NURS 610A Moderate Sedation

This module is designed to be an interactive way to learn about moderate sedation.  It can be used alone or in conjunction with the recorded PowerPoint presentation.  The PowerPoint contains the same content in a slightly different order.  You can do this module all at one time or save it and come back to complete later.  

Review the terminology and purpose of moderate sedation

References

Wagner, K.D. & Hardin-Pierce, M.G. (2014). High acuity nursing (6th ed). Boston, MA: Pearson

Purpose

 

Moderate sedation is used for procedures that do not require general anesthesia or will not take place in the operating room.  It used to be called conscious sedation because it is used to alter or decrease the level of consciousness in order for the procedure to be tolerated.  This is an outdated term.

 

The patient should be able to:

Maintain a patent airway

Keep an intact cough and gag reflex

Breathe spontaneously

Maintain relatively unchanged cardiovascular function

Terminology

 

Moderate Sedation - Depression of consciousness created by medications where a patient is able to respond purposefully to verbal commands or minimal stimulation. The patient is able to maintain airway and there is minimal to no effect on the cardiovascular system.

Sedation – to relax with minimal change to vital signs

Analgesia – reduce pain with minimal side effects

Anxiolytic - medication used to reduce anxiety, generally a benzodiazepine

Terminology Quick Quiz

Please differentiate between the terms by filling in the blanks below:

Nurse Jones knows that patients may requireor medications to keep them relaxed during moderate sedation.  She is very competent at providing to decrease pain in her medical-surgical patients.  She has recently completed competency training to provide  for procedures.  

Nurse Jones is aware that when performing moderate sedation she will need to ensure the patient maintains and reflexes.  She also knows that cardiac and pulmonary status should remain adequate and essentially unchanged.

Explain the sedation continuum using standard sedation scales

Sedation Scales

 

RASS – Richmond Agitation Sedation Scale

  • Ranges from +4 (combative) to 0 (alert and calm) to -5 (unarousable). See attached pdf

Modified Ramsay Sedation Scale

  • Ranges from 1 (awake and alert) to 8 (unresponsive). See Table 4-8 in text

The Joint Commission Sedation Definition

  • See Table 4-8 in text and below

Minimal sedation – normal response with unaffected ventilation and cardiac function

Moderate sedation – purposeful response with decreased LOC, spontaneous ventilation, and no change to cardiac function

Deep sedation – purposeful response to pain with possible inability to maintain patent airway or inadequate ventilation and adequate cardiac function

General anesthesia – loss of consciousness with no response to stimuli. Probable need for ventilatory support and possible impairment of cardiac function.

Joint Commission Sedation Matching

  • minimal sedation
    patients respond normally to all stimuli (verbal, tactile, environmental). May experience impairments in cognition and coordination. Cardiac and respiratory function is not affected.
  • moderate sedation
    patients respond purposefully to verbal stimuli with or without tactile stimulation. Able to maintain patent airway without intervention. Cardiac function is maintained
  • deep sedation
    patients are not easily aroused but will respond purposefully to repeated verbal and/or tactile stimulation. May require assistance or intervention to maintain patent airway and ventilatory function. Cardiac function is usually maintained.
  • general anesthesia
    Patients are unarousable to all stimuli. Require help to maintain patent airway and positive pressure ventilation may be required. Patient may experience depressed neuromuscular function. May require intervention to maintain cardiac function.

Describe steps to ensure a safe procedure and the registered nurse scope of practice related to moderate sedation

Safety Considerations

 

Ensure age appropriate equipment is available

  • Suction, airway supplies, medications to sedate/reverse/rescue

Prepare for the procedure in collaboration with the licensed independent provider who will be in the room with the patient and RN

Recognize that the RN performing moderate sedation must be trained at a competency level beyond moderate sedation, and all providers should be capable of rescuing from one level deeper than the intended sedation level.

  • ACLS preferred
  • Competent per hospital policy
  • Demonstrated ability to rescue from deep sedation or general anesthesia and demonstrate ability to handle compromised cardiac and respiratory systems.

