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Role of Registered Nurse (RN) in the Management of Patients Receiving Moderate Sedation/Analgesia for Therapeutic, Diagnostic, or Surgical Procedures
 

  1. Continuum of Depth of Sedation

Minimal Sedation (ie, Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands.  Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia is a drug-induced depression of consciousness during which patients respond purposefully* to verbal commands, either alone or accompanied by light tactile stimulation.  No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.  Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation.  The ability to independently maintain ventilatory function may be impaired.  Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.  Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.  The ability to independently maintain ventilatory function is often impaired.  Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.  Cardiovascular function may be impaired.

*Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

  1. Qualifications
    1. Administration of minimal sedation in the form of nitrous oxide/oxygen-inhalation by non-anesthetist RNs is allowed by state laws and institutional policy, procedures, and protocol.
    2. Administration of moderate sedation/analgesia medications by non-anesthetist RNs is allowed by state laws and institutional policy, procedures, and protocol.
    3. A licensed nurse who is not a Certified Registered Nurse Anesthetist may not administer general anesthesia or conscious/moderate sedation, if the drug manufacturer’s general warning advises the drug should be administered and monitored by persons experienced in the use of general anesthesia who are not involved in the conduct of the surgical and/or diagnostic procedure.
    4. The registered nurse managing the care of patients receiving sedation/analgesia is able to:
      1. Demonstrate the acquired knowledge of anatomy, physiology,  
          pharmacology, cardiac arrhythmia recognition and complications related to sedation/analgesia and medications.
      2. Assess total patient care requirements before and during the administration of sedation/analgesia including the recovery phase. 
      3. Understand the principles of oxygen delivery, respiratory physiology, transport and uptake, and demonstrate the ability to use oxygen delivery devices. 
      4. Recognize potential complications of sedation/analgesia for each type of agent being administered.
      5. Possess the requisite knowledge and skills to assess, diagnose and intervene in the event of complications or undesired outcomes and to institute nursing interventions in compliance with orders (including standing orders) or institutional protocols or guidelines.
      6. Demonstrate competency, through ACLS or PALS or appropriate competency assessment, in airway management and resuscitation  appropriate to the age of the patient and to meet facility requirements.
    5. The registered nurse administering sedation/analgesia and/or monitoring patients receiving sedation/analgesia understands the legal ramifications, including the RN’s responsibility and liability in the event of an untoward reaction or life-threatening complication.
    6. The institution or practice setting has in place an educational/competency validation mechanism that includes a process for evaluating and documenting the individuals’ demonstration of the knowledge, skills, and abilities related to the management of patients receiving sedation/analgesia.  Evaluation and documentation of competence occurs on a periodic basis according to institutional policy.
  2. Management and Monitoring

Registered nurses who are not qualified anesthesia providers may be authorized to manage and monitor minimum sedation in the form of nitrous oxide or moderate sedation/analgesia during therapeutic, diagnostic or surgical procedures if the following criteria are met. 

  1. A qualified anesthesia provider or attending physician selects and orders the medications to achieve sedation/analgesia.
  2. Written guidelines for patient monitoring, drug administration, and protocols for dealing with potential complications or emergency situations are available and have been developed in accordance with accepted standards of practice.
  3. The registered nurse managing and monitoring the patient receiving moderate sedation/analgesia shall have no other responsibilities that would leave the patient unattended or compromise continuous patient monitoring.
  4. Venous access shall be maintained for all patients having moderate sedation/analgesia.
  5. Documentation and monitoring of physiologic measurements including, but not limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and level of consciousness should be recorded according to facility policy.
  6. Supplemental oxygen shall be available for any patient receiving sedation/analgesia and where appropriate in the post procedure period.
  7. An emergency cart must be immediately accessible to every location where sedation/analgesia is administered.  This cart must include emergency resuscitative drugs, airway and ventilatory adjunct equipment, defibrillator, and a source for administration of 100% oxygen.  A positive pressure breathing device, oxygen, suction and appropriate airways must be placed in each room where moderate sedation/analgesia is administered.
  8. Qualified personnel who are experts in airway management, emergency intubations, and advanced cardiopulmonary resuscitation must be available as back-up.


REFERENCES

American Association of Nurse Anesthetists: CRNA Practice (June 2003).  Qualified providers of sedation and analgesia, No.2.2.

American Association of Nurse Anesthetists: CRNA Practice (June 2003).  Considerations for policy guidelines for registered nurses engaged in the administration of conscious sedation, pp. 1-4.

American Nurses Association: Position Statements (1991).  Endorsement of position statement on the role of the registered nurse (RN) in the management of patients receiving IV conscious sedation for short-term therapeutic, diagnostic, or surgical procedures. No.12.8. 

American Society of Anesthesiologists, Inc. (October 2002).  Practice guidelines for sedation and analgesia by non-anesthesiologists.  Park Ridge: Illinois. 

AstraZeneca Pharmaceuticals. Anesthesia – Target Controlled Infusion. (2002). http://www.anaesthesia-az.com/

Goldstein, Robert C. (November 2002).  Guidelines for sedation and analgesia by nonanesthesiologists have gone too far! ASA Newsletter, 66(11), 1-2.

Lockwood, James (Winter 2007).  Nitrous Oxide in the Pediatric Setting:  Creating Program, Better Experiences for Young Patients.  Children’s Practice, Vol. 1, No. 1, pp. 3-7.

Frampton, A., et al (2003). Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department, Emergency Medicine Journal, 20(5), 410.  Downloaded from proquest,umi. 3/28/07.

Meltzer, Bill (July 2003).  RNs pushing Propofol. Outpatient Surgery Magazine. Pp. 24-37.

National Council State Boards of Nursing (2003) State updates on conscious sedation. http://www.ncsbn.org/

Oklahoma Board of Nursing (November 2005).  Guidelines for Registered Nurse Managing and Monitoring Conscious Sedation. www.ok.gov/nursing

Rex, Douglas, et al (May 2002).  Safety of Propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. American Journal of Gastroenterology, 97(5),1159-1162.

Rex, Douglas k, overly, Christine A., Walker, John (2003).  Registered Nurse- Administered Propofol sedation for upper endoscopy and colonoscopy: Why? When? How? Reviews in Gastroenterological Disorders, 3(2), pp. 70-80.

RxMed: Pharmaceutical Information – Diprivan http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20D)/DIPRIVAN.html

Texas Board of Nursing (January 2003).  Administration of conscious sedation by the registered nurse. http://www.bne.state.tx.us/

Thompson, Sally (November 2006).  I had a dream – a good dream!   Children’s Magazine, Vol 8, No 1, pp. 15-19. 

Walker, John W. (February 25, 2003. Letter to Executive Director of North Dakota Board of Nursing. NAPS, pp. 1-2.

 

Adopted:  05/90;
Reviewed/Revised:  10/12