Procedural Sedation Checklist and Record Sheet



Procedure:Date and Time:Sedationist:Proceduralist:Nurse:? Resus room and staff available including for recovery; calm quiet environment if using ketamineInformed Consent:?Written?VerbalInfo sheet given? Yes / No (Ketamine Sedation Patent Information Pamphlet)Pre-Procedure AssessmentRelevant history and physical exam:ASA Classification (please tick):?Class 1: Healthy patient. ?Class 2: Mild systemic disease.?Class 3: Significant systemic disease, but not incapacitating – Consider alternative if possible?Class 4: Severe systemic disease that is a constant threat to life*?Class 5: Moribund, not expected to live 24 hours, irrespective of procedure/ operation** Highly unlikely to be suitable to receive procedural sedation at Dunstan. Consider alternatives.Allergies:Relevant Meds:Last Ate: Last Drank: Weight:Prior Problems with Sedation/Anaesthesia:Airway AssessmentDifficult BVM Ventilation: Beard, Obese, No teeth, Elderly, Sleep Apnoea / SnoringDifficult Laryngoscopy: Look externally, Evaluate 3-3-2 rule, Mallampati score ___, Obstruction, Neck MobilityDifficult Rescue Airway: Restricted mouth opening, Distorted airway or neck, Neck radiotherapy/surgeryleft2540000 Equipment Checklist (tick when checked): ? Pre-oxygenation ? Airway Adjuncts ? Ambu bag ? Suction – (checked) ? Advanced Airway equipment as per RSI checklist ? IV access: ? Monitoring: ECG, SpO2, NIBP, ETCO2 ? Sedation Meds? Push dose pressors? Rescue Meds?Time out prior to sedation, introductions, confirmation of procedure and checklist completeDrugRouteDoseTime Checked byGiven byIf patient requires in-patient admission please use EWS observation chartObservationsPre ProcedurehrshrshrshrshrshrshrsHRRRSp02Capnography *BPProcedure completed at:Continuous monitoring of HR, SpO2, *ETCO2 & *ECG (*not mandatory for Ketamine sedation). BP at beginning and end of procedure (minimum) unless other vitals abnormal. Documentation at least every 15 minutes until patient at pre-sedation state.Discharge Criteria Scoring Total score prior to discharge must be 7 Activity0Unable to lift head or move extremities voluntarily or on command1Lifts head spontaneously and moves extremities to command2Able to ambulate without assistanceBreathing0Apnoeic1Dyspnoea or shallow irregular breathing2Able to breathe deeply and cough on commandCirculation0Systolic BP below 80mmHg1Systolic BP below100mmHg2Systolic BP within normal limits for patients – age appropriateConsciousness0Not responding or responding only to painful stimuli1Responds to verbal stimuli but falls asleep readily2Awake, alert and orientated to time person or place (recognises parent)Ketamine Sedation Discharge Criteria?Obtains pre-sedation level of consciousness?Exhibits purposeful neuromuscular activity?Verbalises appropriately for age?Final set of vital signs are within normal limits?Able to ambulate if developmentally appropriate (with assistance if necessary)?Able to sit without support?Able to tolerate oral fluids TimehrshrshrshrshrshrshrshrsActivityBreathingCirculationConsciousnessTotal ScoreAdverse Events (and management): (Include 02sats <92%, loss of respiratory effort for 30secs, airway obstruction/laryngospasm, bradycardia, hypotension, arrhythmia, vomiting, retching, excitatory movements – myoclonus/muscle rigidity/seizure and adverse behavioural reactions, bag valve mask / LMA / ETT / reversal agent)OutcomesProcedure:? Successful? UnsuccessfulPatient disposition:? Home ? Ward? Dunedin? Other: (specify)________________Discharge instructions given:? Procedure? Sedation ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download