CONSCIOUS SEDATION MONITORING

Patient Name: MR #
SEDATION SCALE
PRE-PROCEDURE ASSESSMENT Arrival Date: ________________ Time: __________ (LEVEL OF CONSCIOUSNESS)
Time MD Notified: ____________________________
T __________ Current 1. Alert
Explanation of procedure/sedation given:
P __________ Medications: _____ 2. Occasionally drowsy;
YES NO
_______________ Easy to arouse
R __________ Patient accepts plan for conscious sedation:
_______________ 3. Frequently drowsy;
B/P __________ YES NO Easy to arouse
_______________
Patient to be discharged to care of: ______________ 4. Sleep; Easy to arouse
Height __________ ___
Possibility of pregnancy? YES NO 5. Somnolent; Difficult to arouse
Weight __________ Allergies: _______ Preg. test results: ____________________________
_______________ Continuous IV infusion _____ (Solution) _____ (Rate)
O2 Sat __________
_______________ Chief Complaints:
___________________ (Cath) _____________ (Site)
LOC __________ __ Time: ________ Signature: ____________________
ASA Class by MD:
_______________
_
Respiratory Cardiovascular Neurological Psychological
Regular Irregular Pink Other Awake Asleep Calm Anxious
Moderately Deep Shallow Warm Cold Alert Drowsy Communicative Withdrawn
Unlabored Labored Dry Moist Oriented Disoriented Cooperative Uncooperative
Clear Congested Hx of mi (when? ___________________) Loss of sensation
Room Air O2 @ _____ lpm Current c/o chest pain? _____________ ________________

Summary reviewed and updated if appropriate Side Rails Up To Surgery @ Time: __________
Signature _________________________________________________________________________________

INTRA-PROCEDURE Monitors On: Patient Safety/ Infuse or Pump Setting by MD

MONITORING/RE-ASSESSMENT Comfort Measures

EKG Bed Locked Body Wt: __________ Kg.

BP Safety Belt Bolus: __________ mcg/Kg.
SEE CONTINUOUS STRIP FOR MONITORING SaO2 Padded Boney Prominence Cont.
O2 @ _____ l/min Gonadal Shield Infusion: __________ mcg/Kg/min

TIME MEDICATION ROUTE PATIENT RESPONSE/LOC GIVEN BY

Biopsy - Washings - Brushings Obtained: YES NO Procedure Started: _________________________________________

Sent to Lab - Pathology: YES NO Procedure Ended: __________________________________________
Procedure Performed: ____________________________________ Monitored By: _____________________________________________
Assisted By: ______________________________________________
MD: _____________________________________________________

PAIN MANAGEMENT: Epidural Test Dose at __________(Time) Trigger Points:

Xylocaine 1.5% MPF c Epinephrine 1:200,000 (1.5ml)
FACET BLOCK: Negative Positive

Cervical Left Right Medication

_______________ _______________ Injection
Thoracic _______________ _______________ _______________
_______________ _______________ _______________
Lumbar
_______________ _______________ _______________
_______________ _______________ _______________
_______________ _______________ _______________
_______________ _______________ _______________
CONSCIOUS SEDATION MONITORING (continued)
Patient Name: MR #

POST PROCEDURE MONITORING To PACU at _______________ (time)

Time Vital Signs Patient Response/LOC Intervention

Patient Transferred to: Home Inpatient Facility: __________ at _____ (time)

Discharge Criteria Met: Yes No
NURSE’S NOTES:

DISCHARGE ASSESSMENT:
Vital Signs Respiratory Cardiovascular
T____________________________________ Regular Irregular Pink Other _________
P ____________________________________ Moderately Deep Shallow Warm Cold __________
R ____________________________________ Unlabored Labored Dry Moist _________
B/P __________________________________ Clear Congested Hx of MI when? Current c/o chest
Room Air O2 @ ______ lpm _________________ pain?

Psychological Neurological Musculo/Skeletal

Calm Anxious Awake Asleep Amb Independently Wheel Chair Bound
Communicative Withdrawn Alert Drowsy Amb. w/ Assist of: Loss of Extremity
Cooperative Oriented Disoriented Cane ______________
Uncooperative Loss of Sensation Walker
______________ Another Person

DISCHARGE YES NO
Patient able to tolerate food/fluids
Patient able to bear weight/ambulate safely
Patient able to void
Patient given follow-up appointment/instructions
Patient discharged to the care of an adult: __________________________
Patient discharged to physician’s office: ____________________________
Patient discharged Other: ____________________ at ____________ (time)

Signature: