Pre-Sedation Assessment History & Physical for Non ... Assessment History & Physical for...
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Pre-Sedation AssessmentHistory & Physical
forNon-Operative Procedure
WITH Sedation
History: Pertinent to Anesthesia
• Previous problems with sedation or anesthesia in past?– Significant nausea/vomiting?– Significant drug reactions/allergies?– MH or Psuedocholinesterase defiency should not be an issue since
Non-Anesthesia provider do not use triggering drugs
• Evidence of predisposition to Airway Obstruction?– Stridor, snoring, or sleep apnea?– History of difficult intubation?
Medication Reconciliation
• Allergies reviewed and listed• “I have reviewed the patient’s home and
current medications and consider the patient appropriate for the procedure indicated above”
Physical Examination
• Document the following:– Heart & Lung Exam– Vital Signs assessed– Airway Exam
• Neck extension – normal or limited extension• Dentition – intact, edentulous, or other (may note
changes such as loose, rotten or capped teeth)• Mallampati Scale (takes into account mouth
opening)
Mallampati ClassificationMP III or IV predicts a difficult airway
ASA Classification
• Class 1: Healthy patient, no medical problems• Class 2: Mild systemic disease• Class 3: Significant systemic disease, but not
incapacitating• Class 4: Severe systemic disease that is a constant
threat to life• Class 5: Moribund, not expected to live 24 hours
irrespective of procedure/operation
Within 15 minutes prior to initiating sedation must verify
with a simple check box:
•Pre-induction assessment performed
Post Procedure Note
9/29/2008 9.19.08
Universal ProtocolPart 2
Mac Whitehouse MDSuzette Bouchard-Isackson RN, MSN
Tom Shehab MD
Universal Protocolnon-operative invasive procedures
with or without sedation
Part 2Tom Shehab MD
Mac Whitehouse MD
Defined as any procedure that
•could do harm to the patient•requires a consent
•Involves an incision or•percutaneous puncture or •insertion of instrumentation
•can be done in settings other than the operating room
Invasive procedures
(non operating room setting)
•checklist elements must be met on the procedure documentation form or •an additional checklist•checklist is included as permanent part of the record
Minimum Documentation requirements
PROCEDURE DOCUMENTATION FORMATVersion 1
Not using the SEPARATE check list format
•Pre procedure phase includes documentation of the following:•Consent signed and on chart •Confirm special equipment is obtained and available for use•Pre procedure assessment complete•Physician assessment is complete•Indications for procedure documented•Nursing assessment complete
Mark the site
•Patient must participate in verification•Mark all cases/ sites involving incision or percutaneous instrumentation•Mark prior to moving the patient to the location where the procedure is performed•Use permanent marker, visible after prepping•Proceduralist’s initials at site•Emphasis on laterality, level of spine, specific digit
Sedation assessment
SJMHS MSP No. 200, Policy for Moderate and Deep Sedation and Analgesia for Non-anesthesiologists
•Cardiac •Respiratory•Airway Mallampati class •ASA score 1-5
•Class I: soft palate, fauces, uvula, pillars
•Class II: soft palate, fauces, portion of uvula
•Class III: soft palate, base of uvula
•Class IV: hard palate only
Airway Mallampati class
•Class 1 Healthy patient, no medical problems
•Class 2 Mild systemic disease
•Class 3 Severe systemic disease, but not incapacitating
•Class 4 Severe systemic disease that is a constant threat to life
•Class 5 Moribund, not expected to live 24 hours irrespective of operation
ASA score 1-5
Elements of universal protocol must be documented on procedure form
Universal protocol implemented prior to starting procedure•Patient identified (2 identifiers)•Correct procedure verified with patient•Correct site and side marked by person performing the procedure•Correct patient position•Relevant image studies reviewed immediately prior to procedure and available for reference•Any special medications or fluids for irrigation •Additional safety precautions individualized to patient history or medication use•Final time out verification step include personnel involved.•________________ date________time_____
