Samples Of Nursing Care Plans

pre-sedation assessment phase, by dr. patriciascherrer, in collaboration with the society for pediatric sedation. welcome to the society for pediatric sedation'sonline provider course on pre-sedation assessment. our goal for this lecture is to review thedifferent levels of sedation, to talk through how to perform a pre-sedation risk assessment,the equipment needed to conduct procedural sedation in a safe manner, and the skill setneeded by sedation team members. we will finish by reviewing a systematic approach to providingsafe and effective pediatric procedural sedation. first, we will review some general considerationsregarding the scope of sedation, including defining different levels of sedation, whichare important for planning your medication

regimen, monitoring, et cetera. we will discusspatient factors that are important in pre-sedation planning, including health history, key pointson the physical examination of the patient, npo status and guidelines, and the americansociety of anesthesiologists physical status scoring system. in addition, we will discuss important providerand procedure factors, including team member skills, necessary monitors and other equipment,and a brief word on documentation. we will look at relevant environmental concerns, includingavailable rescue resources. and finally, we will go through a brief overview of matchingthe sedation medication regimen to these factors, and will continue to expand on that base insubsequent lectures.

the boy scout motto is particularly applicableto this phase of providing sedation. be prepared. the pre-sedation phase is the assessment,preparation, and planning phase. this phase allows for sedation risk assessment, preparationfor the sedation, and planning for the sedation, including taking the time to review the goalsfor the sedation and for the procedure. safety is our top priority. clearly, we want to get the test or procedurecompleted, but we also want to keep the child as comfortable as is safely possible. so weuse the pre-sedation assessment phase to plan for accomplishing these goals. the best wayfor us to accomplish our goals is by carefully considering the various factors that contributeto a successful sedation.

foundational to this process are those factorsassociated with the program itself, namely, the institutional setting or environment,the sedation team itself, and the organizational structure of the program, including its policiesand procedures. these form the pool from which we plan and draw resources. next, we must consider the factors specificto the situation. the patient (having reviewed underlying history and risk factors), theprocedure and its associated need (such as immobility and/or pain control), and the pharmacology--what drugs will be optimal for this case. when these factors come together, qualitysedation care can occur. let's start by discussing some initial generalconsiderations. for each sedation encounter,

we should consider the age of the child aswell as their underlying developmental level and personality in our planning. for example,the same procedure-- let's say a picc line placement-- may require three very differentsedation regimens for three different eight-year-old girls. one may do quite well with topical anestheticsand an expert child-life specialist providing distraction. one may require a bit more anxiolysiswith nitric oxide. and one anxious or developmentally different child may, in fact, require deepsedation in order to accomplish insertion of the picc line. we definitely recommendincluding emotional support and distraction techniques, ideally by child-life specialistcolleagues.

we also strongly encourage the use of adjuncts,such as topical and local anaesthetics, whenever possible. we also need to consider the typeof procedure being performed. will it be painful, suggesting the use of additional analgesics?will the child need to be quite mobile, such as for an extended mri scan, suggesting theneed for a deeper level of sedation in the younger child? we'll talk more about theseconsiderations later on, as well. let's move on in our discussion by reviewingthe levels of sedation. webster's dictionary defines sedation as the inducing of a relaxed,easy state. it is this intent for alteration and level of consciousness and perceptionof environment that is the hallmark of procedural sedation.

minimal sedation is often best described asanxiolysis, with perhaps some blunting of appropriate verbal responsiveness, but maintenanceof intact pain response, airway and breathing control, and circulatory function. moderatesedation involves more significant blunting of the responsiveness to verbal interaction,as well as some alteration and responsiveness to pain. airway tone and respiration may besomewhat impaired, but circulatory function should remain intact. under deep sedation, responsiveness to verbalstimulation is lost, and responsiveness to pain is significantly impaired, though stillpresent. deeply sedated children are at risk for impairment and airway control and respiratoryfunction, as well as some impact on the cardiovascular

system. general anesthesia involves loss ofresponse to pain accompanied by significantly impacted airway and respiratory function. it is very important to note that these levelsof sedation are a continuum. there are no clear, bright lines or defined clinical boundariesseparating the levels when you are in the midst of a sedated procedure. we will continueto emphasize the concept of the sedation continuum throughout this course. looking at each level in more detail, patientswho are minimally sedated typically have some degree of impairment in cognitive functioningand coordination. but they can offer an appropriate response to simple verbal commands and physicalstimulation. airway protective reflexes, breathing,

and circulation are maintained. although wemust be cautious in providing examples for the levels since each individual drug mayprovide a different level of sedation for different patients, even at similar dosing. in pediatrics, we often see a minimal levelof sedation in a teenager who receives a dose of an oral benzodiazepine, such as oral midazolamfor anxiolysis, or in a younger child who receives inhaled nitrous oxide to facilitateperipheral iv placement. a child who is moderately sedated should still have blunted, but purposefulresponse to verbal command or tactile stimulation. there may be associated alterations in airwaytone and ventilatory responsiveness, but airway protective reflexes and circulatory functionare usually maintained.

