Moderate Sedation. Saint Thomas Health Services Clinical Education. System-Wide elearning Course. Content/Screen Layout.

Transcription

1 Title: Moderate Seda%on System- Wide elearning Course Subject: Moderate Seda%on Audio: No Slide: 1 Supported Learning Objec6ve: N/A Graphics: Yes Video: No Saint Thomas Health Services Clinical Education Moderate Sedation System-Wide elearning Course

2 Title: Moderate Seda%on System- Wide elearning Course Subject: Learning Objec%ves Audio: No Slide: 2 Supported Learning Objec6ve: N/A Graphics: No Video: No Learning Objectives Upon successful completion of this course nurses will be able to: 1. Differentiate between the four levels of sedation. 2. List the equipment needed for monitoring a patient receiving moderate sedation. 3. Identify personnel authorized to administer moderate sedation. 4. Identify medications commonly used in moderate sedation. 5. Identify appropriate antidotes to medications commonly used in moderate sedation. 6. Describe the process for monitoring a patient receiving moderate sedation. 7. Recognize the approval criteria for sedation. 8. List the criteria for patient discharge. Sub%tle Area

3 Title: Moderate Seda%on System- Wide elearning Course Subject: Introduc%on Audio: Yes Slide: 3 Supported Learning Objec6ve: N/A Graphics: Yes Video: No MaA, Fade in bullets in sync with narra%on. The following applies to all patients requiring sedation: The standard of care is universal The hospital policy applies to all patients The hospital policy does not include Additionally, the hospital policy does not include Please refer to your hospital s policy for campus-specific nuances. Sub%tle Area

4 Title: Moderate Seda%on System- Wide elearning Course Subject: Moderate Seda%on Facts Audio: Yes Slide: 4 Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: No Video: No Fade in bullets in sync with narra%on. Moderate Sedation Is Typically Administered In: Emergency Departments Intensive Care Units Cardiovascular (CV) Labs Endoscopy Suites Nuclear Medicine/Imaging Sub%tle Area

5 Title: Moderate Seda%on System- Wide elearning Course Subject: Levels of Seda%on & Defini%ons Audio: Yes Slide: 5 Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: Yes Video: No Each buron and its text should fade in with the first line of narra%on in sync with minimal, moderate, deep, and anesthesia The corresponding text to be used with each buron is on the next four slides. Levels of Sedation & Definitions Click each phrase to view definitions. Minimal Sedation (Anxiolysis) Moderate Sedation Deep Sedation Anesthesia Sub%tle Area

6 Title: Moderate Seda%on System- Wide elearning Course Subject: Levels of Seda%on Defini%ons Audio: No Slide: 5a Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: Yes Video: No This is the text to correspond with the Moderate Seda%on buron as learners click for more informa%on. Levels of Sedation Definitions Minimal Sedation (Anxiolysis) The administration of medications for the reduction of anxiety. In this stage the following should be present: Normal respirations Normal eye movements Intact protective reflexes Amnesia may or may not be present with minimal sedation. The patient is technically awake, but under the influence of the medication administered. Sub%tle Area

7 Title: Moderate Seda%on System- Wide elearning Course Subject: Levels of Seda%on Defini%ons Audio: No Slide: 5b Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: Yes Video: Yes This is the text to correspond with the Moderate Seda%on buron as learners click for more informa%on. Levels of Sedation Definitions Moderate Sedation A medically controlled state of depressed consciousness that: Allows protective reflexes to be maintained. Loss of protective reflexes is defined as an inability to handle secretions without aspiration. The loss of protective reflexes can be assumed to correlate with the loss of protective eyelid reflexes. Retains the patient s ability to maintain a patent airway independently and continuously. Permits appropriate response by the patient to physical stimulation or verbal command. Sub%tle Area

8 Title: Moderate Seda%on System- Wide elearning Course Subject: Levels of Seda%on Defini%ons Audio: No Slide: 5c Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: Yes Video: No This is the text to correspond with the Moderate Seda%on buron as learners click for more informa%on. Levels of Sedation Definitions Deep Sedation A medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused: It may be accompanied by a partial or complete loss of protective reflexes AND Includes the inability to maintain a patent airway independently AND Includes the inability to respond purposefully to physical stimulation or verbal command. If protective reflexes or the ability to maintain an airway independently are lost, this period should be brief, recovery should be quick, and physiologic changes minimal.

