Pasero Opioid-Induced Sedation Scale (POSS) with Interventions

Pasero Opioid-Induced Sedation Scale (POSS) with Interventions
S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed. 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed. 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed. 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Copyright 1994, Chris Pasero. Used with permission. Reliability and validity information for the POSS can be found in Nisbet & Mooney-Cotter, 2009. Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25-50% Opioid analgesic orders or a hospital protocol should include the expectation that a nurse will decrease the opioid dose if a patient is excessively sedated. or notify primary For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription. or anesthesia provider for orders; consider administering a nonsedating, opioid-sparing nonopioid, such as acetaminophen or an NSAID, if not contraindicated; ask patient to take deep breaths every 15-30 minutes. 4 = Somnolent, minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone For adults experiencing respiratory depression, give dilute intravenous naloxone very slowly while observing the patient’s response (titrate to effect). , Hospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening, opioid-induced sedation and respiratory depression. ; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory.

S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed. 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed. 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed. 3 = Frequently drowsy, arousable, drifts off to sleep during conversation

Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25-50%

Opioid analgesic orders or a hospital protocol should include the expectation that a nurse will decrease the opioid dose if a patient is excessively sedated.

or notify primary

For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription.

or anesthesia provider for orders; consider administering a nonsedating, opioid-sparing nonopioid, such as acetaminophen or an NSAID, if not contraindicated; ask patient to take deep breaths every 15-30 minutes.

4 = Somnolent, minimal or no response to verbal and physical stimulation

Unacceptable; stop opioid; consider administering naloxone

For adults experiencing respiratory depression, give dilute intravenous naloxone very slowly while observing the patient’s response (titrate to effect).

Hospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening, opioid-induced sedation and respiratory depression.

; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary

or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory.

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