SELF STUDY MODULE
Developed by:
Clelle E. Armstrong, RN, BS, CNOR
WFRMC Clinical Educator – Operating Room
Denise Mabry, RN BS Ed., CNOR
WFRMC Nurse Educator
Revised by:
Lynn Bartlett, RN, CCRN
Ocala Regional Medical Center
December, 1995
With healthcare reform of the 90’s occurring at rapid speed, one can anticipate that the responsibilities, requirements, and skill level of the professional registered nurse will also change. The responsibility of monitoring and/or administering intravenous (IV) medications for conscious sedation has become a routine practice for many nurses in a variety of settings. These practice settings may include traditional operating rooms, ambulatory surgery units, physician’s offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments and all other areas where surgery may be performed. As nurses accept this expanded role in their nursing practice, they will also inherit additional accountability for establishing and maintaining proficient skills necessary to provide quality patient care.
The primary goal of conscious sedation is to allay patient fears and anxiety regarding the planned procedure. To effectively administer conscious sedation, nurses should be familiar with the objectives of this technique. Without an understanding of the objectives, the risk of jeopardizing quality of care is increased. Objectives for the patient receiving conscious sedation include:
Meeting these objectives will provide a relaxed, cooperative patient who may have slurred speech and/or diminished verbal communication but is easily aroused. Verbal reassurance is very effective in allaying the patient’s fears and anxiety. Sensations such as pulling or pressure during the procedure may not be perceived as pain, but can increase the patient’s stress level. Appropriate verbal reassurance along with patient education before an during the procedure can decrease the amount of narcotics and sedatives used and promote the patient’s rapid return to ambulation.
According to AORN standards, each patient receiving conscious sedation should be assessed physiologically and psychologically before the procedure. Pre-procedure assessment should include:
This pre-procedural assessment provides baseline data and identifies patient risk factors. (Certain patients are not candidates for conscious sedation with monitoring by a registered nurse. These patients may require more extensive and intensive monitoring and sedation, as provided by anesthesia personnel, and should be identified in consultation with anesthesiologists, nurses, certified registered nurse anesthetists (CRNA’s), surgeons, and other physicians.)
During the pre-procedural assessment, the nurse can carefully note the patient’s verbal and non-verbal responses to assist in developing an individualized plan of care. The care plan includes patient/family education about the procedure, equipment to be utilized during the procedure, and post-procedural instructions (eg physical activity/limitation, signs and symptoms of complications, when to notify physician, etc.) This will help meet the objectives of allaying the patient’s anxiety and fear, assist in obtaining cooperation from the patient during the procedure, and hopefully promote a trusting rapport to develop between the monitoring nurse and the patient.
The following equipment should be present and ready for use in the room where conscious sedation is to be administered: oxygen, suction device, bag/valve and mask devices, oral nasopharyngeal airways, and endotracheal tubes of various sizes, noninvasive blood pressure monitor, ECG monitor, pulse oximeter, and code cart.
Before conscious sedation is administered, the patient should have supplemental oxygen delivery, IV access line established, and monitoring capabilities in place.
To effectively manage the patient receiving conscious sedation, staffing must include the physician credentialed in conscious sedation, one registered nurse with competency in conscious sedation to provide continuous uninterrupted monitoring and/or administer IV medications, and another qualified individual to assist the physician with the actual procedure.
Monitoring parameters for the patient receiving conscious sedation should include respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, skin condition and level of consciousness. Level of consciousness is assessed using the Modified Aldrete Score, a post anesthetic recovery score. Changes in the patient’s condition should be reported to the physician immediate with appropriate interventions instituted.
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Modified Aldrete ScoreScore of 8 Minimum for
Discharge |
Scoring |
Pre |
Adm |
D/C
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Arrival Time |
2-Lifts
head, good hand grasp 1-Weak
hand grasp, uncoordinated 0-No
movement to verbal command |
Activity |
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|
|
|
Start
Time |
2-Able
to breathe & cough freely 1-Shallow
breathing, airway adjunct, dyspnea 0-Apneic
or obstructed |
Resp. |
|
|
|
|
End
Time |
2-BP
stable x3 1-BP>
20 – 50% admission BP 0-BP>
50% admission BP |
Circulation |
|
|
|
|
D/C Time |
2-Awake,
alert, aware 1-Arousable
on calling 0-Not
responding |
L.O.C. |
|
|
|
|
2-Pink
or normal 1-Pale,
dusky 0-Cyanotic
lips, nailbeds, skin |
Color |
|
|
|
|
|
|
|
Total Score |
|
|
|
During the procedure, the monitoring nurse must stay alert to the desirable and undesirable effects of conscious sedation. The desirable effects include:
Undesirable effects of conscious sedation include:
Rapid intervention is necessary in the event of complications from the undesired effects of the conscious sedation. Therefore, a competent code team and a code cart with resuscitative drugs and a defibrillator should be immediately available to every location where conscious sedation is administered.
