How to Write a Nursing Care Plan for Effective Sedation Care

Registered nurses must demonstrate clinical competency and understanding of their state board of licensing requirements. Registered nurses are also responsible for developing a nursing care plan for each patient based on their diagnoses and treatment strategies. 

In this article, we will discuss nursing care plans and the importance of nurses creating them for sedated patients. 

5 Essential Components of a Nursing Care Plan

A nursing care plan identifies a patient’s needs and nursing interventions using a five-step framework to help build continuity of care. A care plan allows nurses and the interdisciplinary team to organize patient care using a timeline, including the patient’s physical, psychological, social, and spiritual care. 

Assessment of Patient’s Needs

The first step in writing a nursing care plan utilizes critical thinking and assessment of the patient through subjective and objective data collection. Subjective data may include verbal statements from the patient, caretakers, family, or other healthcare members. In contrast, objective data, such as height, weight, vital signs, or intake and output, is measurable. 

Nursing Diagnosis

The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response by an individual, family, group, or community.” A nursing diagnosis is a statement that identifies the actions needed to prioritize treatments and achieve specific outcomes. 

Plan Goals (Desired Outcomes)

Next, SMART (Specific, Measurable, Achievable, Relevant, and Time-based) goals are prepared using evidence-based practice (EBP) guidelines by considering the patient’s overall condition, diagnosis, and other relevant information. The nurse must develop short- and long-term goals to achieve desired and realistic outcomes.

Interventions: Actions to Be Taken

The nurse must provide patient support to achieve the goals by performing interventions written in the care plan. Seven domains of interventions include family, behavioral, physiological, complex physiological, community, safety, and health system interventions. The nurse must implement several basic interventions, such as pain assessment, body positional changes, listening, cluster care, fall prevention, and fluid consumption.

Evaluation of Effectiveness

A nursing care plan includes evaluating whether the nurse or interdisciplinary team met the desired outcomes for the patient. Were the established short- and long-term goals effective in caring for the patient and providing the best care possible? The evaluation can be done at any time during the nurse’s interaction with the patient. 

The final step is documenting all five of the essential components of the nursing care plan. This is done using the format provided by the nurse’s institution. A nurse needs to make sure that a final review and comment are documented when the patient leaves the area of care.

Sedation Administration for Medical Procedures: The Role of Nurses

A registered nurse must acknowledge, understand, and practice according to their state Nursing Practice Act. A registered nurse may administer medications to induce sedation for short-term therapeutic, diagnostic, or surgical procedures. The nurse must be competent to administer sedation, including understanding the medication effects, potential side effects, contraindications, and the required dose. 

In addition, the nurse must anticipate and recognize possible complications, identify emergencies, and institute emergency procedures. Patient safety considerations during sedation include continuous oxygen saturation monitoring, cardiac rate and rhythm, blood pressure, respiratory rate, and level of consciousness. 

If an outward occurrence takes place, a nurse will prepare the sedation room with the equipment needed to ensure patient safety. An emergency cart with resuscitative and antagonist medications must be available, which will include airway and ventilatory adjunct equipment, a defibrillator, suction, and a 100% oxygen administration source. 

A nurse is an integral part of the sedation team and must be adequately prepared to perform the outlined role. This education can be gained through the online Safe Sedation Training course. While this course focuses on intraoperative care of the patient when they receive sedation, the nurse must also understand their role during preoperative and postoperative care. Safe Sedation Training will help every nurse gain the necessary knowledge to be an advocate for patient safety.

Pre-Procedure Care

Pre-procedure care is the medical treatment and preparation the patient receives before a sedation procedure to increase success. 

Preparations 

The patient may undergo a medical history and physical exam, share surgical and anesthesia background information, receive lab tests, ECG, imaging, risk assessment, and review medications during preoperative care. The nurse will answer any patient questions, such as the length of the procedure, potential complications, the surgical process, medications, and discharge instructions. 

Pre-Sedation Documentation

The patient will receive and sign informed consent for the procedure and moderate sedation. The registered nurse must perform a comprehensive assessment and documentation before administering sedation, including a history and physical with pregnancy status, respiratory, cardiovascular, hepatic, gastrointestinal, neurological, musculoskeletal, renal, and endocrine systems evaluation to identify any conditions affecting the patient’s tolerance to sedation or the procedure. 

Pre-sedation documentation must include any history of reaction or problems with anesthesia or sedation, NPO status, and the sedation plan. The nurse will also conduct and document a pre-procedure airway and vital signs assessment. 