9 Title: Moderate Seda%on System- Wide elearning Course Subject: Levels of Seda%on Defini%ons Audio: Yes Slide: 5d Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: Yes Video: No This is the text to correspond with the Moderate Seda%on buron as learners click for more informa%on. Levels of Sedation Definitions Anesthesia This level consists of general anesthesia and spinal or major regional anesthesia and does not include local anesthesia. General anesthesia is a medically controlled loss of consciousness during which patients are not arousable even by painful stimuli. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Sub%tle Area

10 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 6 Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: A patient undergoing colonoscopy receives 1 mg of versed and 50 mcg of fentanyl prior to the procedure. 5 minutes after receiving the medication, the patient is drowsy, but awakens to voice and light physical stimulation. The patient is able to tell the nurse his full name and can hold up two fingers on command. The patient s level of sedation is: A. Minimal B. Moderate C. Deep D. Anesthesia

11 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 7 Supported Learning Objec6ve: Differen%ate between the four levels of seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: A patient needs to have an MRI of her spine. The patient tells her nurse that she experiences claustrophobia when she is in a small, confined space. The nurse asks the doctor for an order for an anxiolytic medication. After 0.5mg of Ativan is given, the patient remains alert and oriented times three and able to follow commands. The patient reports that she feels less anxious. This is an example of what type of sedation? A. Minimal B. Moderate C. Deep D. Anesthesia

12 Title: Moderate Seda%on System- Wide elearning Course Subject: Moderate Seda%on Medica%ons Audio: Yes Slide: 8 Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: Yes Video: Yes MaR, an SME- supplied chart of moderate seda%on medica%ons will be presented to learners upon clicking the buron to display the chart. Chart is on the next two slides. Moderate Sedation Medications Dosage varies according to: Age Weight Physical condition Other clinical considerations Procedure Click here to display chart. Sub%tle Area

13 Title: Moderate Seda%on System- Wide elearning Course Subject: Moderate Seda%on Medica%ons Audio: No Slide: 8a Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: Yes Video: Yes Medications Commonly Used For Moderate Sedation Category Medication Usual Dose Onset to Sedation/ Duration of Action Half-life Contraindications/Special Considerations Benzodiazepine Antidote: Romazicon Diazepam (Valium) 2-20 mg IV minutes prior to procedure Titrate to effect 1-5 minutes/< 1 hour 30 hours Cautious use in the elderly and those with renal or hepatic impairment Benzodiazepine Antidote: Romazicon Midazolam (Versed) 1 mg Titrate to effect 2-5 minutes/ 2 hours 2.5 hours Total dose should not exceed 5 mg for adults < 60 yr and < 3.5mg for adults > 60 years Has NO analgesic properties Use with caution in patients with renal and/or hepatic impairment. Contraindicated in acute narrow angle glaucoma. Not recommended in pregnancy. Administer slowly to avoid hypotension, apnea, respiratory arrest-especially in elderly and debilitated patient. Patients should not use alcohol or CNS depressants for 24 hours after administration unless specifically approved by physician. Opioid Antidote: Narcan Morphine 2-15 mg Titrate in 1-2 mg increments Give slowly 1-3 minutes/ 4-5 hours hours Hypotension and respiratory depression are the most common side effects Opioid Antidote: Narcan Fentanyl (Sublimaze) 2-5mcg/kg Titrate to effect 1-3 minutes/ 1 hour hours times more potent than morphine Administer over at least one minute to avoid muscular rigidity.

14 Title: Moderate Seda%on System- Wide elearning Course Subject: Moderate Seda%on Medica%ons Audio: No Slide: 8b Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: Yes Video: Yes Medications Commonly Used For Moderate Sedation (cont d) Category Medication Usual Dose Onset to Sedation/ Duration of Action General Anesthetic Hypnotic Propofol (Diprovan) 1 mg/kg followed by 0.5 mg/ kg q 3-5 minutes prn for maintained sedation. Average 30 sec./ 3-10 minutes (dose dependent) Half-life minutes Contraindications/Special Considerations Half-life can last up to several hours with continuous infusions. IV push propofol can only be administered by an Anesthesiologist or Emergency Department MD. A smaller dose is required when used in conjunction with narcotics. Wait at least 3-5 minutes between doses to assess effects on patient. Avoid in egg- and soy-allergic patients. Barbiturate (Ultra-short acting) No reversal agent Methohexital (Brevital) 0.75 to 1 mg/kg IV; can be re-dosed 0.5 mg/kg every 2 to 5 minutes as needed Anesthetic Ketamine Adults: I.M.: 2-4 mg/kg I.V.: mg/kg Continuous I.V. infusion: 2-7 mcg/kg/minute Pediatrics: Oral: 5-8 mg/kg for 1 dose (mixed in juice or cola) 30 minutes prior to procedure I.M.: 4-5 mg/kg/dose I.V.: mg/kg/dose Continuous I.V. infusion: 5-20 mcg/kg/minute Atropine can be given 1-2 minutes prior to administration to reduce salivation 2 to 45 seconds/ 3.6 to 8.2 minutes Intravenously: 30 sec-1 minute/ 5-15 minutes Intramuscular: 3-4 minutes/ minutes 1-4 minutes Caution with: geriatric patients, obstructive pulmonary disease, debilitated patients, extreme obesity Primarily used in the pediatric population Full recovery can take up to 2 hours Use with caution in patients with coronary artery disease Contraindicated in pregnancy Side effects include: Nystagmus, hypersalivation and laryngospasm (rare). Emergence reactions can occur and include vivid, unpleasant dreams, visual hallucinations, bizarre/ psychotic behaviors Airway reflexes are protected

15 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 9 Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: A patient receives 1mg of versed before a bronchoscopy. One minute later, the patient tells the physician and nurse that he continues to feel anxious and asks if he can receive additional medication. An appropriate response from the nurse would be: A. This medication takes 2-5 minutes to take effect. Let s wait another minute and reassess how you are feeling. B. Sure, you can receive more versed. Let me ask the doctor how much additional medication I can give you. C. No, I cannot hold up the procedure to give you more medication. The doctor would like to begin the bronchoscopy right away. D. You ll be fine. Just try and relax and you will feel better.