Registered nurses responsible for monitoring the conscious sedation patient must be thoroughly familiar with the drugs administered, the appropriate dosages and potential side effects or adverse reactions. The following is a brief synopsis of the drugs and dosages listed in the ORMC Conscious Sedation policy.
Generic Name: Midazolam Hydrochloride
Brand Name: Versed
Mechanism of action: Short acting benzodiazepine, depresses the CNS at the limbic and subcortical levels of the brain.
Indications and Dosage: Conscious sedation before short diagnostic or endoscopic procedure for adults – 0.035mg/kg slowly IV (not to exceed 2.5 Mg). Dose is then titrated in small amounts to a total dosage of 0.1 mg/kg. Sedation after IV administration is achieved in 3 to 5 minutes. Time of onset is effected by total dose administrated and the concurrent administration of narcotic premedication.
Contraindications: known hypersensitivity to the drug, acute narrow angle glaucoma, open angle glaucoma unless appropriate therapy is being received.
Adverse Reactions:
CNS: headache, over sedation, involuntary movements, combativeness, retrograde amnesia.
CV: variations in BP and pulse, bigeminy, PVC’s, vasovagal episode, bradycardia, tachycardia
Pulmonary: laryngospasm, bronchospasm, dyspnea, hyperventilation, airway obstruction
GI: nausea, vomiting, hiccoughs, excessive salivation
Local IV: pain and tenderness at the site
Drug Interactions: sedative effect of IV Versed is accentuated by premedication, particularly narcotics (eg. Morphine, meperidine and fentanyl) and also secobarbital and Innovar.
Nursing Considerations: 1) Use cautiously in patients with CHF, COPD, or renal disease and in elderly or debilitated patients. 2) Before administering IV, have oxygen and resuscitative equipment available in case of severe respiratory depression. Excessive dosage or rapid infusion has been associated with respiratory arrest. Administer slowly over a least 2 minutes, and wait at least 2 minutes when titrating doses to effect.
Antagonist: Flumazenil
Brand Name: Valium
Generic Name: Diazepam
Mechanism of Action: Benzodiazepine used for management of anxiety disorders or for the short term relief of anxiety.
Indications and Dosage: 5 to 10 mg IV initially, inject slowly – not exceeding 5 mg/min. Titrate IV dosage to desired sedative response.
Contraindications: known hypersensitivity to drug, acute narrow angle glaucoma, open angle glaucoma unless appropriate therapy received.
Drug Interactions: Cimetidine: increased sedation, monitor carefully. Digoxin: may increase serum levels of digoxin, increasing toxicity, monitor closely. Ethanol, other CNS depressants: increased CNS depression. Avoid concomitant use. Phenobarbital: increased effects of both drugs, use together cautiously. Smoking: increased clearance for benzodiazepines, monitor for lack of effect.
Adverse Reactions:
CNS: drowsiness, lethargy, confusion, ataxia, slurred speech, tremor
CV: transient Hypotension, bradycardia, cardiovascular collapse
Pulmonary: respiratory depression
EENT: diplopia, blurred vision, nystagmus
GI: nausea, vomiting, abdominal discomfort
GU: urinary retention, incontinence
Skin: rash, urticaria
Local: desquamation, pain, phlebitis at injection site
Nursing Considerations: 1) Use cautiously in blood dyscrasia, hepatic or renal damage, depression, open angle glaucoma; in elderly or debilitated patients; and in those with limited pulmonary reserve. 2) Do not mix injectable form with other drugs because of incompatibility with most drugs.
Antagonist: Flumazenil
Generic Name: Lorazepam
Brand Name: Ativan
Mechanism of Action: depresses the CNS at the limbic and subcortical levels of the brain
Indications and Dosage: sedation and relief of anxiety—initial dose 2 mg IV or 0.05 mg/kg whichever is smaller. Dilute with equal amount of diluent—sterile water for injection, 0.9% sodium chloride injection, or dextrose 5% injection before injecting slowly (not exceeding 2 mg/minute).
Contraindications: known sensitivity to benzodiazepines or its vehicle (benzyl alcohol, propylene glycol, and polyethylene glycol), acute angle glaucoma, psychoses, or mental depression.
Drug Interactions: Alcohol, other CNS depressants: causes increased CNS depression. Avoid concomitant use. Cigarette smoking: increased clearance of benzodiazepines. Monitor for lack of effect. Digoxin: may increase serum levels of Digoxin, increasing toxicity.
