PROCEDURAL SEDATION ANALGESIA FORM

Patient Information
Name : _________________________________ IC/RN : _______________________________
Date : _____________

Age : ________

Weight : _________kg

Diagnosis : _____________________________________________________________________
Indication for PSA :
CMR
T&S
Acute wound management
Others

Please specify : ________________________

Place of PSA being carried out :

Red Zone

Yellow Zone

IC Ward

Pre-Procedural Assessment :
Past Medical History :
DM

Hx of allergy : _______________________ Yes/No

HPT

Previous complications of PSA/sedation/GA : Yes/No

IHD

If yes, please specify : _________________________

COAD/Asthma
Renal Disease
Liver Disease
Others, please specify

_____________________________
Last meal (refer lampiran 3, item 3) : ______________________________________
Difficulty airway features :

Yes

No

If yes please specify (refer lampiran 3, item 4) : ______________________________

Pre-Procedural Preparation
Complete informed consent for PSA & procedure

Oxygen supply

Prepare medication for PSA (refer lampiran 2)

Suction Machine + tubes

Complete emergency / resuscitation trolley

Defibrillator

(refer lampiran 3, item 5)

Airway Kits (refer lampiran 3, item 3)

Vital signs monitoring device (BP, HR, RR, SPO2)

Jabatan Kecemasan & Trauma, Hospital Keningau, Sabah 2016

Monitoring
Time

Pre

At discharge

BP
HR
RR
SPO2
ETCO2
AVPU
* To take vital signs every 5 minutes during procedure, and every 15 minutes during observation until
fully conscious
* A-Alert

V - Response to Verbal

P - Response to Pain

U - Unconscious

Medications
Drugs

1st dose

2nd dose

Time

Time

3rd dose

Time

Total
Dose

Given by

Post-Procedural assessment
Adverse event (hypoxia (SPO2 <91%), hypotension, cardiac arrest, vomiting, apnoe, etc.)
Intervention post procedure or usage of reversal agent
Normal vital sign during observation
Mental status return to state before procedure done and ambulating
Patient fulfill criteria for discharge (refer lampiran 3, item 6)

Remarks / Adverse event :

____________________________________________________________________
____________________________________________________________________

Name & signature of doctor

Years of working experience

: ___________________________
: ___________________________

Name of SN / MA

: ___________________________ Date & Time : ________________

Jabatan Kecemasan & Trauma, Hospital Keningau, Sabah 2016