16 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 10 Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: Fentanyl should be administered slowly via IV push to avoid which of the following adverse effects: A. Hypotension B. Anaphylaxis C. Over sedation D. Chest wall muscle rigidity

17 Title: Moderate Seda%on System- Wide elearning Course Subject: Reversal Agents Audio: Yes Slide: 11 Supported Learning Objec6ve: Iden%fy appropriate an%dotes to medica%ons commonly used in moderate seda%on. Graphics: Yes Video: No Chart is on the next slide. Reversal Agents Flumazenil (Romazicon) Naloxone (Narcan) Click here to display chart. Sub%tle Area

18 Title: Moderate Seda%on System- Wide elearning Course Subject: Reversal Agents Audio: No Slide: 11a Supported Learning Objec6ve: Iden%fy appropriate an%dotes to medica%ons commonly used in moderate seda%on. Graphics: Yes Video: No Reversal Agents For Moderate Sedation Medications Category Medication Usual Dose Onset to Sedation/Duration of Action Half-life Contraindications/Special Considerations Reversal Agent Flumazenil (Romazicon) 0.2 mg IV over 15 seconds x 2, 60 seconds apart. Reversal should be seen within 2 minutes. Peak effects occur in 10 minutes with duration of 20 minutes to 3 hours. 1-2 minutes 1 hour 54 minutes Serious adverse reactions may occur in high-risk patients so use smallest dose that is effective. May provoke panic attack in those with panic disorder. Adverse reactions: nausea, vomiting, and dizziness Contraindicated in tricyclic antidepressant overdoses and patients receiving benzodiazepines for seizures. Use with caution in patients receiving long-term benzodiazepine treatment. Reversal Agent Naloxone (Narcan) mg Repeat at 2-3 min intervals Max dose: 10mg in adults 2 minutes 45 minutes minutes Adverse reactions: B/P changes, irritability, arrhythmias, pain recurrence that may cause tachycardia or hypertension. Use with caution in addict or detoxified patients-give ¼ usual dose.

19 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 12 Supported Learning Objec6ve: Iden%fy appropriate an%dotes to medica%ons commonly used in moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: Following the administration of 3mg of Versed, you note that an adult patient s blood pressure has dropped by 20mmHg, he is difficult to awaken, and the SpO2 is now 84% (from 97% prior to administration of the drug). Which of the following reactions would be most appropriate initially? A. Elevate the patient s legs B. Give a 500mL fluid bolus C. Give Romazicon (Flumazenil) immediately D. Check the airway and assist ventilations

20 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 13 Supported Learning Objec6ve: Iden%fy appropriate an%dotes to medica%ons commonly used in moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: An appropriate initial dose of Narcan given to a patient following a moderate sedation procedure is: A. 1-2 mg B mg C mg D mcg

21 Title: Moderate Seda%on System- Wide elearning Course Subject: Assessment & Approval For Seda%on Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Fade in bullets in sync with narra%on. The voiceover script will conclude a`er bullet number 5, and its subsequent text will display on screen w/o voiceover. MaA, please use a clipboard graphic here to stress the concept of accoun%ng for the items on the checklist. Content/Screen Layout Assessment & Approval For Sedation Audio: Yes Slide: 14 Graphics: Yes Video: No

22 Title: Moderate Seda%on System- Wide elearning Course Subject: Assessment & Approval For Seda%on Audio: Yes Slide: 15 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: Yes Video: No Fade in bullets in sync with narra%on. Assessment & Approval For Sedation The proceduralist must document the ASA score in one of the following manners: In the progress notes, or On the consent for procedure, or In the history and physical Sub%tle Area

23 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 16 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: Which of the following is NOT an appropriate manner in which to document a patient s ASA score: A. On the time-out form B. In the progress notes C. On the consent for procedure D. In the history and physical

24 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: Yes Slide: 17 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: The patient undergoing moderate sedation will be assessed and deemed an appropriate candidate for moderate sedation by: A. The physician performing the procedure B. CRNA/anesthesiologist performing the procedure C. The nurse D. Both A & B

25 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent- Monitoring Equipment Audio: Yes Slide: 18 Supported Learning Objec6ve: List the equipment needed for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No Fade in bullets in sync with narra%on. Patient-Monitoring Equipment 1. Suction at bedside 2. Emergency Cart with defibrillator and emergency/reversal drugs 3. Oxygen and delivery devices (cannula, mask) 4. Appropriate oral and nasal airways (pediatric and adult) 5. Cardiac monitor 6. Pulse Oximeter 7. Non-invasive blood pressure monitor 8. Bag/mask ventilation apparatus 9. Intubation tray 10. IV supplies and equipment Sub%tle Area