Adverse Reactions:
CNS: drowsiness, lethargy, fainting, anterograde amnesia, restlessness
CV: transient Hypotension
EENT: visual disturbances
GI: dry mouth, abdominal discomfort
GU: incontinence, urine retention
Other: acute abstinence syndrome following sudden withdrawal in physically dependent persons.
Nursing Considerations:
Use cautiously in organic brain syndrome, myasthenia gravis, and pulmonary, renal or hepatic impairment 2) Dosage should be decreased in elderly or debilitated patients. Preoperative dose should not exceed 2 mg in patients over 50. 3) Monitor respirations every 5 to 15 minutes and before each repeated dose IV. Have emergency resuscitative equipment and oxygen at bedside. 4) If lorazepam overdose occurs, use flumazenil as antagonist. Re-sedation is possible because lorazepam’s duration of action is longer than flumazenil.
Antagonist: Flumazenil
Brand Name: Demerol
Generic Name: Meperidine Hydrochloride
Mechanism of Action: produces narcotic analgesia and sedation, binds with opiate receptors at many sites in the CNV (brain, brain stem, and spinal cord), altering both perception of and emotional response to pain through an unknown mechanism. Onset of about 1 minute following IV administration, peak effect occurs within 5-7 minutes after IV injection.
Indications and Dosage: Start with 12.5 mg IV. Slow IV injections of fractional doses titrated to patient need.
Contraindications: hypersensitivity to the drug, patients receiving MAO inhibitors within 14 days, status asthmaticus
Drug Interactions: Barbiturates: incompatible when mixed in the same IV container. CNS depressants, ethanol, general anesthetics, hypnotics, other narcotic analgesics, phenothiazines, sedatives, tricyclic antidepressants: possible respiratory depression, Hypotension, profound sedation, or coma. Use together with extreme caution. Reduce meperidine dosage. MAO inhibitors: increased CNS excitation or depression that can be severe or fatal. Phenytoin: decreased blood levels of meperidine, monitor for decreased analgesia.
Adverse Reactions:
CNS: lightheadedness, somnolence, clouded sensorium, euphoria, paradoxical excitement, tremor, dizziness, seizures with large doses.
CV: Hypotension, bradycardia, tachycardia, Hypotension
Pulmonary: respiratory depression
GI: nausea, vomiting, constipation, ileus
GU: urinary retention
Local: pain at injection site, phlebitis after IV use
Other: pruritus, urticaria
Nursing Considerations:
1) Respiratory depression and Hypotension can occur with IV administration. Give very slowly and monitor constantly, have resuscitative equipment available. 2) Use with extreme caution in patients with increased CSF pressure, respiratory depression, hepatic or renal disease, hypothyroidism, shock, Addison’s Disease, acute alcoholism, seizures, head injury, severe CNS depression, brain tumor, bronchial asthma, and COPD and in elderly or debilitated patients.
Antagonist: Narcan (naloxone)
Generic Name: Morphine Sulfate
Brand Name: Morphine Sulfate (and other various trade names)
Mechanism of Action: Narcotic analgesic that binds with opiate receptors at many sites in the CNS (brain, brain stem, and spinal cord), altering both perception of and emotional response to pain through an unknown mechanism.
Indications and Dosage: Start with 1-2 mg IV and titrate to effect. IV administration onset of action is less than 5 minutes with peak in 20 minutes.
Contraindications: hypersensitivity to the drug or other opiate analgesics, narcotic addiction. Use with extreme caution in patients with head injury, increased intracranial pressure, seizures, asthma, COPD, alcoholism, prostatic hyperplasia, severe hepatic or renal disease, acute abdominal conditions, hypothroidism, Addison’s disease, increased CSF pressure, urethral stricture, cardiac arrhythmias, reduced blood volume, and toxic psychosis. Also use with extreme caution in elderly or debilitated patients.
Drug Interactions: CNS depressants, ethanol, general anesthetics, hypnotics, other narcotic analgesics, sedatives, tranquilizers, tricyclic antidepressants: possible respiratory depression, Hypotension, profound sedation, or coma. Use together with extreme caution. Reduce morphine dose and monitor patient response.
Adverse Reactions:
CNS: sedation, somnolence, clouded sensorium, euphoria, seizures with large doses, dizziness
CV: Hypotension, bradycardia
Pulmonary: respiratory depression
GI: nausea, vomiting, constipation, ileus
GU: urinary retention
Other: physical dependence, pruritus
Nursing Considerations: 1) Monitor respiratory status closely, if respirations are below 12 breaths/min notify M.D. Keep narcotic antagonist and resuscitative equipment within immediate reach. 2) Morphine sulfate is compatible with most common IV solutions.
