Reading materials for conscious sedation - Yale-New Haven Hospital

UNIT NO.NAME:ADDRESS:DOB:VISIT NO.APPENDIX G(If handwritten, record name, unit no., and DOB)DATE: _______SEX: ___AGE: ____WT:________________DIAGNOSIS:Ordering LIP: _______________PROCEDURE: _____________________________________Medication(s) Used & Dose:Midazolam IV ________mg. Flumazenil _______Fentanyl IV________ mcg.Nalaxone ________Meperidine IV ________mg.Propofol ________ mg.Other _______________________Sedation Events: (Complete only if adverse event occurs)Sedation: Failed (Proc. Cancelled)Inadequate (Pt. Complained of discomfort)Over-sedation (Proc. delayed due to sedation)Prolonged (Proc. Delayed due to sedation)Airway:Airway management required (oral, naso-pharyngeal, jawsupport/chin lift, BVM, intubation)circle or specify:_____________________________Difficult airway managementRespiratory:Oxygen Saturation < 5% below baselineWheezing Stridor AspirationResp. Arrest BronchospasmRecovery Events: (Complete only if event is sedation related)Airway:Airway management required (oral, naso-pharyngeal, jawsupport/chin lift, BVM, intubation)circle or specify:_____________________________Difficult airway managementRespiratory:Oxygen Saturation < 90% on Room Air (or baseline FIO 2 )Wheezing Stridor AspirationResp. Arrest BronchospasmComments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature: ______________________________________________Printed Name: ___________________________________Yale New Haven HospitalAdult Sedation Quality Improvement FormProcedure completed, no reportable occurrences (All ED andfloor sedations must be reported)Reportable occurrence, see formProcedure completed, unexpected admission or elevation incare related to sedation: Admission Transfer to ICUPROCEDURE LOCATION: _________________________SEDATION RN: ___________________________________RECOVERY RN: __________________________________Exam:CTUpper EndoscopyMRIColonoscopyNuc. MedPEGCardiac Cath/PTCA ERCPBronchoscopy .Interventional (specify)____________________Other (specify)____________________Area of Body:Head/Neck Spine Thorax Abdomen ExtremityCardiovascular:Bradycardia (140 and 30% above baseline)Arrhythmia specify: ____________________________Hypotension (< 90 syst. and 10% below baseline)Hypertension (> 170 syst., 105 diast., and 10% above baseline)Cardiac ArrestMedication:Medication error specify: _____________________Adverse reaction specify: _____________________Other:Equipment failure Unplanned admissionSeizure Vomiting Corneal AbrasionOther specify: ___________________________________Cardiovascular:Bradycardia (140 and 30% above baseline)Arrhythmia specify: ____________________________Hypotension (< 90 syst. and 10% below baseline)Hypertension (> 170 syst., 105 diast., and 10% above baseline)Cardiac ArrestOther:Equipment failure Unplanned admissionSeizure Vomiting Corneal AbrasionOther specify: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(RN or Sedation Practitioner may complete)