26 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 19 Supported Learning Objec6ve: List the equipment needed for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No MaA, Please create a drag and drop ac%vity where the learner has to drag the required equipment Knowledge Check What equipment is needed for monitoring a patient receiving moderate sedation? Drag your selections into the box to the right. Select all that apply. 1. Suction at bedside 2. Emergency Cart with defibrillator and emergency/reversal drugs 3. Restraints 4. Oxygen and delivery devices (cannula, mask) 5. Appropriate oral and nasal airways (pediatric and adult) 6. Blood-transfusion supplies 7. Cardiac monitor 8. Pulse Oximeter 9. Non-invasive blood pressure monitor 10. Bag/mask ventilation apparatus 11. Smelling salts 12. Intubation tray 13. IV supplies and equipment

27 Title: Moderate Seda%on System- Wide elearning Course Subject: Authorized Personnel Audio: Yes Slide: 20 Supported Learning Objec6ve: Iden%fy personnel authorized to administer moderate seda%on. Graphics: Yes Video: No Fade in bullets in sync with narra%on. Authorized Personnel Physicians Privileging criteria shall include: Verification of competency Practitioners who have appropriate privileges Sub%tle Area

28 Title: Moderate Seda%on System- Wide elearning Course Subject: Authorized Personnel Audio: Yes Slide: 21 Supported Learning Objec6ve: Iden%fy personnel authorized to administer moderate seda%on. Graphics: Yes Video: No Fade in bullets in sync with narra%on. MaR, there is a lot of text in the v/o script, so I underlined the text that should be in sync with the bullets. Authorized Personnel Registered Nurses A registered nurse must be present In ancillary departments Reasonable expectation of deep sedation Competency Demonstration or Maintenance of Skills Records Monitoring and documenting the patient s physiologic parameters is the only responsibility of this RN during the procedure. The Main O.R. desk may be contacted to locate an anesthesiologist for assistance 24-hours a day. Sub%tle Area

29 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 22 Supported Learning Objec6ve: Iden%fy personnel authorized to administer moderate seda%on. Graphics: Yes Video: No Knowledge Check Patient Scenario: The role of the nurse during a moderate sedation procedure includes all of the following EXCEPT: A. Monitoring the patient and the patient s vital signs B. Documenting the patient s physiologic parameters C. Caring for additional patients in her assignment D. Recognizing and documenting/reporting cardiac arrhythmias

30 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 23 Supported Learning Objec6ve: Iden%fy personnel authorized to administer moderate seda%on. Graphics: Yes Video: No Knowledge Check Patient Scenario: Any registered nurse who works in an area where patients undergo procedures requiring moderate sedation, must update his or her competency in moderate sedation: A. Every 6 months B. Annually C. Every 2 years D. Initially on orientation only

31 Title: Moderate Seda%on System- Wide elearning Course Subject: Procedure Audio: Yes Slide: 24 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No MaA, Learners will click burons to display informa%on in pop- up boxes; content is on the next three slides. The following guidelines apply to the moderate sedation standard of care. Click for more information NPO status on chart Click for more information Informed written consent History and physical Sub%tle Area

32 Title: Moderate Seda%on System- Wide elearning Course Subject: Procedure Audio: Yes Slide: 24a Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No This is the content for the NPO Status pop- up box. NPO Status These suggested guidelines apply only to healthy patients. Adults Solids Clear Liquids Breast Milk Formula 6-8 hours or NPO P MN 2-4 hours Children 6-8 hours 2 hours 4 hours 6 hours Click for more NPO Status information Sub%tle Area

33 Title: Moderate Seda%on System- Wide elearning Course Subject: Procedure Audio: Yes Slide: 24b Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No This is the content for the NPO Status (more informa%on) pop- up box. NPO Status 1. Prevention of pulmonary aspiration is part of pre-procedure evaluation of patients for moderate sedation. Every attempt should be made to ensure that patients are NPO for an appropriate length of time to decrease the severity of complications of pulmonary aspiration of gastric contents, should it occur. 2. The suggested guidelines do not guarantee that complete gastric emptying has occurred and apply only to healthy patients undergoing elective procedures. 3. These suggested guidelines do not apply (or may need to be modified) for patients with coexisting diseases or conditions that might affect gastric emptying or gastric fluid volume e.g., pregnancy, obesity, diabetes, hiatal hernia, gastroesophageal reflux disease, ileus, bowel obstruction or emergency care. 4. These suggested guidelines do not apply to patients who undergo procedures with no moderate sedation or local-only anesthesia when the upper airway protective reflexes are not impaired. 5. Unless contraindicated, pediatric patients should be offered clear liquids until two hours before sedation to minimize the risk of dehydration. A pediatric patient under 36 months should be offered breast milk until 4 hours before sedation, formula until 6 hours before sedation and solid food 6 to 8 hours before sedation.