Procedure documentation formatVersion 2
Using a separate check list similar to the operating room
•Consider having the separate Universal Protocol check list in phases
•Pre procedure phase•Check in phase •Final verification (time out)•Sign out phase
See operating room checklist for an example
•Universal protocol implemented•Check list elements met (2009 patient safety goals)•See page Operating room check sheet•Time out completed________date and time
•Personnel involved___________________________________________
•Check list included in patient record
Procedure form documentation must have
Process flow
Pocket card in development
Universal Protocol Flow Process - Non-Operative Procedure with SedationC
heck
In P
hase
Tim
e O
ut P
hase
Sig
n O
ut P
hase
Pre
Pro
cedu
re P
hase Required by patient, nurse, and
anesthesia providerPt asked to state full
name & DOB, verified by matching ID band
Pt states procedure, site,and side and verified
by consent
Site is marked by theprovider initiating
procedure (physician) andverified by the patient
Pt asked when last ate,NPO status confirmed
All data in the medicalchart and consent is
consistent with patientresponse
Required by physician, nurse, scrubtech/nurse, physician assistant, and
anesthesia provider Team membersintroduced
Pt identity confirmed. Procedure
reviewed verbally with teammembers
Laterality confirmedwith team verbal
(correct side)
Imaging, specialimplants and
equipment available
If applicable, pre-procedure antibiotics
available andinitiated on time
Additional safety precautionsindividualized to patent
history or medication use
Any specialmedication or fluids
for irrigation
Medical record andimaging confirms
correct side and site
Patient positionconfirmed
Procedure reviewedverbally with team and
confirmed with consent
Laterality confirmedverbally with team
and marked sitevisible after prep
Patient identityconfirmed
If applicable, correctinstrument, sponge,
and needle count
Physician, anesthesia providerand nurse and/or tech review
key concerns forpost procedure care of patient
Name of correct procedureon record, all specimens
labeled correctly
Review any itemsneeding follow up
Nursing assessmentcomplete
Sedation assessment complete:cardiac, respiratory airway
Mallampati class, ASA score
Required by physician, nurse, scrubtech/nurse, physician assistant, and
anesthesia provider
Required by surgeon, nurse, scrubtech/nurse, physician assistant, and
anesthesia provider
2009
Universal Protocol Flow Process - Non-Operative Procedure without SedationC
heck
In P
hase
Tim
e O
ut P
hase
Sig
n O
ut P
hase
Pre
Pro
cedu
re P
hase Required by patient and nurse and/or
procedure techPt asked to state full
name & DOB, verified by matching ID band
Pt states procedure, site,and side and verified
by consent
Site is marked by theprovider initiating
procedure and verified bythe patient
If applicable, pt askedwhen last ate, NPOstatus confirmed,
All data in the medicalchart and consent is
consistent with patientresponse
Required by physician, nurse, scrubtech/nurse, procedure tech, and/or
physician assistant Team membersintroduced
Pt identity confirmed. Procedure
reviewed verbally with teammembers
Laterality confirmedwith team verbal
(correct side)
Imaging, specialequipment available
Additional safety precautionsindividualized to patienthistory or medication use
Any specialmedication or fluids
for irrigation
Medical record andimaging confirms
correct side and site
Patient positionconfirmed
Procedure reviewedverbally with team and
confirmed with consent
Laterality confirmedverbally with team
and marked sitevisible after prep
Patient identityconfirmed
If applicable, correctinstrument, sponge,
and needle count
Provider performing procedureand nurse and/or tech review
key concerns forpost procedure care of patient
Name of correct procedureon record, all specimens
labeled correctly
Review any itemsneeding follow up
Nursing assessmentcomplete
Required by physician, nurse, scrubtech/nurse, procedure tech, and/or
physician assistant
Required by physician, nurse, scrubtech/nurse, procedure tech, and/or
physician assistant
2009