Moderate Sedation

The provider orders and supervises all moderate sedation for the specific procedure. Sedation may be administered by the ordering provider, the provider performing the procedure, the anesthesia provider, or a qualified registered nurse. 

Intraprocedural Care

Intraprocedural care is the healthcare a patient receives during a procedure. According to the American Association of Nurse Anesthetists (AANA), after administering sedation, the monitoring nurse’s sole responsibility is to remain with the patient at all times during the procedure. 

Vitals Monitoring

The nurse is responsible for monitoring blood pressure, heart rate, respirations, oxygen saturation, and level of consciousness every 15 minutes during the procedure and at its conclusion. Vital sign monitoring may be conducted more frequently if necessary. 

Emergency Response

Emergency preparedness must include written policies and procedures, including training requirements. To promote cardiac, airway, and medication effectiveness, the nurse must be prepared for adverse events or complications during sedation. It is critical for the nurse to continuously produce a sedated state and to minimize complications, such as respiratory distress, cardiovascular depression, and hypoxemia. 

Sedation Support and Monitoring

The nurse will monitor the patient’s pain level, procedure tolerance, medication response, hypersensitivity, and adverse drug events if any. 

Post-Procedure Care

The nurse will monitor and document the patient’s vital signs and cardiac rhythm every 15 minutes or less if needed, until the patient meets the discharge criteria. The documentation will include intravenous medications and any unusual events or post-sedation complications. 

Evaluate the Patient as per Discharge Criteria

Each institution requires different discharge criteria from the post-procedure unit, such as requiring a physician assessment for each patient before discharge. There are also different procedures for when discharge criteria are not met and hospital admission is required. However, depending on particular situations, the registered nurse will perform an evaluation based on a modified Aldrete scale, the most common system to determine discharge readiness. 

Basic life-sustaining needs are of utmost importance in identifying discharge criteria. The patient must have been discontinued from oxygen therapy for at least 30 minutes to one hour before discharge and have an oxygen saturation level greater than 95%. The last dose of a respiratory depressant must have been administered at least 15 minutes for IV, epidural, or intrathecal bolus or 30 minutes for IM injections. 

The RN must monitor the patient for at least 30 minutes, and possibly up to two hours if the patient received a reversal agent for a neurovascular blockade or sedative and opioids. Using the verbal or nonverbal scale, the RN will assess the patient’s pain level. The patient’s pre-anesthesia or sedation orientation level must return to alertness and the patient must follow commands while sitting upright and without having symptoms of orthostatic hypotension. The patient must also exhibit signs of ambulation with minimal nausea or vomiting. Being required to void before discharge depends on the medication and procedure.

Patient Education

Patient education can be one of the most satisfactory parts of the nurse’s job. A nurse will teach and focus on post-sedation and pre-procedure care. Information will be given to the patient and, most importantly, the family member. This education will prepare the patient and family members for discharge with all the information needed for the continuation of care at home; this should include a phone number to contact the institutional staff if there are questions. Discharge medications are also discussed and given to the patient; all of these instructions should be included in written form to go home with the patient. 

Before the procedure, the nurse should make sure the patient has a ride home and someone to care for them. The nurse should inform the patient and family that the patient cannot drive home after sedation and must be driven by someone else. The patient is also required to have someone at home for a recommended 24 hours to monitor post-sedation symptoms and ensure the patient is not affected by residual effects.

Pain Management

Pain relief is significant for patients receiving sedation procedures with minimal side effects. The patient may receive various pain relief agents, including opioids and non-opioids. The physician or RN will discuss the appropriate method of pain relief with the patient or family members and discuss the proper delivery. 

Support & Ambulation

It is up to the nurse to ensure the patient can ambulate safely before discharge. This should include the nurse being by the patient’s side to make sure the effects of any medication have worn off. A patient will have to get from the car to inside their home with minimal help; a nurse should be able to assess whether a post-sedation patient can achieve this. They should also assess any nausea that may occur when a patient ambulates for the first time after the procedure.

Nursing Care Plan Examples

Nursing care plans are essential to guide nurses and the interdisciplinary team to make informed decisions; they use a step-by-step treatment plan for the patient based on their specific diagnoses. 

Nursing Care Plan for Gastroscopy

Nursing Care Plan for Skin Biopsy

In Conclusion

The nursing care plan provides a critical component of each patient’s treatment and helps nurses schedule their treatments accordingly, which ensures safety and optimal care. Registered nurses must understand their role and responsibilities when administering sedation to patients, including adverse signs and symptoms, as well as interventions within each stage of the operative procedure.