34 Title: Moderate Seda%on System- Wide elearning Course Subject: Procedure Audio: No Slide: 24c Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No This is the content for the Informed Written Consent and the History and Physical Examination popup boxes. Informed Written Consent It is the sole responsibility of the physician to obtain and document the patient s informed written consent for the procedure and moderate sedation prior to the administration of moderate sedation medications. History and Physical Examination Prior to sedation, a health evaluation will be performed and documented by the physician or his/her designee (an NP, a PA, or an MD). The minimum health evaluation is required for all patients and should contain information obtained from patient History & Physical. Specific department policy may exceed these minimal requirements. Sub%tle Area

35 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 25 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No Knowledge Check Patient Scenario: Patients scheduled for moderate sedation should not have had solid food for how long? A. 6-8 hours B. 2-4 hours C. 24 hours D. 12 hours

36 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 26 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No Knowledge Check Patient Scenario: Patients that will receive moderate sedation must be evaluated by the physician performing or managing the procedure prior to administration of any medication. The evaluation prior to medication administration should be performed when? A. In the patients room prior to leaving to go to the procedure area B. On the admission note C. Immediately prior to administration of sedation D. During preadmission testing

37 Title: Moderate Seda%on System- Wide elearning Course Subject: Requirements For History & Physical Audio: Yes Slide: 27 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No Fade in bullets in sync with narra%on. MaR, Airway Assessment and Aldre% Scoring System will be hyperlinks. Clicking the Airway Assessment buron, and the Aldre% Scoring System buron, and the Mallampa% Classifica%on buron will present learners with pop- up windows displaying the content as shown on next three slides. Requirements For History & Physical Age & Weight Medical history Drug allergies Current medications Relevant diseases Physical abnormalities Review of systems Specific drug history History of food or fluid intake within the past 8 hours Vital signs Click hyperlink to view Click hyperlink view Pregnancy status Adverse drug reactions Previous complications with sedation or anesthesia Relevant family history Airway Assessment (as performed by physician) Aldrete Scoring System/Clinical Assessment Scale Click hyperlink to view Mallampati Classification

38 Title: Moderate Seda%on System- Wide elearning Course Subject: Airway Assessment By Physician Audio: No Slide: 27a Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: No Video: No On- screen text for previous slide. Airway Assessment By Physician a. Airway assessment including the following: 1. History of previous airway difficulties. 2. Cervical spine disease. 3. Temporomandibular joint problems. b. Physical exam of airway, focusing on: 1. Mouth opening of greater than 2 fingerbreadths. 2. Ability to see the uvula when patient extends tongue. 3. Submandibular distance from the inside edge of the Mandible to the midline of the hyoid bone should be greater than 2-3 fingerbreadths. 4. Full range of motion of the cervical spine.

39 Title: Moderate Seda%on System- Wide elearning Course Subject: Aldrete Scoring System Audio: Yes Slide: 27b Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Aldrete Scoring System/Clinical Assessment Scale Ac%vity Respira%on Circula%on Consciousness Color Moves 4 Extremities Score = 2 Moves 2 Extremities Score = 1 Moves 0 Extremities Score = 0 Deep Breath and Cough Score = 2 Dyspnea or Limited Score = 1 Apnea Score = 0 Systolic BP 20 mmhg of Pre-op BP Score = 2 Systolic BP mmhg of Pre-op BP Score = 1 Systolic BP 50 mmhg of Pre-op BP Score = 0 Fully Awake Score = 2 Arousable Score = 1 Non-responsive Score = 0 Pink Score = 2 Pale, Dusky, Jaundices Score = 1 Cyanotic Score = 0 Total should be 9-10

40 Title: Moderate Seda%on System- Wide elearning Course Subject: Mallampa% Classifica%on Audio: Yes Slide: 27c Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: Yes Video: No MaA, hovering over each Grade graphic will enlarge the descrip%ve text. Mallampati Classification I: Visualization of the soft palate, fauces, uvula, anterior and posterior pillars II: Visualization of the soft palate, fauces and uvula III: Visualization of the soft palate and base of the uvula IV: Only hard palate is visible; soft palate is not visible at all Hold cursor over each Grade description to enlarge the text.

41 Title: Moderate Seda%on System- Wide elearning Course Subject: Pre- seda%on Assessment Audio: Yes Slide: 28 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Fade in bullet in sync with narra%on. Pre-sedation Assessment Joint commission requirement Post-procedure transportation Sub%tle Area

42 Title: Moderate Seda%on System- Wide elearning Course Subject: Most Common Causes of Airway Obstruc%on Audio: Yes Slide: 29 Supported Learning Objec6ve: Describe the process for monitoring a pa%ent receiving moderate seda%on. Graphics: Yes Video: No Fade in bullets in sync with the first line of narra%on. Most Common Causes Of Airway Obstruction Soft tissue or tongue obstruction Laryngeal obstruction Sub%tle Area

43 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 30 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: The evaluation of the assessment of the extent that the base of the tongue is able to mask the visibility of pharyngeal structures is known as: a. Murphy s sign b. Chvostek sign c. Mallampati classification d. Allen s test

44 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 31 Supported Learning Objec6ve: Iden%fy the guidelines for administering moderate seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: The most common cause of airway obstruction in a patient receiving moderate sedation is: A. Oral airway placement B. Soft tissue and laryngeal obstruction C. Recent food ingestion D. Large tonsils