Antagonist: Narcan (naloxone)
Brand Name: Stadol
Generic Name: Butorphanol tartrate
Mechanism of Action: mixed agonist-antagonist, synthetic opioid analgesic that binds with opiate receptors at many sites in the CNS (brain, brain stem, and spinal cord), altering both perceptions of and emotional response to pain through an unknown mechanism.
Indications and Dosage: Recommended initial dosage for pain relief 1 mg IV for adults. IV administration onset is 1 minute with peak at 5 minutes.
Contraindications: hypersensitivity to the drug or to the preservative benzethonium chloride; in narcotic addiction, may precipitate narcotic abstinence syndrome.
Adverse Reactions:
CNS: sedation, headache, vertigo, floating sensation, lethargy, confusion, nervousness, agitation, euphoria, hallucinations, flushing
CV: palpitations, fluctuation in BP
Pulmonary: respiratory depression
EENT: diplopia, blurred vision
GI: nausea, vomiting, dry mouth, constipation
Skin: rash, hives, clamminess, excessive sweating
Nursing Considerations:
1) psychological and physical addiction may occur. 2) Use cautiously in head injury, increased intracranial pressure, acute MI, coronary insufficiency, respiratory disease or depression, and renal or hepatic dysfunction.
Antagonist: Narcan (naloxone), repeated doses may be needed because duration of action of Stadol is longer.
Brand Name: Sublimaze
Generic Name: Fentanyl citrate
Mechanism of Action: potent narcotic (opioid) analgesic that binds with opiate receptors at many sites in the CNS (brain, brain stem, and spinal cord), altering both perception of and emotional response to pain through an unknown mechanism.
Indications and Dosage: adjunct to general anesthesia: 0.05 to 0.1 mg IV repeated every 2 to 3 minutes prn. Dose should be reduced in elderly and high risk patients.
Contraindications: known intolerance to the drug, patients who have received MAO inhibitors within 14 days and in those with myasthenia gravis.
Drug Interactions: alcohol, CNS depressants: additive effects. Use together cautiously.
Adverse Reactions:
CNS: sedation, somnolence, clouded sensorium, euphoria, dizziness, seizures with large doses.
CV: Hypotension, bradycardia
Pulmonary: respiratory depression
GI: nausea, vomiting, constipation, ileus
GU: urinary retentin
Other: muscle rigidity, physical dependence, pruritus
Nursing Considerations: 1) Use cautiously in head injury, increased CSF pressure, asthma, COPD, respiratory depression, seizures, hepatic or renal disease, hypothyroidism, Addison’s Disease, alcoholism, increased intracranial pressure, CNS depression, and shock and in elderly and debilitated patients. 2) High doses can produce muscle rigidity, which can be reversed with neuromuscular blockers; however patient must be artificially ventilated. 3) Keep narcotic antagonist (nalaxone) and resuscitative equipment available when giving drug IV. 4) Monitor circulatory and respiratory status and urinary function carefully. Immediately report respiratory rate below 12 breaths/minutes, decreased respiratory volume, or decreased SaO2. 5) Respiratory depression, Hypotension, profound sedation, and coma may result if used with other narcotic analgesics, general anesthetics, tranquilizers, alcohol, sedative, hypnotics, tricyclic antidepressants, or MAO inhibitors. Fentanyl dose should be reduced by one-fourth to one-third. Also give above drugs in reduced dosages.
Antagonist: Narcan (naloxone)
Brand Name: Innovar
Generic Name: Fentanyl citrate 0.05 mg with droperidol 2.5 mg per ml
Mechanism of Action: Acts as a CNS depressant to produce a general calming effect, reduced motor activity, alpha blockade, and analgesia. Fentanyl is a potent opioid analgesic and droperidol is a neuroleptic tranquilizer agent.
Indications and Dosage: Tranquilization and analgesia for surgical and diagnostic procedures: Starting dose of ½ cc, administer additional ½ cc IV to titrate to effect. Used in combination with other agents.
Contraindications: intolerance to either component
Adverse Reactions:
CNS: Postoperative drowsiness, emergence delirium, hallucinations, restlessness, hyperactivity, anxiety
CV: vasodilation, Hypotension, decreased pulmonary arterial pressure, bradycardia, tachycardia
Pulmonary: respiratory depression, apnea, or arrest
EENT: blurred vision, laryngospasm
GI: nausea, vomiting
Other: drug dependence, muscle rigidity, chills, shivering, diaphoresis
Nursing Considerations:
1) Hypotension is a common adverse reaction. However, if BP drops, also consider hypovolemia as a possible cause. Use appropriate parenteral fluids to help restore BP. Do not treat with epinephrine; it may worsen Hypotension. 2) Vital signs should be monitored frequently. 3) Be aware that respiratory depression, rigidity of respiratory muscles, and respiratory arrest can occur. Have narcotic antagonist and resuscitative equipment readily available. 4) Use cautiously in patients with head injuries and increased intracranial pressure, COPD, hepatic and renal dysfunction, brady-arrhythmias, and in elderly and debilitated patients. 5) In IV use, inject undiluted drug directly into vein or into IV tubing containing a free-flowing compatible solution. Alternatively, rapidly infuse diluted drug until onset of drowsiness. Then slow infusion or stop drip and administer general anesthetic, as appropriate. Intermittent infusion is not recommended. 6) When Innovar is given for anesthesia induction, fentanyl should be used for maintenance analgesia during procedure.