moderate sedation can be challenging to achievein pediatrics, but perhaps a good example would be a child who has received enteralchloral hydrate or dexmedetomidine for a sedated echocardiogram. combination of a benzodiazepineand an opioid may also result in a depth of sedation consistent with moderate sedation.deep sedation is associated with further blunting of the response to painful stimulation, aswell as increased risk for impairment and natural airway control, and respiratory responsiveness. cardiovascular function may at times be impactedas well. many of us provide deep sedation as the bulk of our patient care experiencessuch as children receiving propofol for mri scans and intravenous ketamine for fracturereductions. though we will talk a bit more

about the uniqueness of ketamine in furtherlectures. general anesthesia removes the response topainful stimulation. and as such, airway reflexes and breathing are often impaired leading toartificial airway placement and/or assisted ventilation. again, we must be clear. usinglarge enough doses and/or combinations of most of the medications we'll be discussingcan lead to a state of deep sedation or even general anesthesia. to reiterate, these definitions are somewhatarbitrary and do not come with a clear, bright lines between the levels, especially in clinicalsituations. also, different levels of sedation are in no way specific to any particular oneof the medications we will be discussing since

it is not always possible to predict to theeffect that a given dose of a given medication will have on a specific patient, in a specificclinical situation. because of the different associated risksto airway and respiratory function, the different levels of sedation do require different levelsof experience and expertise for patient management. joint commission regulations state that aprovider of sedation must be able to rescue a patient from one level of sedation deeperthan what is intended. so for example, for a patient receiving moderate sedation, thesedation provider must be able to support the patient's ventilation, and provide airwayrescue adjuncts, including endotracheal intubation if they are needed. for patients receivingdeep sedation, practitioners must be additionally

competent to manage an unstable cardiovascularsystem. now let's move on to evaluation of the patient.we need to consider a number of different factors about the child during our evaluation,including their underlying health history, relevant findings on physical examination,their npo status, and their american society of anesthesiologists physical status score.we will look at each of these categories in more detail in the next several slides. in terms of health history, we primarily needto consider factors that could impact the sedation. as we have discussed, age, developmentallevel, and personality are all important considerations. weight and body mass percentile for age arevery important to review since we know that

obesity is associated with an increased riskfor airway and respiratory related adverse events and interventions. allergies should also be considered. we willspeak a little more about the ongoing controversy regarding the association of propofol withegg anaphylaxis in future lectures. evaluating the child's medication history is also important,especially to consider medication interactions and potential alterations in response to theplanned sedation regimen. for example, anticonvulsant medications may alter anticipated patientresponse to sedatives such as benzodiazepines and barbiturates. we know that there are a number of geneticsyndromes associated with risk of underlying

airway anomalies, altered respiratory mechanics,and other issues that may impact the sedation process. for example, trisomy 21 is associatedwith macroglossia and poor upper airway tone. goldenhar syndrome is associated with an inabilityto fully open the mouth and successfully endotracheally intubate via direct laryngoscopy. tuberoussclerosis patients, especially infants, may have intracardiac rhabdomyomas associatedwith potential obstruction of the left ventricular outflow tract. we could spend a number of hours just reviewingthese associations. there is a reference article included at the end of this talk, and thereare a number of other similar articles and texts available for reference. we also knowthat sedation of former premature infants,

and even term neonates, can be associatedwith an increased risk of apnea due to immaturity of the respiratory control center. underlying asthma and chronic lung diseasecan increase the risk for bronchospasm, desaturation, and other respiratory complications duringsedation. obstructive sleep apnea at baseline is, not surprisingly, associated with an increasedrisk of upper airway obstruction, desaturation, and the need for rescue interventions. manyof the medications and imaging modalities we use are contraindicated in the developingfetus, so pregnancy status is important to be aware of. current health issues, such as recent illnesses,can impact sedation safety. upper respiratory