45 Title: Moderate Seda%on System- Wide elearning Course Subject: Assessment & Reassessment Requirements Audio: Yes Slide: 32 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: Yes Video: No Fade in bullets in sync with narra%on. MaR, Please make Timeout a hyperlink; the content is on slide 32a Assessment & Reassessment Requirements Be sure the following has been documented before the first dose of medication is administered. History and Physical (H&P) within 24-hours. Airway assessed by physician. ASA score. Informed written consent and permit signed. Click hyperlink to view Timeout Sub%tle Area

46 Title: Moderate Seda%on System- Wide elearning Course Subject: Timeout Audio: Yes Slide: 32a Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: Yes Video: No Timeout Initiated immediately before starting the procedure Correct patient Correct site/side Correct procedure Relevant information Relevant documents Relevant equipment Consent Accurate documentation Sub%tle Area

47 Title: Moderate Seda%on System- Wide elearning Course Subject: Documenta%on Audio: Yes Slide: 33 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Fade in bullets in sync with narra%on. Documenting & Monitoring 1. Monitoring requirements 2. Vital signs and oxygen saturation 3. Achievement of deep sedation either intentionally or inadvertently Sub%tle Area

48 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 34 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: The timeout procedure requires that all of the following be verified except: A. Correct insurance B. Correct patient C. Correct site/side D. Correct procedure

49 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: No Slide: 35 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No Knowledge Check Patient Scenario: During administration of moderate sedation, vital signs, SpO2, and level of consciousness are monitored and recorded: A. Prior to the start and end only B. Every 15 minutes C. Every 5 minutes D. As needed

50 Title: Moderate Seda%on System- Wide elearning Course Subject: Post- Procedure & Monitoring Audio: Yes Slide: 36 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No MaA, Fade in bullets in sync with narra%on. Post-Procedure Care & Monitoring 1. Recovery site 2. Reversal agents 3. RN patient assessment and documentation 4. Patient discharge Sub%tle Area

51 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent Discharge Audio: Yes Slide: 37 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No MaA, Fade in bullets in sync with narra%on. Patient Discharge 1. Vital signs 2. Pre-sedation level of consciousness 3. Written instructions for post-procedure care Restrictions Prescribed medications Follow-up care When to call physician Post-procedure problems Sub%tle Area

52 Title: Moderate Seda%on System- Wide elearning Course Subject: Aldrete Scoring System Audio: Yes Slide: 38 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Aldrete Scoring System/Clinical Assessment Scale Ac%vity Respira%on Circula%on Consciousness Color Moves 4 Extremities Score = 2 Moves 2 Extremities Score = 1 Moves 0 Extremities Score = 0 Deep Breath and Cough Score = 2 Dyspnea or Limited Score = 1 Apnea Score = 0 Systolic BP 20 mmhg of Pre-op BP Score = 2 Systolic BP mmhg of Pre-op BP Score = 1 Systolic BP 50 mmhg of Pre-op BP Score = 0 Fully Awake Score = 2 Arousable Score = 1 Non-responsive Score = 0 Pink Score = 2 Pale, Dusky, Jaundices Score = 1 Cyanotic Score = 0 Total should be 9-10

53 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: Yes Slide: 39 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Knowledge Check Patient Scenario: After a patient receiving moderate sedation is given a reversal agent, Romazicon or Narcan, which of the following is required prior to patient discharge? A. No monitoring required and the patient may transfer to the floor at any time. B. The patient may transfer to the floor as long as he or she is no longer sedated and the physician approves. C. A minimum of 90 minutes of monitoring is required after a reversal agent is given. D. A minimum of 6 hours of monitoring is required and the patient must be transferred to the ICU.

54 Title: Moderate Seda%on System- Wide elearning Course Subject: Knowledge Check Audio: Yes Slide: 40 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Knowledge Check Patient Scenario: A 46-year-old patient is to receive moderate sedation for an upper endoscopy. The patient is alone and drove himself to the hospital. Which of the following is the MOST appropriate solution to this situation: A. The physician cancels the procedure. B. The physician admits the patient post procedure for 23 hours. C. The patient is allowed to leave post procedure as long as he is alert and oriented times three. D. The nurse calls and arranges for a taxi to transport the patient home.

55 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent Scenario Instruc%ons Audio: No Slide: 41 Supported Learning Objec6ve: Graphics: No Video: No MaA, Here are the instruc%ons to be used with the next three slides: Pa%ent Scenario, and Pa%ent Scenario Assessment. Patient Scenario Instructions: On the next slide you will find a patient scenario. When you are ready, click the button to view Vital Signs & Labs. During the assessment, if you need to review the scenario, click the View Patient Scenario button.

