NITROUS OXIDE - OXYGEN ANALGESIA - CH. 44

Loss of consciousness - Unconscious is a sign of deep sedation. - Deep sedation is contraindicated in the dental hygiene setting. - Relaxing of feet, tingling sensation, and red blotching on face and neck are signs and symptoms of minimal nitrous oxide-oxygen sedation. - Minimal sedation (<50%N2O) is often appropriate for most dental hygiene procedures.

Oversedation with nitrous oxide may be manifested by which of the following? a. Loss of consciousness b. Tingling sensation c. Relaxed appearance of feet d. Red blotching on face and neck

Subjective symptoms of relative analgesia

1. Heaviness of limbs, floating sensation, tingling 2. Decreased fear, decreased pain memory 3. Desire to maintain that state 4. Feeling of warmth 5. Decreased awareness of time List above are subjective symptoms of what?

Takes out nitrous oxide that is exhaled through the mask. - The purpose of a scavenger system is to reduce the nitrous oxide exhaled into the air by collecting oxygen to be remixed into the reservoir bag. - A scavenger system does not collect nitrous to be reused, collect and remix oxygen, or monitor the operatory room air.

A scavenger system incorporated into the nitrous oxide-oxygen analgesia unit does which of the following? a. Collects nitrous oxide to be reused. b. Takes out nitrous oxide that is exhaled through the mask. c. Monitors the operatory room air. d. Collects oxygen to be remixed into the reservoir bag.

5 - When scaling and root planing are completed, the nitrous oxide should be turned off and oxygen increased to 100%. - This will saturate the respiratory system with oxygen. - It is recommended the patient receive 100% oxygen postoperatively for a minimum of 5 minutes. - This time is usually sufficient for a patient to return to a normal state. - There are exceptions as some patients may require more oxygenation time. - Assessment is also accomplished by asking how the patient feels.

After the administration of nitrous oxide-oxygen analgesia, oxygen alone should be given for a minimum of _____ minutes before the patient is released. a. 10 b. 7 c. 3 d. 5

Avoid large meals within 3 hours of appointment

Before receiving N2O, what should the client be made aware of?

N2O reduces the gag reflex but does not eliminate it

Can N2O eliminate the gag reflex?

Early pregnancy - Because nitrous oxide-oxygen relaxes the patient, it is indicated for use with patients suffering from hypertension. - Nitrous oxide-oxygen is contraindicated for pregnancy, language or consent difficulties, and upper respiratory diseases.

Contraindications for nitrous oxide-oxygen analgesia include all of the following EXCEPT which one? a. Breathing difficulties b. Hypertension c. Communication problems with the patient d. Early pregnancy

False For every 15 minutes of exposure to N2O, the client must receive 5 minutes of 100% O2. - Oversedation with nitrous oxide may be manifested by loss of consciousness. - Clients receiving dental hygiene care should never be unconscious. - Loss of consciousness is evidence of oversedation.

For every 15 minutes of exposure to N2O, the client must receive 25 minutes of 100% O2.

- Stored in green compressed-gas cylinders - Delivered as a gas

How is oxygen stored?

- Repeated closing of the mouth: Turn the N2O down by 2 L and turn up the O2 by 2 L. - Sudden movements: Discontinue N2O-O2 sedation and oxygenate the client. - Uncontrollable crying: Discontinue N2O-O2 sedation and oxygenate the client. - Amorous or sexual behavior: Turn the N2O down by 2 L and turn up the O2 by 2 L or discontinue N2O-O2 sedation and oxygenate the client.

How should behavioral problems be handled during N2O use?

Seesawing the nitrous oxide delivery - Seesawing or suddenly increasing the level of nitrous oxide causes nausea and vomiting. - Titration, the administration of incremental doses of an intravenous or inhalation drug over time, is recommended to bring the patient to the desired level of sedation helps prevent nausea. - Placing the patient on 100% oxygen and lowering the nitrous will help alleviate the nausea.

Nausea after nitrous oxide exposure may occur as a result of which of the following? a. Turning down the nitrous oxide too quickly b. Titrating the levels of nitrous oxide delivered c. Seesawing the nitrous oxide delivery d. Over-oxygenating at the end of the appointment

Advanced age - Children are more prone to nausea during nitrous oxide-oxygen sedation than adults. - Patients experiencing anxiety, under deeper sedation, or having ingested a heavy metal before the appointment are more prone to nausea during nitrous oxide-oxygen sedation.

