Patient Assessment
CHAPTER OBJECTIVES
Upon completion of this chapter, the reader should be able to:
1. Appreciate the value of patient health history information.
2. Understand the necessity of assessing patient risk before N2O/O2 sedation.
3. Recognize the ASA Physical Status Classification System as a method of categorizing patient health.
4. Identify the components included in a preprocedural patient evaluation for N2O/O2 sedation.
5. Recognize measures for patient preparation before N2O/O2 sedation.
6. Understand the necessity for patient monitoring during N2O/O2 sedation.
7. Recognize the monitoring procedures associated with N2O/O2 sedation.
8. Recognize the importance of emergency preparedness in terms of personnel preparation and necessary equipment.
To best serve the patient, it is imperative that the healthcare provider obtain an initial medical history from the patient. This information is acquired through a formal interview and updated at each visit. Undivided attention is necessary to assess the patient’s physiologic and psychological status so that the best pain and anxiety management option may be selected. The American Society of Anesthesiologists (ASA) Task Force1 agrees that obtaining a preprocedural evaluation increases the likelihood of success during sedation and decreases the chance for adverse outcomes. The American Dental Association, the American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) offer guidelines for patient assessment and management before, during, and after sedation.2–4 Successful patient experiences depend on operator attention and vigilance. Even friends and relatives who practitioners think they know well must have this formal scrutiny. Hence the familiar axiom: Never treat a stranger.
1 Obtaining Patient History Information
A. The patient often completes questions about health and personal information in the reception area, with no further inquiries made by a practitioner. It is assumed that this information is seen before patient treatment; however, this may not always be the case.
B. It is advantageous to obtain this information through direct interaction with patients. Information exchanged through a formal interview enables practitioners to further question responses and make an assessment of patient pain and anxiety.5 The person directly involved with the treatment of the patient should complete the interview.
C. If the patient is less than 18 years of age or has need for guardianship, the interview must be completed by the parent or guardian.
D. Information specific to sedation that should be collected includes (1) diseases, disorders, abnormalities of the major organ systems, and reasons for hospitalizations; (2) pregnancy status; (3) previous adverse experience with sedation or analgesia; (4) drug allergies, current medications, and potential drug interactions; (5) time and nature of last oral intake; and (6) history of tobacco, alcohol, or substance use or abuse.1–4
E. It is highly recommended to include a question(s) about pain and anxiety on the health history form itself.6 This question provides patients with a nonthreatening way to communicate anxious feelings that they may be hesitant to divulge verbally. The following are some examples of such questions: “Is there anything about being here for treatment that bothers you?” “Have you had a negative experience in an office or clinic before?” “Have you previously required special procedures or medication for nervousness before an appointment?”
1. Scales indicating pain and/or anxiety levels can be included on the health history form as well. A question as simple as “On a scale of 1 to 10, what is your level of comfort?” can be asked.
2. Some patients will feel comfortable about communicating their anxious feelings verbally. Others will not admit to uncomfortable feelings but may show outward signs such as sweating, shaking, and syncope. In any case, those initial minutes of dialogue are valuable for gathering information.
F. Standard forms for recording health information are readily available or can be generated easily. Standardization of interviewing and recording is part of prudent practice. It is also recommended that the patient or parent/guardian sign and date the form to acknowledge accuracy and currency of information taken.
G. A comprehensive health history must be completed at the initial visit and then updated at each visit thereafter.
H. A professional can then use the health information obtained from the interview to make an assessment about the health risk to the patient before performing a medical or dental procedure.
2 Assessment of Patient Risk
A. The American Society of Anesthesiologists (ASA) developed a method of classifying patients according to medical risk. The Physical Status Classification System was initiated in the early 1960s and is recognized around the world.7 Its applicability and validity for almost every health discipline are the reasons for its continued use today. During assessment of the health and physical status of patients, this system helps determine whether a patient is an appropriate candidate for sedation (Box 10-1).
B. The ASA physical status classification system7
1. ASA 1(I)—Patients with no systemic disease. These patients are able to tolerate mild physical exertion and psychologic stresses. They do not possess any organic, physiologic, biochemical, or psychiatric disturbances. These patients may be considered appropriate candidates for N2O/O2 sedation.
2. ASA 2 (II)—Patients with mild-to-moderate physiologic disturbance that is under good control. There is no significant compromise of normal activity; however, the patient’s specific condition could possibly affect the safety of surgery and anesthesia. Depending on their particular situation, these patients are usually considered appropriate candidates for N2O/O2 sedation.
3. ASA 3 (III)—Patients with a major systemic disturbance that is difficult to control. There is significant compromise of normal activity for this patient. This situation creates a significant impact on surgery and anesthesia. Medical consultation is recommended for these patients. These patients present greater risk for treatment; however, N2O/O2 sedation may still be used following medical advice.
4. ASA 4 (IV)—Patients with severe and potentially life-threatening systemic disease that significantly limits their activity are not usually seen in an ambulatory health setting. Because of their unstable health problems, they are categorized as high risk for many situations; the potential for an acute emergency situation is great. Seek medical consultation and/or referral. N2O/O2 is usually not indicated except in emergency situations.
5. ASA 5 (V)—Moribund patients in whom immediate surgery is the last effort to save their lives. In some cases, N2O/O2 is recommended for pain and anxiety relief in these final stages.
6. ASA 6 (VI)—The patient in this classification is clinically dead but being maintained for organ donation.
7. ASA E—Designation for a patient in any ASA classification requiring an emergency procedure.
C. Assigning an ASA classification to a patient undergoing sedation indicates the operator has made an initial assessment based on the health history information. This classification is recorded on the sedation record (see Appendix G).
3 Preprocedural Patient Evaluation
A. Vital Signs
1. Evaluating preoperative, intraoperative, and postoperative vital signs is considered the standard of care by the ASA, the American Dental Society of Anesthesiology (ADSA), and several other health societies and organizations.1–4,8 Vital sign values should be recorded in the patient’s chart each time they are measured. It is appropriate to obtain baseline values at the initial visit and then periodically thereafter.
2. Depending on the discipline, specialties with established guidelines for delivering anesthesia and sedation may recommend that vital signs be measured whenever N2O/O2 is used.1–4,9–11 State governing bodies may also require that vital signs be measured.11
3. There are a total of six vital signs: height, weight, body temperature, blood pressure, pulse, and respiration.
4. Depending on the clinical setting and treatment being performed, some vital signs are measured more frequently than others. Blood pressure, pulse, and respiration are the most dynamic vital signs and should be recorded at each visit. Oxygen saturation level is recommended or required for moderate and deep sedation plus general anesthesia.1–4
5. Vital sign measurements recommended for minimal sedation are blood pressure, pulse, and respiration. These should be obtained preoperatively to provide a baseline reference before N2O/O2 administration. Postoperative vital signs serve as an objective measure of recovery from N2O/O2 sedation. These values are compared with those obtained preoperatively and are assessed for the degree of variation.
a. Guidelines regarding hypertension and blood pressure indicators for adults have recently changed according to the National Heart, Lung, and Blood Institute.12,13 Normal blood pressure is classified as < 120 mm Hg systolic and < 80 mm Hg diastolic readings. Prehypertension is classified when systolic readings are within the range of 120 to 139 mm Hg or a diastolic reading within the range of 80 />
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