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Audit ItemYesNoComments/ActionPre-sedation Patient AssessmentPerforms and documents a nursing assessment that includes a review of:allergies and sensitivitiesageheight, weight, and body mass indexmedical and surgical history and physical examinationcurrent medications (eg, prescribed, over-the-counter, alternative/complementary therapies, supplements), dosage, last dose, and frequencyhistory and current drug use (eg, street drugs, nonprescribed prescription drugs)history and current tobacco, alcohol, and cannabis uselaboratory and diagnostic test resultsbaseline cardiac, respiratory, and neurological statusairway (eg, obstructive sleep apnea, difficult mask ventilation)physical limitations or sensory impairmentlevel of anxietylevel of painpregnancy test results when applicableNPO statusprevious adverse experiences with anesthesia or moderate sedation (eg, delayed emergence, postoperative nausea and vomiting, malignant hyperthermia, airway or breathing problems)informed consentarrangement for a responsible adult caregiver to escort the patient home or two adults (ie, driver and observer) for an infant or toddler riding home in a car seatAssesses older adult patients for:frailtyfunctional statuscognitive impairment (eg, delirium)Uses additional assessment criteria for pediatric patients as determined by the interdisciplinary team.Uses a physical status classification tool (eg, the American Society of Anesthesiologists [ASA] Physical Status Classification) to determine patient acuity.Uses the results of the nursing assessment to develop and document the sedation plan in collaboration with the licensed independent practitioner.Plan of CareConsults with the supervising licensed independent practitioner and an anesthesia professional when the patient presents with any of the following:previous difficulties with anesthesia or sedation, including a difficult airwayobstructive sleep apnea or other airway-related issuesknown history of respiratory instability or hemodynamic instabilityhistory of coagulation abnormalitymoderate to severe neurologic, cardiac, or endocrine diseasehistory of renal disease that may affect metabolism of medications administered for moderate sedation/analgesiaone or more significant comorbiditiespregnancyinability to tolerate the proceduremultiple drug allergiesuse of medications with potential for drug interaction with sedative analgesicspolypharmacycurrent substance abuseASA physical status classification of ASA III or aboveDetermines the need for IV access depending on the level of sedation intended; the route of medication administration (eg, intravenous, intranasal, oral); and organizational policy, procedure, and protocol.Medication 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.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/analgesia.Does not perform the role of circulating nurse when administering moderate sedation.Performs only short, interruptible tasks when monitoring the patient, such as opening suture or tying a gown.Ensures monitoring equipment is available and working and alarms are set and audible.Uses bispectral index monitoring (BIS) when appropriate to measure the level of sedation.Ensures an emergency cart is available and stocked with age- and size- appropriate resuscitation medications and rescue equipment.Includes the following in the intraoperative patient monitoring and documentation: cardiac rate and rhythmblood pressurerespiratory rateblood oxygen level by pulse oximetryend-tidal carbon dioxide by capnographydepth of sedationpain levellevel of consciousnessIncludes the following in the postoperative assessment, monitoring, and documentation:cardiac rate and rhythmblood pressurerespiratory rateblood oxygen level by pulse oximetrypain levelsedation levellevel of consciousnessintravenous line (eg, patency, site, type of fluid)condition of the dressing and woundtype and patency of drainage tubesDischarge ReadinessEvaluates the patient for discharge readiness based on criteria developed by an interdisciplinary team.Provides the patient and caregiver with verbal and written discharge instructions and places a copy in the patient’s medical record.Asks the patient or caregiver to verbalize understanding of the discharge instructions.Includes the following in discharge instructions for adults responsible for the care of an infant or toddler riding home in a car safety seat:careful observation of the child’s head position to avoid airway obstructioncare of two responsible adults (ie, driver and observer) ................
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