitioner. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4

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8. In the scenario, each time medication is administered, the nurse documents the 1. dosage. 2. effect on the patient. 3. route. 4. time of administration. a. 1 and 4 b. 2 and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4 9. Elements that signify a patient may be ready for discharge include that the patient has 1. returned to baseline mental status. 2. received an antagonist during the course of care. 3. stable vital signs. 4. sufficient pain management. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4 10. All patients and their caregivers must receive both oral and written discharge instructions. a. true b. false

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LEARNER EVALUATION

Continuing Education: Guideline Implementation: Moderate Sedation/Analgesia 1.5 www.aornjournal.org/content/cme

T

his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.

8.

Will you be able to use the information from this article in your work setting? 1. Yes 2. No

9.

Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)

9A.

How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________

9B.

If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________

10.

Our accrediting body requires that we verify the time you needed to complete the 1.5 continuing education contact hour (90-minute) program: ______________

OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the RN’s scope of practice related to moderate sedation/analgesia. Low 1. 2. 3. 4. 5. High 2.

Describe elements of a preoperative assessment for a patient who may receive moderate sedation/analgesia. Low 1. 2. 3. 4. 5. High

3.

Discuss monitoring of the patient undergoing moderate sedation/analgesia. Low 1. 2. 3. 4. 5. High

4.

Identify steps the RN should take to ensure safe administration of moderate sedation/analgesia medications. Low 1. 2. 3. 4. 5. High

5.

Discuss discharge criteria for a patient who has received moderate sedation/analgesia. Low 1. 2. 3. 4. 5. High

CONTENT 6.

To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High

7.

To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

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