Moderate Sedation Presentation - Mayo Clinic Health System

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Emergency Equipment Requirements • Supplemental oxygen strongly recommended for patient safety • Age/size-appropriate equipment available in room • Suction, oxygen, bag-valve-mask, airway adjuncts (oral and nasal), pulse oximeter, non-invasive blood pressure monitor, ECG monitor, reversal medications • Code cart immediately available (within five minutes) with monitor/defibrillator and advanced airway equipment ©2011 MFMER | slide-20
Physician/Provider Pre-Procedure Responsibilities (To be completed and signed by the provider performing the procedure and/or the provider administering the sedation) Complete the H&P – Pre Procedure Assessment form CC HPI Past Medical History Physical Exam/Review of Systems ASA Classification ( one) Chief Complaint:__________________________________________________________________ HPI:____________________________________________________________________________________ Medications reviewed Allergies reviewed Record reviewed No change from H & P of___________ (date) (must be within 30 days) Illnesses:________________________________________________________________________________ Previous Surgeries:________________________________________________________________________ Family History/Social History:________________________________________________________________ NOTE: If H & P is less than 30 days, only heart Pre-Procedure Airway Assessment and lung assessment/examination is required. Yes No □ Vital Signs Reviewed History of difficult intubation or surgical airway (i.e trach): Normal Abnormal Inability to extend neck: Heart _______________________ Lungs _______________________ Mouth opening less than two finger breadth: Neuro _______________________ Diagnosis of sleep apnea: Abdomen _______________________ Mental Status _______________________ Less than three finger breadth to hyoid bone: Other pertinent to exam:_________________________ _____________________________________________ 1 Healthy, normal 2 Mild systemic disease 3 Severe systemic disease 4 Severe systemic disease constant threat to life 5 Moribund No functional limitations, midl obesity, DM w/o complications, HTN some functional limitation, stable angina, morbid obesity, controlled COPD/Asthma/CHF Unstable angina, active symptoms of COPD/Asthma, CHF/HTN Circle appropriate class. Informed consent obtained after discussion of risks, benefits, alternatives and potential complications. Patient/guardian understands and desires to proceed. Plan for Sedation Plan Patient re-evaluated immediately prior to moderate sedation Medication: Versed Fentanyl Demerol Morphine Ketamine * Etomidate * Other:_____________________________________________________ * = Requires provider with advanced intubation skills present during sedation. Plan: Moderate Sedation MAC Post Sedation Plan of Care: Departmental Post Procedure Area Inpatient Room PACU Other:________________________________________________________________________________ Impression: _________________________________________________________________ Treatment Plan:______________________________________________________________ Provider Signature:____________________Pager:______Date:___________ Time:________ TRIAL NS-1003 we/forms/H P sedation 6/30/10 ©2011 MFMER | slide-21
Page 1 and 2: Moderate Sedation at Mayo Clinic He
Page 3 and 4: Administrative Policy 335 • A mul
Page 5 and 6: Goals of Procedural Sedation and An
Page 7 and 8: Joint Commission Standards and Mode
Page 9 and 10: Moderate Sedation/Analgesia • Mod
Page 11 and 12: • Moderate Sedation is Performed
Page 13 and 14: Moderate Sedation Policy Defines Pe
Page 15 and 16: The Moderate Sedation Policy Define
Page 17 and 18: Nurse (RN) Competency Requirement
Page 19: IV Access • IV access is required
Page 23 and 24: Intraprocedure Assessment, Monitori
Page 25 and 26: Post-Procedure Assessment Monitorin
Page 27 and 28: MHS Criteria for Transfer Aldrete I
Page 29 and 30: Emergency Interventions • Unexpec
Page 31 and 32: Quality Requirements • The Modera
Page 33 and 34: Suggested Medication Doses • The
Page 35 and 36: General Cautions for Medication Adm
Page 37 and 38: Medication Classifications for Mode
Page 39: Summary • Sedation is a continuum

Moderate Sedation Presentation - Mayo Clinic Health System

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