AORN Guideline Audit Tool: Moderate Sedation Insert Facility Name Or a Header

AORN Guideline Audit Tool: Moderate Sedation[Insert facility name or a header]

Audit Item / Yes / No / Comments/Action
Nursing Assessment
Performs a nursing assessment that includes a review of:

medical history

allergies and sensitivities

age, height, weight, and body mass index

laboratory tests results

current medications and supplements

tobacco, alcohol, and drug use

vital signs

level of consciousness

airway (for difficult mask ventilation, obstructive sleep apnea)

sensory impairments (visual, auditory)

levels of anxiety and pain

consent, including risks, benefits, and alternatives to sedation

pregnancy test results if applicable

NPO status

previous adverse experiences with moderate sedation

need for IV access

Ensures 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 Assessment
Assesses for characteristics of a difficult mask ventilation:

> 55 years of age

BMI ≥ 30

history of snoring, stridor, or sleep apnea

missing teeth

beard

short neck

limited neck extension

small mouth opening

jaw abnormalities

large tongue

nonvisible uvula

previous difficulty with anesthesia or sedation

rheumatoid arthritis

chromosomal abnormality (such as trisomy 21)

tonsillar hypertrophy

Uses 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 sex

talks in his or her sleep

restless sleep, difficulty breathing, and struggling respiratory effort during sleep

night terrors

unusual sleep positions

new onset of enuresis

daytime sleepiness

distracted behavior

overly aggressive behavior

irritability

difficulty concentrating

Anesthesia Consultation
Consults with a anesthesia professional when the patient presents with any of the following:

known history of respiratory or hemodynamic instability

coagulation abnormality

previous difficulties with anesthesia or sedation

severe sleep apnea or other airway-related issues

one or more significant comorbidities that may affect metabolism of medications administered for moderate sedation

pregnancy

inability to communicate

inability to cooperate

multiple medication allergies

multiple medications with the potential to cause drug interactions with sedative analgesics

current substance abuse (street drugs, alcohol, non-prescribed prescription drugs)

a classification of unstable ASA III or ASA IV or above

Medication Administration
Verifies 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 Monitoring
Is 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.
Documentation
Documents baseline and intraoperative monitoring, including:

pulse

blood pressure

respiratory rate

pulse oximetry

end-tidal carbon dioxide

pain level

anxiety level

level of consciousness

Monitors 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:

type

strength

amount

route

time

response

adverse reactions

After surgery, documents:

pulse

blood pressure

respiratory rate

pulse oximetry

pain level

anxiety level

sedation level

level of consciousness

Discharge Readiness
Uses 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 apnea

use of an antagonist

prolonged nausea and vomiting

use of a medication with a long half-life

altered absorption