Antagonist: Narcan (naloxone)
Brand Name: Ketalar
Generic Name: Ketamine Hydrochloride
Mechanism of Action: Interrupts association pathways in the brain, causing dissociative anesthesia, a feeling of dissociation from the environment.
Indications and Dosage: Induce anesthesia for procedures, especially short term diagnostic or surgical, not requiring skeletal muscle relaxation. 0.25 – 0.50 mg/kg IV administered over 60 seconds. To maintain anesthesia, repeat in increments of half to full initial dose.
Contraindications: patients with history of CVA; patients who would be endangered by a significant rise in BP (including those with increased ICP and increased intraocular pressure; severe hypertension, severe cardiac decompensation, or surgery of the pharynx, larynx, or bronchial tree (unless used with muscle relaxants).
Drug Interactions: Barbiturates, opiates, other CNS depressants: may prolong recovery time. Monitor closely. Thyroid hormones: may elevate BP and cause tachycardia.
Adverse Reactions:
CNS: tonic and clonic movements resembling seizures, dream-like states, hallucinations, confusion, excitement, irrational behavior, psychic abnormalities, emergence delirium.
CV: increased BP and pulse rate, Hypotension, bradycardia
Pulmonary: respiratory depression, apnea when administered too rapidly
EENT: diplopia, nystagmus, slight increase in intraocular pressure, oaryngospasm, salivation
GI: mild anorexia, nausea, vomiting
Skin: transient erythema, measles-like rash
Nursing considerations: 1) For IV use, inject slowly over 1 minute. Inject initial dose directly into vein or into IV tubing containing a free flowing compatible solution. Intermittent infusion is not recommended. For continuous infusion, infuse diluted drug at a rate of 1 to 2 mg/minute. 2) Do not inject barbiturates and ketamine from the same syringe, as they are chemically incompatible. 3) Because of rapid induction, patient should be physically supported during administration. 4) Use cautiously in chronic alcoholism, alcohol-intoxicated patients, and in patients with increased CSF pressure before anesthesia. 5) Monitor vital signs before, during, and after anesthesia. 6) Maintain airway and resuscitative equipment should be immediate available for use. 7) Keep verbal, tactile, and visual stimulation at a minimum during recovery phase to reduce incidence of emergent reactions. 8) Hallucinations and excitement can occur on emergence from anesthesia; they can be abated by administering diazepam.
Antagonist: Physostigmine
Brand Name: Romazicon
Generic Name: Flumazenil
Mechanism of Action: Benzodiazepine antagonist that competitively inhibits the actions of benzodiazepines on the gamma-aminobutyric acid-benzodiazepine receptor complex. Onset is 1 – 2 minutes with a duration of 1 to 4 hours.
Indications and Dosage: Complete or partial reversal of sedative effects of benzodiazepines after anesthesia or short diagnostic procedures (conscious sedation). For adults, initially give 0.2 mg IV over 15 seconds. If the patient does not reach the desired level of consciousness after 45 seconds, repeat dose. Repeat at one minute intervals until a cumulative dose of 1 mg has been given (initial dose plus four additional doses). Most patients respond after 0.6 to 1 mg of drug. In case of re-sedation, dosage may be repeated after 20 minutes; however no more than 1 mg should be given at any one time, and no more than 3 mg/hour.
Contraindications: Patients with know hypersensitivity to flumazenil or to benzodiazepines. Patients who are showing signs of serious cyclic antidepressant overdose. Patients who have been given a benzodiazepine for control of a potentially life threatening condition (e.g. control of intracranial pressure or status epilepticus). Patients who are benzodiazepine-dependent may have seizures when given Flumazenil.
Drug Interactions: Antidepressants, drugs that can cause seizures or arrhythmias: seizures or arrhythmias can develop after effect of benzodiazepine overdose is removed. Use Flumazenil with caution in cases of mixed overdose.
Adverse Reactions:
CNS: dizziness, abnormal or blurred vision, headache, seizures, fatigue, agitation, emotional lability.
