NURSING PATIENT CARE POLICY & PROCEDURE
May 27, 2015
Nursing Manual (Red)
Policy #: 4.16
Title: Patient Monitoring During
To ensure a consistent, safe approach to monitoring patients receiving IV pain and
anxiolytic medications during burn/wound care.
A. RNs will successfully demonstrate competency in administration of IV pain and
B. Burn/wound care is routinely performed once or twice daily. The specific
objectives are maintenance of consciousness and cooperation, improved
management of pain with minimal changes in vital signs, partial amnesia and a
prompt, safe return to activities of daily living. According to UWHC Hospital
Administrative Policies 8.38, Adult Sedation and 8.56, Pediatric Sedation, this
would fall under the definition of “minimal sedation” and would correlate with a
1, 2, or 3 on the adult sedation scale and a 3 on the pediatric sedation scale.
C. According to UWHC Hospital Administrative Policy 8.38, Adult Sedation,
“patients may receive sedative drugs for short-term therapeutic indications (e.g.,
stabilization of the intensive care patient, nausea, anxiety, pain relief, muscle
spasticity, insomnia, agitation) in non-procedural settings.” Anxiolytic
medications ordered for use during burn/wound care are not intended to produce
anesthesia. They are to be used in a manner and in a dose which may be
reasonably expected not to result in the loss of protective reflexes.
D. If a patient is anticipated to require a higher level of sedation during burn/wound
care, such as “moderate sedation” (with the exception of mechanically ventilated
patients), refer to UWHC Hospital Administrative Policies 8.38, Adult Sedation
and 8.56, Pediatric Sedation.
A. A patient assessment will be completed and documented in the patient's clinical
record prior to administration of IV pain and anxiolytic medications.
1. History and Physical completed: age, weight, allergies
2. Current and PRN medications
3. Baseline vital signs prior to medication administration
4. Baseline oxygen saturation and, if indicated, end tidal carbon dioxide
(ETCO2) prior to medication administration
5. Level of consciousness and risk for airway compromise
6. Respiratory and cardiovascular status
Page 2 of 3
B. Patient/Clinic/Hydrotherapy room will have access to the following resuscitative
and monitoring equipment:
1. Cardiac monitor and battery operated continuous pulse oximeter and
ETCO2, if indicated
2. Wall suction with suction tubing and Yankauer
3. Wall oxygen flow meter with nasal cannula
4. Resuscitation bag with appropriate size mask
5. Appropriate size oral airways
6. Reversal agent available
C. Patient will have appropriate venous access.
1. RN will inspect venous access site for patency, redness, swelling, heat, or
pain prior to use.
2. The venous access will be a dedicated line that will be used for only IV
pain and anxiolytic medication administration during the procedure.
D. Patient will receive IV pain and anxiolytic medications as ordered. RN will:
1. Review patient's medication administration record prior to administration
of pain and anxiolytic medications.
2. Have available at the bedside or in clinic/tub room, appropriate medication
and flushes for medication administration.
3. Start with the lower end dosage range of IV medications and administer
medications in small incremental doses.
4. Taper IV medications and wean to enteral medications as patient's
wounds/burns heal and/or patient experiences a decrease in pain.
5. Document all medications administered including dosage, time, route, and
E. Patient will be monitored by RN while receiving IV pain and anxiolytic
1. At minimum, continuous pulse oximetry and ETCO2 (if indicated) is to be
used on all patients throughout burn/wound care.
2. RN will monitor patient response using the Pediatric or Adult Sedation
Scale. Refer to UWHC Hospital Administrative Policies 8.38, Adult
Sedation and 8.56, Pediatric Sedation.
3. Monitor pain using the age-appropriate pain scale and report dosage as
4. RN will immediately treat and document any unexpected or adverse
events, the management of those events and the patient's response.
F. Patient will be monitored in the post wound/burn care phase until return to
1. Document patient status at the completion of burn/wound care including
heart rate, blood pressure, respiratory rate, oxygen saturation, ETCO2 (if
indicated) sedation score, and pain score.
2. RN will immediately treat and document any post wound/burn care
complications, the management of those events and the patient's response.
G. Off-unit patients
1. For patients requiring burn/wound care who are not in the Burn Unit, who
are to receive burn/wound care in their own room.
a. The Burn RN will contact the patient’s Primary/Team RN to
mutually determine the time for the wound/burn care. The Burn
Page 3 of 3
RN will coordinate with the patient’s RN once arriving on the
floor. It is the expectation that the patient’s RN be involved with
the wound care plan and meet face-to-face with the Burn RN.
b. The patient’s RN is responsible for the administration of any pre-
medications and IV analgesics during wound/burn care and any
associated monitoring. IV anxiolytics are not routinely used for
this patient population.
c. The Burn RN will verbally report off to the patient’s RN when
wound care is complete and coordinate a plan to monitor the
patient until returned to baseline.
2. Off-unit patients who come to the Burn Unit for burn/wound care and
receive IV pain and anxiolytic medications will remain on the unit until
returning to baseline.
IV. UWHC CROSS REFERENCES
A. Hospital Administrative Policy 8.38, Adult Sedation Policy
B. Hospital Administrative Policy 8.56, Pediatric Sedation Policy
V. REVIEWED BY
Clinical Nurse Manager, Burn Unit
Nursing Patient Care Policy and Procedure Committee, May 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer