Association of periOperative Registered Nurses | AORN



Audit ItemYesNoComments/ActionNursing AssessmentPerforms a nursing assessment that includes a review of:medical historyallergies and sensitivitiesage, height, weight, and body mass indexlaboratory tests resultscurrent medications and supplementstobacco, alcohol, and drug usevital signslevel of consciousnessairway (for difficult mask ventilation, obstructive sleep apnea)sensory impairments (visual, auditory)levels of anxiety and painconsent, including risks, benefits, and alternatives to sedationpregnancy test results if applicableNPO statusprevious adverse experiences with moderate sedationneed for IV accessEnsures there is a responsible adult to escort the patient home.Uses a tool to determine the patient’s acuity.Uses results of the nursing assessment to develop and document the sedation plan in collaboration with the licensed independent practitioner.Airway AssessmentAssesses for characteristics of a difficult mask ventilation:> 55 years of ageBMI ≥ 30history of snoring, stridor, or sleep apneamissing teethbeardshort necklimited neck extensionsmall mouth openingjaw abnormalitieslarge tonguenonvisible uvulaprevious difficulty with anesthesia or sedationrheumatoid arthritischromosomal abnormality (such as trisomy 21)tonsillar hypertrophyUses a sleep apnea assessment screening tool.Consults with the anesthesia professional if the patient has a history of obstructive sleep apnea.Screens for obstructive sleep apnea in a pediatric patient who presents with the following symptoms:weight above the 95th percentile for age and sextalks in his or her sleeprestless sleep, difficulty breathing, and struggling respiratory effort during sleepnight terrorsunusual sleep positionsnew onset of enuresisdaytime sleepinessdistracted behavioroverly aggressive behaviorirritabilitydifficulty concentratingAnesthesia ConsultationConsults with a anesthesia professional when the patient presents with any of the following:known history of respiratory or hemodynamic instabilitycoagulation abnormalityprevious difficulties with anesthesia or sedationsevere sleep apnea or other airway-related issuesone or more significant comorbidities that may affect metabolism of medications administered for moderate sedationpregnancyinability to communicateinability to cooperatemultiple medication allergiesmultiple medications with the potential to cause drug interactions with sedative analgesicscurrent substance abuse (street drugs, alcohol, non-prescribed prescription drugs)a classification of unstable ASA III or ASA IV or aboveMedication AdministrationVerifies medications administered are within the scope of nursing practice for your state.Verifies physician's orders.Adjusts dose according to the patient's age and under the supervision of a licensed independent practitioner.Knows the recommended dose, dilution, onset, effects, potential adverse reactions, drug compatibility, and contraindications for each medication.Administers intravenous medication separately in incremental doses and titrates to the desired effect.Allows sufficient time for drug absorption before considering additional medication.Monitors the patient continuously.If using computer-assisted personalized sedation (CAPS) technology, ensures that an anesthesia professional is immediately available.Follows manufacturer's recommendations for use of CAPS technology.Administers supplemental oxygen as needed and as ordered.Administers opioid antagonists if applicable and as ordered.Patient MonitoringIs in constant attendance and continuously cares for patient when administering moderate sedation.Does not perform the role of circulating nurse when administering moderate sedation.Performs only short, interruptible tasks when monitoring the patient.Ensures monitoring equipment is available, working, and alarms are set and audible.Uses bispectral index monitoring (BIS) when appropriate to measure the level of sedation.When propofol is used, does not perform any other tasks and monitors the patient without interruption.Ensures an emergency cart is available and stocked with age- and size-appropriate resuscitation medications and rescue equipment.DocumentationDocuments baseline and intraoperative monitoring, including:pulseblood pressurerespiratory ratepulse oximetryend-tidal carbon dioxidepain levelanxiety levellevel of consciousnessMonitors and documents vital signs before the procedure, after administration of the sedative or analgesics, at least every 5 minutes during the procedure based on the patient's condition, and after the procedure.Assesses and documents the depth of sedation using an objective scale.Documents the moderate sedation medications administered, including: typestrengthamountroutetimeresponseadverse reactionsAfter surgery, documents: pulseblood pressurerespiratory ratepulse oximetrypain levelanxiety levelsedation levellevel of consciousnessDischarge ReadinessUses facility-established criteria to determine discharge readiness.Provides a copy of the written discharge instructions and documents the patient's or responsible adult's verbal understanding.Provides additional discharge instructions to adults caring for an infant or toddler in a car seat (careful observation of the child's head position to avoid airway obstruction, need for two responsible adults [a driver and an observer]).Delays discharge in cases of:obstructive sleep apneause of an antagonistprolonged nausea and vomitinguse of a medication with a long half-lifealtered absorption0 ................
................

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

Google Online Preview   Download