CV: arrhythmias, cutaneous vasodilation
GI: nausea, vomiting
Other: diaphoresis, pain at the injection site
Nursing Considerations: 1) For IV use, administer drug into IV line in a large vein with a free flowing IV solution to minimize pain at the injection site. Compatible solutions include D5W, lactated Ringer’s solution, or 0.9% sodium chloride. 2) Monitor patients closely for resedation that may occur after reversal of benzodiazepines effects because flumazenil’s duration of action is shorter than that of all benzodiazepines. Duration of monitoring period depends on specific drug being reversed. Monitor closely after long acting benzodiazepines such as diazepam, or after high doses of short acting benzodiazepines, such as 10 mg of midazolam. In most cases, severe re-sedation is unlikely in patients who fail to show signs of re-sedation 2 hours after a 1 mg dose of Flumazenil. 3) Warn patients not to perform hazardous activities, such as driving or operating heavy equipment, within 24 hours of procedure because of re-sedation risk. 4) Do not expect patients to recall information told to them in the post-procedure period because drug does not reverse the amnesic effects of benzodiazepines. Give patients written instructions or tell family members important instructions. 5) Instruct patients to avoid alcohol, CNS depressants, and OTC drugs for 24 hours.
Brand Name: Narcan
Generic Name: Naloxone Hydrochloride
Mechanism of Action: Displaces previously administered narcotic analgesics from their receptors (competitive antogonism). Has no pharmacologic activity of its own. Onset is 1 to 2 minutes after IV use with a duration of 45 minutes to 4 hours.
Indications and Dosage: Known or suspected narcotic induced respiratory depression, including that caused by pentazocine and propoxyphene. In adults, start with 0.1 mg IV. May repeat every 2 to 3 minutes, prn till respiratory rate > 12 per minute and patient exhibits increased level of consciousness eg. Alert. If no response is observed after 1 mg has been administered, the diagnosis of narcotic-induced toxicity should be questioned.
Contraindications: Patients who are hypersensitive to this drug. Use cautiously in patients with cardiac irritability and opiate addiction. Abrupt reversal of opiate-induced CNS depression may result in nausea, vomiting, diaphoresis, tachycardia, CNS excitement, and increased blood pressure.
Drug Interactions: None significant.
Adverse Reactions:
CV: tachycardia and hypertension with higher-than-recommended doses.
GI: nausea and vomiting with higher than recommended doses.
Other: tremors and withdrawal symptoms in narcotic-dependent patients with higher-than-recommended doses.
Nursing Considerations: 1) Duration of action of the narcotic may exceed that of naloxone and patients may relapse into respiratory depression. 2) Monitor respiratory depth and rate. Be prepared to provide oxygen, ventilation, and other resuscitative measures. 3) Respiratory rate increases within 1 to 2 minutes after administration. Effect lasts 1 to 4 hurs, but dosage may have to be repeated every 20 minutes. 4) Be aware that patients who receive naloxone to reverse opiod-induced respiratory depression may exhibit tachypnea.
Documentation on the patient’s medical record during the administration of conscious sedation should reflect evidence of continued assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care.
Documentation should include:
(Please review the ORMC Conscious Sedation Assessment & Plan documentation form.) This documentation of patient care provides information for continuity of care, a mechanism for evaluating the effects of nursing interventions, and information for quality assessment and improvement.
Post-procedure care, monitoring, and discharge criteria may vary depending on the type and amount of IV sedative administered, procedure performed, location and type of patient care unit, patient admission status (eg. Inpatient or outpatient), and institutional policy. Therefore, it is imperative that you review the ORMC policy on Conscious Sedation in your Policy and Procedure manual. Outpatients usually require a longer recovery time to return to a safe physiological level that will allow for discharge to home care in comparison to inpatients, who may require minimal recovery time, as they will continue to receive nursing care.
Patients and their families/significant others should receive written discharge instructions and verbalize an understanding of the instructions. Pre-procedure and post-procedure instruction, as well as verbalization of understanding, is encouraged because at certain dosages, drugs used for conscious sedation may cause amnesia, and patient recall may be affected.
Discharge guidelines provide specific criteria for assessing and evaluating the patient’s readiness for discharge and home care. Discharge criteria should reflect indicators that the patient has returned to a safe physiologic level. These indicators may include vital signs, level of consciousness, mobility, airway patency, intact protective reflexes, skin color and condition, condition of dressing and surgical site, absence of protracted vomiting, and the ability to urinate. Finally, the presence of a responsible adult escort is included as a necessary criterion for discharge.
In summary, all conscious sedation will be ordered and supervised by the physician credentialed for the specific procedure and administration of IV anesthetics.