infections, especially those associated withsignificant nasal congestion, productive cough, and/or a history of reactive airway disease,are associated with the occurrence of cough, upper airway congestion, desaturation, bronchospasm,and apnea during sedation and anesthesia of children. recent or active vomiting, increasesthe risk for vomiting during the procedure with the attendant risk of aspiration. it can be very helpful to explore the childand family's experiences with previous sedation and anesthesia, both to provide additionalreference for the current experience, and to review any complications. it often helpsto ask fairly concrete questions about these experiences such as, were there any problemsputting in the breathing tube? did she get

happy or upset with the pink medicine, i.e.midazolam, that they gave her to drink beforehand, and so forth. in discussing the sedation-based review ofsystems with the child and family, we focus more specifically on airway and respiratoryconcerns, asking questions about a history of snoring, wheezing, cold symptoms, and thelike. although we usually are hoping not to provide airway interventions, it is importantto review mechanical risks beforehand such as loose teeth, braces, and other orthodonticappliances. it's particularly bad form to find the rubber bands when the suction catheterbecomes filled with them. review of baseline cardiovascular status isvery helpful as many of the medications we

use can negatively impact cardiovascular performance,especially in the tenuous child. ge reflux disease is diagnosed quite frequently in thepediatric population. but for those patients with true reflux, we do consider the riskof aspiration and laryngospasm, especially with any risk of delayed gastric emptying,finally, impairment and underlying renal and/or hepatic function can dramatically alter metabolismand excretion of a number of different medications. for example, the clinical effects of benzodiazepinescan be quite prolonged in patients with the hepatic failure. now let's move on to important findings onthe pre-sedation physical examination. the joint commission does mandate baseline vitalsigns, as well as repeated vital signs, immediately

before the procedure. it is helpful to knowthe patient's baseline systemic oxygen saturations, respiratory rate, heart rate, and blood pressureto allow for trending during the procedure. patient temperature monitoring may be indicatedby patient history, or may be clinically indicated for procedures with the potential for swingsin environmental temperature. during our examination, we focus primarily on sedation-relevant systemssuch as the airway, respiratory tract, cardiovascular, and nervous systems. since most clinicallysignificant sedation-related adverse events are upper airway in nature, particular focuswill be placed on properly examining the upper airway. in examining the upper airway, we are lookingfor findings that would limit our ability

to keep the child's airway patent with positioning,suctioning, et cetera, and for factors that would limit our ability to rescue the childwith bag valve mask ventilation and endotracheal intubation, if needed. as such, it is importantto evaluate for any craniofacial abnormalities, unusual dentition, alteration and pharyngealstructures, tonsillar hypertrophy, or limitations to neck mobility. the mallampati score is the most often usedsystem to evaluate the airway in cooperative adults. and we'll review that score two slideson. however, formal mallampati evaluation requires co-operative opening of the mouth,which doesn't always happen with our smaller patients. another way to assess the adequacyof airway size in terms of the ability to

open the airway for bag valve mask ventilationand to visualize the glottic inlet if needed for intubation, is to assess the thyromentalor cricomental distance. in adults with normal airway architecture,we can put at least three finger widths in the space between the thyroid cartilage andthe tip of the chin. take a moment and check this on yourself. obviously, this distancehas to be modified, and somewhat ballparked for younger children, but ideally, we shouldbe able to get three of our finger widths between the thyroid cartilage and the tipof the chin down to younger school-aged children, and two finger widths even in many infants.again, the space reflects the ability to open and view the airway if required.

another important consideration, especiallyin children, is the tonsil score. we know that increasing tonsil size is associatedwith an increased risk of airway obstruction and difficulty maintaining a patent naturalairway, especially in the supine position. note that a score of zero are tonsils thatfit within the tonsillar fossa, whereas 4 plus tonsils occupy greater than 75% of thespace between the tonsillar pillars. again, the mallampati score is the gold standardfor upper airway assessment in cooperative older children and adults. as the picturedemonstrates, the mallampati class correlates with the ability to visualize the glotic inletduring direct laryngoscopy for younger children, this can also be estimated by getting a reasonablelook at their mouth opening while they are

screaming at you. in general, a high-- 3-4-- mallampati classificationassociated with any other abnormality of the head and neck is indicative of an airway thatmay well be difficult to manage, particularly if endotracheal intubation is required. thepatient is classified a mallampati 1 if the examiner can see down to the tonsillar pillars,class 2 if the examiner can visualize just the full uvula, class 3 if only the soft palatecan be seen, and class 4 if the hard palate is all that is visualized. in examining the respiratory system, we evaluatebreath sounds for symmetry and presence of any adventitious sounds such as wheezing,congestion, or decreased air entry. restriction

to chest wall movement by adipose tissue,mass, or external bracing like a tlso, may lead to further issues with spontaneous ventilationwhen sedated. from the cardiovascular standpoint, many sedatives can decrease cardiac outputthat could be concerning for children with already borderline perfusion or compromisedoxygen delivery. there are several different angles to considerfrom the neurologic perspective. first of all, we need to assess the child's abilityto control airway tone and secretions. will they be able to maintain a patent airway whensedated? will they be able to handle any secretions that develop? it is also important to documentbaseline neurologic status so that this may be referred back to, and return to base whenconfirmed on the post-sedation assessment.