56 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent Scenario Audio: No Slide: 41a Supported Learning Objec6ve: Graphics: No Video: No MaA, Please use a clipboard graphic to display Labs & Vital Signs when learners click the hyperlink. The content is in the sec%on below. Patient Scenario A 59-year-old male weighing 70 kg presents to the ED with complaints of dizziness, dyspnea, restlessness, and anxiety. He reports a two-day history of hematemesis with some bright red blood and large amounts of "coffee ground" emesis. He denies any recent or chronic illnesses. He admits to drinking a six-pack every day for the past seven years. Your assessment shows cool clammy skin, distended abdomen, hyperactive bowel sounds and tachycardia. He has not had anything to eat or drink since last night at 7:00 p.m. He was admitted to the ICU, with IV Normal Saline. Two (2) Units of PRBCs were administered. He was scheduled for a stat diagnostic fiberoptic endoscopy, which revealed a large esophageal varice (1.5 cm) above the gastroesophageal junction. During the procedure he was given 2 mg of Versed and 150 mcg of Fentanyl. Post procedure, his respiratory rate dropped to less than 10 breaths per minute. Click here to view Labs & Vital Signs.

57 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent Scenario Assessment Audio: No Slide: 41b Supported Learning Objec6ve: Graphics: No Video: No MaA, Please provide a hyperlink for the graphic to allow learners to View Pa%ent Scenario. MaA, These will be mul%ple- choice test items. Patient Scenario Assessment: 1. What needs to be documented prior to the start of the procedure? Please select all that apply. q History and Physical (H&P) within 24-hours. q Glasgow Coma Scale (GCS) score. q Airway assessed by physician. q ASA score. q Home medication list. q Informed written consent and permit signed. q Timeout 2. Was the amount of sedation given within the recommended range? q Yes q No 3. What dose of reversal agents should be given? q Romazicon 0.2 mg IV and Narcan mg IV q Romazicon 0.4 mg IV and Narcan 2 mg IV q Romazicon 2.0 mg IV and Narcan 1.0 mg IV 4. What should be the patient s post-procedure Aldrete score? q 8-9 q 9-10 q 7-10 View Patient Scenario

58 Title: Moderate Seda%on System- Wide elearning Course Subject: Pa%ent Scenario Assessment Audio: No Slide: 41c Supported Learning Objec6ve: Graphics: No Video: No MaA, These will be mul%ple- choice test items. Incorrect answers are listed below. Patient Scenario Assessment: 6. What equipment is needed at the beside? Please select all that apply. q Restraints q Emergency cart with defibrillator and emergency/reversal drugs q Oxygen and delivery devices (cannula, mask) q Appropriate oral and nasal airways (pediatric and adult) q Cardiac monitor q Suction q Non-invasive blood pressure monitor q Pulse Oximeter q Smelling salts q Bag/mask ventilation apparatus q Blood-transfusion supplies q IV supplies and equipment q Intubation tray View Patient Scenario

59 Title: Moderate Seda%on System- Wide elearning Course Subject: Learning Summary Audio: Yes Slide: 42 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Learning Summary The four levels of sedation, minimal sedation, moderate sedation, deep sedation, and anesthesia occur on a continuum. Equipment needed for moderate sedation includes: bedside suction, Emergency Cart with defibrillator and reversal drugs, oxygen and delivery devices, oral and nasal airways, cardiac monitor, pulse oximeter, non-invasive blood pressure cuff, bag/mask ventilation apparatus, intubation tray, appropriate IV access Personnel administering and monitoring a patient receiving moderate sedation must be appropriately credentialed, licensed, and competent to manage a compromised airway and provide adequate oxygenation and ventilation in the event that a patient must be rescued from a deeper level of sedation Patients receiving moderate sedation will be monitored by a registered nurse who will assess and document vital signs at least every 5 minutes. The registered nurse cannot be involved in the actual procedure.

60 Title: Moderate Seda%on System- Wide elearning Course Subject: Learning Summary Audio: Yes Slide: 42a Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No Learning Summary (cont d) The approval criteria for moderate sedation includes: a history and physical completed by a physician (or a PA, NP) within 24-hours of the procedure, airway assessment by physician, ASA score, informed written consent and permit signed, timeout completed. In order to be discharged post-procedure, the patient recovering from moderate sedation must have: vital signs that are stable and within pre-procedure range, a return to pre-sedation level of consciousness (see the Aldrete Score), written instructions for post-procedure care, a responsible individual who can safely transport the patient home. An awareness of the medications used to achieve moderate sedation and an understanding of the range of patient responses to the medications is imperative to patient safety. Nursing knowledge of appropriate reversal agents to medications commonly used in moderate sedation is essential.

61 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 43 Supported Learning Objec6ve: Recognize the approval criteria for seda%on Graphics: No Video: No This is the start of the test items. 1. The following would be included in the complete assessment of any patient undergoing moderate sedation, except: a. Medical history including allergies. b. Current medications, including date and time of last dose. c. NPO status (time of last food/drink consumed). d. Cranial nerve assessment.

62 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 44 Supported Learning Objec6ve: Recognize the approval criteria for seda%on Graphics: No Video: No 2. Why is the amount of posterior pharynx that can be visualized with maximal mouth opening and tongue protrusion in the sitting position an important part of the airway assessment? a. Aids in determining the presence of a gag reflex. b. Correlates with difficulty of intubation. c. Assesses cranial nerve reflexes. d. Helps determine how long a patient should remain NPO prior to a procedure.