The licensed professional nurse (RN) responsible for managing the care of the patients receiving conscious sedation will complete and maintain competency in this skill.
The persons responsible for administering or monitoring conscious sedation patients are required to:
Finally, conscious sedation practices throughout ORMC will be monitored and evaluated by the Department of Anesthesia, according to the policy outlined. However, the Department of Anesthesia can only be responsible for helping to establish and monitor the conscious sedation policy. Individual physicians administering conscious sedation are ultimately responsible for the care and well being of their patients.
Agonist: A drug capable of combining with receptors in initiate drug action, possesses affinity and intrinsic activity.
Antagonist: A drug that counteracts or neutralizes another drug.
Barbiturate: A pharmacological family of central nervous system depressants that can be used for their hypnotic, sedative, anticonvulsant, and muscle relaxant effects.
Benzodiazepines: A pharmacological family of central nervous system depressants possessing anxiolytic, hypnotic, and skeletal muscle relaxant properties. These agents are used to allay anxiety and fear and produce varying amnesic effects during conscious sedation. Diazepam and midazolam are two benzodiazepines commonly used for conscious sedation.
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 respond purposefully to physical stimulation or verbal command.
Light Sedation: The administration of oral medications for the purpose of reducing the patient’s anxiety level. In this stage, the following should be present: normal respirations, normal eye movements and intact protective reflexes. Amnesia may or may not be present. The patient is technically awake, but under the influence of the drug administered. Groups of drugs that may be administered for this purpose include sedatives-hypnotics, anti-anxiety, benzodiazepines, antihistamines and narcotics.
Monitoring: Clinical observation of the patient, which is individualized to patient need based on data obtained from patient assessment. The objective of monitoring conscious sedation is to improve patient outcome by decreasing the risks of conscious sedation as well as the procedure. Monitoring includes the use of mechanical devices and direct observation.
Opioid: A naturally occurring or synthetic pharmacologic agent that acts to produce varying degrees of analgesia, sedation, and elevation of the pain threshold. Fentanyl and meperidine are two opioids commonly used for conscious sedation.
Procedure: A generic term used to describe therapeutic, diagnostic, and surgical interventions where the patient receives conscious sedation.
Sedative: A generic term for pharmacologic agents that produce a calming effect and allay anxiety.
Joint Commission on Accreditation of Healthcare Organizations. 1996
Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL, 1995.
Nursing ’95 Drug Handbook. Springhouse, PA: Springhouse Corporation, 1995.
Physician’s Desk Reference. Montvale, NJ: Medical Economics Data Production Company, 1995.
“Recommended Practices for Monitoring the Patient Receiving IV Conscious Sedation.” AORN 1995 Standards and Recommended Practices. Denver: Association of Operating Room Nurses, 1995.
Vender, Jeffrey S., M.D., F.C.C.M. and Bruce D. Spiess, M.D. Post Anesthesia Care. Philadelphia: W.B. Saunders Company, 1992.
Watson, D.S. and D. S. James. “Intravenous Conscious Sedation: Implications of Monitoring Patients Receiving Local Anesthesia.” AORN Journal 51, June 1991, p. 1513.
POST TEST
1. Desirable effects of conscious sedation include all of the following except:
A. Diminished verbal communication
B. Severe respiratory depression
C. Relaxation and cooperation
D. Slight initiation of slurred speech
2. Objectives of conscious sedation include all of the following except:
A. Alteration of mood
B. Maintenance of consciousness
C. Decrease of pain threshold
D. Slight variations in vital signs
3. If a patient under conscious sedation has noisy, gurgling respirations at a rate of eight per minute, appropriate nursing interventions include which of the following?
A. Immediately report condition to physician
B. Open airway using head-tilt/chin-lift method
C. Administer supplemental oxygen as directed
D. Monitor vital signs closely
1. all of the above
2. 1, 2, and 3
3. 1 only
4. none of the above
4. The patient’s non-verbal response is not important when monitoring during conscious sedation.
A. True
B. False
5. The patient undergoing conscious sedation should be able to retain the ability to:
A. Breathe spontaneously
B. Respond to physical stimulation or verbal command
C. Protect the airway
1. 1 only
2. 2 and 3
3. 1, 2, and 3
4. None of the above
6. _______________________ is very effective in allaying the patient’s fear and anxiety.