finally, we need to be sure that from a neurodevelopmentalperspective, we will be able to keep the patient, their family members, and our team memberssafe throughout the course of the procedure. adult-sized patients with significant cognitivedelays and behavioral issues may require different levels of preparation and environments ofcare to keep everyone safe. there has been much recent discussion regardingthe need for prolonged npo times for sedated procedures in children that do not requireairway manipulation. for now, there is no definitive data on risk, and so for elective,non-emergent procedural sedation in children, we will continue to follow the american societyof anesthesiologists' guidelines. the asa guidelines recommend that patients be npofor a minimum of two hours for clear liquids,

four hours for breast milk, six hours forinfant formula, non-human milk, and nonfat solids, and eight hours for a full meal. finally, as part of our pre-sedation assessment,we assign patients an asa physical status score. this scoring system was developed bythe asa to aid in assessments of anesthesia risk. and we know that risks of sedation andanesthesia, adverse events, and interventions are higher in patients with higher asa scores,typically greater than or equal to an asa level of three or greater. although this is known to a relatively subjectivescoring system with inherent flaws, it is currently the best available risk scoringsystem for procedural sedation.

an asa class 1 patient is a child who's essentiallycompletely healthy with no major underlying medical issues. examples would be a toddlerrequiring procedural sedation for a follow-up, auditory brainstem response hearing test,or a child with no previous history who requires procedural sedation for reduction in castingof a forearm fracture. an asa class 2 patients is a child with aknown underlying systemic disease that does not result in significant functional limitation.this group comprises the bulk of pediatric procedural sedation patients and includesexamples such as a child with well-controlled asthma who requires sedation for a lacerationrepair, a toddler with an underlying seizure disorder, but no recent seizures who requiresedation for mri imaging, or a teen in maintenance

therapy for leukemia who requires sedationand analgesia for a follow-up bone marrow aspirate and biopsy. an asa class 3 patient is a child with moresignificant and active underlying systemic disease that is associated with some notabledegree of functional limitation. examples might include a child with chronic persistentasthma who requires sedation for an unrelated procedure, a toddler with ongoing active seizuresand neurologic impairment who require sedation for a brain mri while hospitalized, an obeseteen who requires sedation for dental work, or a child with newly-diagnosed leukemia requiringsedation for their day eight lumbar puncture. asa four patients are typically cared forin an emergency department or critical care

environment, if not in the or, but may requireprocedural sedation to facilitate lifesaving procedures such as cardioversion or chesttube placement. by the asa's definition, these patients have severe systemic disease thatis a constant threat to life. in summary, the asa physical status scoring system isa broad classification scheme, but it does give us at least some framework for categorizingpatient risk. now let's switch gears and talk about teamand setting, environmental factors that impact sedation quality and safety. and we continuethe rely heavily on our "be prepared" motto. we need to consider our answers to the followingquestions. who are the members of our sedation team, and what are their skill sets? whatmonitors and equipment do we need, both to

perform the sedated procedure itself, andto rescue if there are any problems? what are our rescue resources in case of an emergency? to start, in terms of our team members, thejoint commission states that "appropriate physiologic monitoring and continuous observationby personnel not directly involved with the procedure allow for accurate and rapid diagnosisand initiation of appropriate rescue interventions." or, we need separate folks specifically designatedfor the sedation who bear no responsibility for performing the procedure. remember thatthe joint commission also states the providers and teams must be able to rescue a patientfrom a level of sedation deeper than what is intended, meaning that we need to havethe expertise, the equipment, and the resources

for that deeper level of sedation immediatelyavailable. sedation team members should possess somedegree of experience with the entire process of procedural sedation including the medicationregimen and it's titration and recognition and management of potential adverse effects.team members should have successfully participated in current basic and advanced life supporttraining for pediatric airway and emergency management as well. next, we move to considerationof the physical environment, or the setting of the sedation. in terms of equipment and supplies, thereare some basic airway intervention supplies that have a number of different associatedacronyms. one of the more popular is soap