 

RN Scope of Practice

Essential Safety Items

  • Cardiac monitor
  • Suction
  • BP cuff
  • Ambu bag
  • Code cart with emergency meds and airway supplies
  • O2 on pt

RN Scope of Practice

The RN performing moderate sedation should ideally meet all the following criteria (select all that apply):

  • demonstrate ability to care for patients with respiratory and cardiac compromise
  • maintain trauma certification
  • maintain advanced cardiac life support certification
  • maintain competency according to hospital policy
  • have obtained a master's degree in nursing

Differentiate between sedatives and analgesics commonly used in moderate sedation

Medications

 

Opioids

  • Fentanyl - 25mcg-100mcg
  • Morphine - 2-4 mg

Benzodiazepines

  • Midazolam (Versed) – 1-2mg
  • Others – Ativan, Valium, Xanax

Dissociative anesthetic

  • Ketamine - 1-4.5 mg/kg
  • Pediatric video 6:35

Sedative hypnotic (controversial for RNs to administer)

  • Propofol – start at 5mcg/kg/min or bolus dose of 100-200mcg

Reversal Agents

  • Flumazenil - reverses Benzodiazepines, start at 0.2mg IV
  • Naloxone (Narcan) - reverses opioids, dilute 0.4mg in 10ml and start at 0.04mg IV

Entire list of anesthetic and sedative medications found in textbook.

Medication Matching

  • Propofol (Diprivan)
    Sedative hypnotic
  • Ketamine (Ketalar)
    Dissociative anesthetic
  • Fentanyl (Sublimaze)
    Opioid
  • Midazolam (Versed)
    Benzodiazepine
  • Flumazenil (Romazicon)
    Benzodiazepine reversal agent
  • Naloxone (Narcan)
    Opioid reversal agent

Discuss possible complications and legal ramifications of moderate sedation

Complications

 

Possible complications include: 

Oversedation

  • In the case of deep sedation maintain a patent airway and consider stopping the procedure until the patient returns to a moderately sedated level

Cardiac compromise

  • Includes hypotension, bradycardia, tachycardia, and cardiac arrest

Respiratory compromise

  • Includes risk of aspiration and hypoxemia

Prolonged sedation

Death

Legal Ramifications

 

Know hospital policy, state board of nursing recommendations, and national scope of practice for RN performing moderate sedation

  • For example, know the state policy on informed consent. In many states the physician is required to obtain it.
  • Ensure you are signed off as competent according to your facility and know your individual ability to handle compromised patients.

Documentation legality

  • Best practice is to go over discharge instructions and other teaching prior to sedation
  • Know whether the AMA form can legally be signed by an impaired patient.

Assessment

  • Obtain a good assessment of allergies, medications, and previous problems with procedural sedation or anesthesia
  • Perform a good cardiac and respiratory history and assessment prior to sedation
  • Make sure the patient has a driver

 

 

Legal True and False

  • Any registered nurse can give moderate sedation
  • Registered nurses should assess allergies, medications, and previous anesthesia issues
  • The RN should assess the patient's cardiac and pulmonary status
  • The RN needs to know state laws regarding informed consent and discharging patients AMA
  • The RN can perform conscious sedation according to the board of nursing even if the hospital has no policy

Summarize key points for care of patients undergoing moderate sedation.

Prior to Sedation

Before

Understand the medications to be given

  • Risks, benefits, adverse reactions, alternatives

Collaborate with physician performing the procedure and agree on medications to be given

Gain informed consent

Be relieved of all other patient care duties

During Sedation Procedure

During

Do not perform any other patient care tasks

Document vitals every 5 minutes or more frequently as needed

Connect patient to monitoring devices to measure

  • BP
  • HR and rhythm
  • pulse oximetry
  • respiratory rate

Provide oxygenation via nasal cannula with other oxygen apparatus and airway devices at bedside

Recommend connecting to an end tidal CO2 monitor

Recovery from Sedation

After

Monitor the patient until fully awake and do not perform other patient care duties until sedation is cleared.

Do not allow unlicensed personnel to monitor patient while sedated

Know the hospital’s standard sedation scale and/or recovery scale

  • RASS, Ramsay, TJC
  • Aldrete – Level of consciousness, BP, O2 status, movement, pain back to baseline

 

Three minute video

Case scenario

Complete the scenario below by choosing the next step needed to safely complete moderate sedation for a procedure.  Your team will help you out as you go through the scenario.  You have completed the module when you're done with this scenario, regardless of what the module says.