A. Morphine
B. Music
C. Silence
D. Verbal reassurance
7. Accurate documentation should occur _______________________________.
A. Every 5 to 15 minutes
B. Every minute
C. Every 3 to 4 minutes
D. Whenever the nurse wishes
8. Narcan is administered to provide:
A. Narcotic agonist to help provide analgesia
B. Narcotic agonist to reverse respiratory depression
C. Narcotic antagonist to provide analgesia
D. Narcotic antagonist to reverse respiratory depression
9. After Versed is administered, the nurse should monitor the patient closely for early signs of under ventilation.
A. True
B. False
10. Which drug provides good amnesic effect for the patient?
A. Demerol
B. Versed
C. Acetaminophen
D. Morphine
11. The patient under conscious sedation can
A. Have a depressed level of consciousness
B. Maintain a patent airway
C. Follow verbal commands appropriately
D. All of the above
12. Physiologic measurements should include, but not be limited to respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patient’s level of consciousness.
A. True
B. False
13. The monitoring nurse’s plan of care intra-procedure should include:
A. Appropriate documentation of all monitoring utilized
B. Observation for adverse reactions for medications administered
C. Providing prompt appropriate interventions if an adverse reaction occurs
1. 1 and 2
2. 2 and 3
3. 1 and 3
4. 1, 2, and 3
14. Versed given by rapid intravenous administration allows the patient to have the best therapeutic results for sedation.
A. True
B. False
15. Equipment or supplies the nurse must have accessible during conscious sedation include:
A. Ambu with mask
B. Oxygen
C. Suction
D. Defibrillator
1. 1 only
2. 1, 2, and 3
3. 4 only
4. all of the above
.
16. Nursing interventions for the treatment of dyspnea include:
A. Open airway – heal tilt-chin lift
B. Lower the head of the bed as permitted by the procedure
C. Support ventilations with appropriate oxygen delivery system
D. Administer narcotic antagonist as ordered
1. 1, 2, and 3
2. 1, 3, and 4
3. 2, 3, and 4
4. all of the above
17. Treatment for symptomatic bradycardia or Hypotension includes:
A. Repositioning of patient in modified Trendelenburg as procedure permits
B. Administer fluids
C. Give Atropine as directed by physician
D. Administer vasopressors as directed
1. none of the above
2. 1 and 2
3. 2, 3, and 4
4. 1, 2, 3, and 4
18. You are monitoring a 72 year old male patient who received 1mg Versed and 25 mg of Demerol IV pre-procedurally. He is cooperative, relaxed and had diminished verbal communication. You notice a gradual decrease in his 02 SAT (SPO2) with prolonged inspiration and delayed expirations. Should you:
A. Continue monitoring
B. Call a code
C. Stimulate the patient to take a breath
D. Suspect a narcotic dose-related respiratory depression
1. 1, 3 and 4
2. 3 only
3. 3, 4 and 5
4. 5 only
19. Documentation for conscious sedation should include:
A. Dosage, route, time, and effect of all drugs or agents used
B. Type and amount of fluids administered, including blood and blood products, monitoring devices or equipment used.
C. Physiologic data from continuous monitoring documented at 5 to 15 minute intervals and at any significant event.
D. Level of consciousness
E. Any interventions and the patient’s response
F. Any untoward or significant patient reaction and its resolution
1. 1,2, 4, 5
2. 1,3, 4, 5
3. 1,3, 4, 6
4. all of the above
20. Because of the amnesic effects of certain drugs used for conscious sedation, Patient/Family Education should include:
A. Pre and post-procedure instruction
B. Verbalization of understanding
C. Written discharge instructions
D. All of the above
21. Using the Modified Aldrete Score, a patient must have a minimum score of 10 (post procedure) to be discharged and returned to the nursing floor.
A. True
B. False
22. Diazepam (Valium) and midazolam (Versed) are two benzodiazepines commonly used for conscious sedation.
A. True
B. False
23. Flumazenil is the antagonist or reversal agent for benzodiazepines given during conscious sedation.
A. True
B. False
24. The nurse should monitor a patient who has received conscious sedation closely for re-sedation that may occur after reversal of benzodiazepines effect because flumazenil’s duration of action is shorter than that of all benzodiazepines.
A. True
B. False
25. The use of Demerol in conscious sedation is indicated for patients with known hypersensitivity to the drug, status asthmaticus, and patients having MAO inhibitors in the past 14 days.
A. True
B. False
26. Excessive dosage or rapid infusion of Versed has been associated with respiratory arrest.
A. True
B. False
27. The sedative effect of Versed is accentuated by premedication with narcotic analgesics such as morphine, meperidine and fentanyl.
A. True
B. False
28. The injectable form of Valium should not be mixed with other drugs because of incompatibility.
A. True
B. False
29. Discharge indicators may include vital signs, level of consciousness, mobility, airway patency, intact protective reflexes, skin color and condition, condition of dressing and surgical site, absence of protected vomiting, and ability to urinate.
A. True
B. False
30. An antagonist is a drug that combines with receptors to initiate drug action; possesses affinity and intrinsic activity.
A. True
B. False