me, which covers suction, oxygen, airway equipment,pharmacy, monitors, and extra equipment. reviewing this list in more detail, in terms of suction,we should have both yankauer and smaller bore suction catheters available as well as functionalvacuum apparatus. we should have a guaranteed adequate oxygensupply system with flow meters. these should be checked for working condition before thesedation begins each and every time. a variety of equipment should be available at the sedationprovider's disposal, all age and size appropriate for the patient in question. these include nasal pharyngeal airways-- ortrumpets-- oral airways, laryngeal mask airways, which are the asa recommended rescue devicesfor patients who can neither be bag valve

mask ventilated nor intubated successfullyin an emergency situation. additionally, laryngoscope blades and handles, endotracheal tubes, facemasks, self-inflating or anesthesia-style bags for hand ventilation, and so on. we should be able to answer the followingquestions for every sedation. what would we need available to manage apnea? what aboutlaryngospasm? what would we need to intubate the child's trachea? is all of this equipmenteasily and rapidly accessible? how quickly could we access and deliver emergency medications,including neuromuscular blocking agents in the setting of critical laryngospasm? we will review sedative and analgesic medicationsin the next lecture. but in terms of preparation,

our chosen armamentarium should be rapidlyaccessible, including repeat doses if required, as well as emergency medications and reversalagents. we will also discuss monitoring at length in a subsequent lecture. but for now,based on the level of sedation, we need to have available pulse oximetry, cardiovascularmonitoring, end capnography, all in working order with power cords and/or charged batteries. many sedation programs have developed a pre-sedationchecklist that is reviewed along with a standard time out procedure to ensure that all equipmentmonitors have been evaluated prior to each sedation encounter. other equipment that mightcome in handy include iv supplies, lab supplies, fluids, and medication sheets. finally, availabilityof rescue equipment is another key point in

sedation safety. we know that adverse events are most commonin systems that do not have adequate, reliable emergency support. so as we are preparingfor each sedation encounter, it is critical to ask, who will be our rescue net if we needassistance? how quickly will they respond? what additional resources do they possess?advanced airway skills? will they need additional equipment and supplies? if so, are these available? we should review,and ideally practice with high-fidelity simulation, our ability to respond rapidly and fully toa sedation-related emergency in any area in which we offer sedation services.

finally, as part of the pre-sedation preparation,we must be prepared to provide an appropriate level of documentation for each sedation.this documentation mirrors the organizational structure and basis of the sedation process.the american academy of pediatrics states that informed consent must be obtained anddocumented according to applicable policies. also, families and guardians must receiveappropriate information and instructions, including the overall sedation plan and expectations,anticipated changes during and after the sedation, activity and diet instructions, as well ascontact information for questions or concerns after discharge. prior to beginning the sedation,the provider must document a focused pre-sedation evaluation. important elements include relevanthistory, previous sedation or anesthesia issues,

relevant review of systems, a focused physicalexamination, commenting particularly on the airway, npo status, asa score, and the proceduralsedation plan. we must document performance of a timeoutperformed prior to beginning the sedated procedure. during the sedation, we must keep a time-basedrecord of medications administered, the level of sedation, vital signs, and any adverseevents and their associated management. the american society of anesthesiologists hassimilar guidelines for monitored anesthesia care, including procedural sedation, withsimilar recommendations for time-based documentation of sedation score and relevant vital signsbased on level of sedation. the asa also states that parameters shouldbe monitored and documented until the child

has returned to their pre-sedation baseline.and in similar fashion to the aap recommendations, including documentation before the beginningof the procedure, after administration of any sedative or analgesic agents, at regularintervals during the procedure, while recovering, and prior to discharge from the recovery area. so, let's try and put this all together. whois a good procedural sedation candidate for us? in general, non-anesthesia based sedationprograms are caring for asa 1 or 2 patients with a natural airway-based sedation. thatdoesn't mean we can't or don't sedate more complex patients. but we need to recognizeand keep in mind that higher risk patients and deeper levels of sedation imply the needfor more intensive monitoring and a greater

skill set, as well as an ability for rescue. we encourage case by case consideration ofall factors, patient, procedure, provider, and environment, in order to decide who weare adequately prepared to sedate. in general, there are no defined time limits for naturalairway procedural sedation. but we do need to be aware that total sedation time of greaterthan around 2-3 hours begins to be associated with a higher risk of adverse respiratoryand cardiovascular events. also, there are airway maintenance risks associated with numerousposition changes and procedure locations that must be considered as well. in conclusion, from our pre-sedation assessment,we should know that our patients seem like

reasonable candidates for our team. this isbased on a review of patient factors as well as our team's experience and abilities, thenecessary monitoring and emergency rescue equipment, our medication options, and ourrescue resources in case of emergency. please help us improve the content by providingus with some feedback.