Recommended practices for managing the patient receiving moderate sedation/analgesia

AORN Journal, March, 2002

The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comments by members and others. They are effective Jan 1, 2002.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

Purpose: The use of moderate sedation/analgesia allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function, protective reflexes, and the ability to respond purposefully to verbal and/or tactile stimulation. (1)

Moderate sedation/analgesia is a specific level or depth of sedation in the continuum of sedation (Table 1). It is not always possible to gauge how a patient may respond to sedation; therefore, the health care professional intending to produce moderate sedation/analgesia should be able to rescue patients whose level of consciousness progresses to deep sedation. The possibility that the patient may enter a deeper state, such as general anesthesia, must be considered, and rescue measures by credentialed anesthesia care providers must be available. (2)

These recommended practices provide guidelines for RNs who manage the care of patients receiving moderate sedation/analgesia. Patient selection for moderate sedation/analgesia should be based on established criteria developed through interdisciplinary collaboration by health care professionals. The type of monitoring used with patients who receive moderate sedation/analgesia, the medications selected, and the interventions taken must be within the legally defined scope of practice for perioperative RNs. (3)

Certain patients are not candidates for moderate sedation/analgesia monitored by RNs. Such patients may require more extensive sedation and should be identified, monitored, and managed by credentialed anesthesia care providers, surgeons, or other physicians. (4)

RECOMMENDED PRACTICE I

Registered nurses should understand the goals and objectives of moderate sedation/analgesia.

1. The primary goal of moderate sedation/analgesia is to reduce the patient's anxiety and discomfort. Moderate sedation/analgesia also can facilitate cooperation between the patient and caregivers. (5) Moderate sedation/analgesia produces a condition in which the patient exhibits a depressed level of consciousness and an altered perception of pain but retains the ability to respond appropriately to verbal and/or tactile stimulation and maintains protective reflexes.

2. The RN should be knowledgeable about the following desired outcomes when moderate sedation/analgesia medications are administered:

* alteration of mood;

* enhanced cooperation;

* alteration in perception of pain;

* maintenance of consciousness;

* maintenance of intact protective reflexes;

* minimal variation of vital signs;

* some degree of amnesia; and

* a rapid, safe return to activities of daily living. (6)

3. The RN may be responsible for administering ordered medications based on the patient's response and according to established protocols and defined scope of practice. Adequate preoperative patient preparation and verbal reassurances from the RN facilitate the desired effects of moderate sedation/analgesia and may allow for a decrease in the dosages of opioids and sedatives. (7)

RECOMMENDED PRACTICE II

The RN managing the nursing care of the patient receiving moderate sedation/analgesia should have no other responsibilities that would require leaving the patient unattended or compromising continuous patient monitoring during the procedure.

1. There should be an additional RN serving as the circulating nurse during any procedure in which a patient receives moderate sedation/analgesia. Continuous monitoring of the patient's physiological and psychological status by a competent RN leads to early detection of potential complications and increases the likelihood of positive outcomes. (8)

RECOMMENDED PRACTICE III

The RN should be clinically competent, possessing the skills necessary to manage the nursing care of the patient receiving moderate sedation/analgesia.

1. Health care facilities should provide or make available competency-based education programs for all RNs who manage the care of patients receiving moderate sedation/analgesia. These programs should include a competency-validation process for evaluating and documenting RNs' demonstration of relevant knowledge, skills, and abilities. Standardized competency-based programs establish baseline educational requirements and ensure comparable training throughout a facility. Evaluation and documentation of competence should occur on a periodic basis according to the health care facility's policies and procedures and according to regulatory requirements. (9)