63 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 45 Supported Learning Objec6ve: Describe the process for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No 3. The most common causes of airway obstruction in the patient receiving moderate sedation is: a. Soft tissue and laryngeal obstruction. b. Head of bed (HOB) positioned at less than thirty degrees. c. Patient history of asthma. d. Patient history of esophageal reflux.

64 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 46 Supported Learning Objec6ve: Describe the process for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No 4. Monitoring of any patient receiving moderate sedation includes all of the following except: a. Heart rate of rhythm via cardiac monitor b. Temperature c. O2 sat and respiratory rate d. Blood pressure

65 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 47 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No 5. Prior to sedation a health assessment must be performed including all of the following elements except: a. Age and weight b. Medical history including: drug allergies, current medications, relevant diseases, physical abnormalities, pregnancy status, adverse drug reactions or previous complications associated with sedation or anesthesia, and any relevant family history. c. Marital status d. Vital signs including: heart rate, blood pressure, respiratory rate, level of consciousness and temperature.

66 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 48 Supported Learning Objec6ve: List the equipment needed for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No 6. All of the following equipment should be readily available in the event of respiratory compromise in the patient receiving moderate sedation except: a. Supplemental oxygen b. Age- and size-appropriate airway equipment c. 12 lead EKG machine d. Defibrillator and crash cart

67 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 49 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No 7. Patients that will receive moderate sedation must be evaluated by the physician performing or managing the procedure prior to administration. This evaluation prior to administration should be performed and documented when? a. In the patients room prior to leaving to go to procedural area or OR b. On the admission note. c. Immediately prior to administration of sedation. d. During preadmission testing.

68 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 50 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No 8. ASA score (American Society of Anesthesiology) must be noted prior to administration of moderate sedation and can be determined by: a. The nurse assisting the patient. b. The proceduralist (physician). c. The patient care technician (PCT) assisting the patient. d. The patient s admission note from a previous hospitalization.

69 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 51 Supported Learning Objec6ve: Recognize the approval criteria for seda%on. Graphics: No Video: No 9. Patients scheduled for moderate sedation should not have had solid food for how long? a. 6-8 hours or after midnight b. 2-4 hours c. 24 hours d. 6 hours

70 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 52 Supported Learning Objec6ve: Describe the process for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No 10. During administration of moderate sedation, vital signs, O 2 Sat, and level of consciousness are monitored and recorded at least: a. Prior to the start and the end b. Every 15 minutes c. Every 5 minutes d. As needed

71 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 53 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No 11. Following moderate sedation, each patient must undergo a recovery period. Appropriate discharge criteria includes: a. Patient has reached their pre-sedation Aldrete score (post anesthesia score). b. Patient received Narcan 30 minutes ago and is awake. c. Patient can tell you their name. d. Patient has voided.

72 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 54 Supported Learning Objec6ve: List the criteria for pa%ent discharge. Graphics: No Video: No 12. Which of the following is not assessed prior to discharge in the patient who has received moderate sedation? a. Level of consciousness b. Respirations c. Verbal skills d. Appetite

73 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 55 Supported Learning Objec6ve: Iden%fy appropriate an%dotes to medica%ons commonly used in moderate seda%on. Graphics: No Video: No 13. Romazicon (flumazenil) is the reversal agent used for: a. Barbituates, such as Methohexital (Brevital) b. Hypontics, such as Diprivan (Propofol) c. Narcotics, such as Morphine d. Benzodiazepines, such as Midazolam (Versed)

74 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 56 Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: No Video: No 14. According to your institution s policy, Diprivan (Propofol) may be administered I.V. push for moderate sedation by: a. The patient s Primary Care Physician (PCP). b. A nurse who has completed the annual competency in moderate sedation. c. An Anesthesiologist (anesthesia provider-crna) or emergency department physician only. d. The Nurse Manager of the clinical area in which the procedure is performed.

75 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 57 Supported Learning Objec6ve: Iden%fy medica%ons commonly used in moderate seda%on. Graphics: No Video: No 15. A physician is about to perform a procedure in which moderate sedation will be administered. The patient is an 81-year-old with a history of COPD. He orders 20 mg of Morphine sulfate to be given IV push quickly. Which of the following initial actions would be appropriate for you, as the nurse responsible for monitoring the patient? a. Give the drug, but administer it over 3-5 minutes. b. Refuse to give the drug and leave the room. c. Consult with the physician regarding the dose, the patient s history, and the recommended dose according to our guidelines. d. Give only 2 mg of the drug.

76 Title: Moderate Seda%on System- Wide elearning Course Subject: Test Items Audio: No Slide: 58 Supported Learning Objec6ve: Describe the process for monitoring a pa%ent receiving moderate seda%on. Graphics: No Video: No 16. Who is authorized to participate in the administration and/or monitoring of a patient receiving moderate sedation? Select the best answer. a. The proceduralist (MD) and a BLS certified nurse on a general medical floor who does not have competency in moderate sedation. b. The proceduralist (MD) and a nurse manager of a general medical floor who is BLS certified, but does not have competency in moderate sedation. c. The proceduralist (MD) and a BLS/ACLS certified critical care RN who completed his or her annual competency in moderate sedation. d. The proceduralist (MD) and a patient care technician (PCT) who is BLS certified.