Nausea during nitrous oxide-oxygen sedation can be experienced by the patient for all of the following reasons EXCEPT which one? a. Advanced age b. Heavy metal ingestion before appointment c. Anxiety d. Deeper sedation

Decreases the MAC - N2O/O2 is given throughout most surgical procedures that necessitate the use of general anesthesia because it reduces the concentration of other agents needed to obtain the desired depth of anesthesia

Nitrous oxide combined with a halogenated inhalational anesthetic (N2O/O2) causes which changes to the MAC?

Both statements are true. - The initial flow rate using oxygen should be established prior to nitrous oxide-oxygen sedation to determine the amount of air the patient must breathe comfortably. - A good rule of thumb for the initial flow rate of oxygen is 6 L for the average adult and 4 L for a child. - To assure patient comfort and adequate flow, it is necessary to observe the reservoir bag after placing the nasal hood on the patient with the oxygen flowing. - Once the flow rate has been established with 100% oxygen, nitrous oxide can be introduced.

The flow rate should be established using oxygen prior to nitrous oxide-oxygen sedation. When establishing the flow rate, the suggested rate for an adult is 6 L of oxygen and 4 L of oxygen for a child. a. The first statement is true, the second statement is false. b. Both statements are false. c. The first statement is false, the second statement is true. d. Both statements are true.

None - some relative contraindications

What are the absolute medical contraindication to N2O?

- rapid onset - less than 5 minutes - easy administration - inhalation (no needles) - close control - via flow meters - rapid recovery - no need for designated driver - acceptability for children - apprehensive children - relaxed dental team

What are the advantages of N2O/O2 technique?

- Can cause vertigo, nausea or vomiting if not administered correctly - Individuals with extremely difficult behavioral problems cannot always be managed - Mask can get in the way of instrumenting teeth in the maxillary anterior region

What are the disadvantages of nitrous oxide?

- pregnancy - difficulties communicating - nasal obstruction - COPD - emotional instability - epilepsy - fear of sedation - claustrophobia - cystic fibrosis

What are the relative medical contraindication to N2O?

Nitrous oxide has been shown to reduce the activity of methionine synthetase, the enzyme involved with the function of vitamin B12

What has N2O shown to reduce the activity of?

Caused by leakage of gas from the mask that can dry out the eyes and cause corneal abrasion in individuals wearing contact lenses. - Have clients remove contacts before N2O-O2 is administered

What is corneal irritation?

A drug-induced depression of consciousness during which patients are not aroused easily, but will respond to painful or repeated stimulation

What is deep sedation?

It is characterized by headache, grogginess, nausea, and a hungover feeling after N2O-O2 sedation. - It is caused by not being oxygenated for an appropriate period after the completion of the sedation procedure

What is diffusion hypoxia?

Hypoxia is a lack of O2 to the tissues and occurs with oversedation of N2O causing a headache and nausea

What is hypoxia and how is it caused?

Best defined as a minimally depressed level of consciousness, produced by a pharmacologic method that retains the patient's ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal commands

What is minimal sedation?

A drug-induced depression of consciousness, during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation

What is moderate sedation?

- Colorless, tasteless, sweet-smelling agent - Supports combustion - Stored in blue compressed-gas cylinders - Liquid or gaseous states

What is nitrous oxide?

The reduction of anxiety or agitation, typically by administering sedative drugs

What is sedation?

35% - 100% O2 (2-3 minutes) → N2O added in 5-10% increments → until patient response indicates level of sedation reached→ after termination of N2O, 100% O2 (at least 5 minutes)

What is the average percentage of N2O required for client comfort?

Clients response to questions - slurred or slow response

What is the best indicator to the degree of clients N2O sedation?

The goal of titration is to produce baseline sedation signs and symptoms in the client.

What is the goal of titration?

The ideal minimal amount of nitrous oxide-oxygen needed to relax the client is the point at which the client reports one or all of the listed symptoms

What is the ideal minimal amount of N2O?

Low potency (MAC > 100), it is unsatisfactory as a general anesthetic when used alone

What is the potency of N2O?

To monitor exhaled carbon dioxide - Capnography monitors exhaled carbon dioxide in waveform. - This feature allows for continuous assessment of depth and frequency of each respiratory cycle. - Capnography alerts the dental care provider to hyperventilation, hypoxia, airway obstructions, and other emergencies quickly. - Oxygen and nitrous oxide volume are monitored by the flowmeter. - Pulse oximetry is used in moderate and deeper sedations. - It tells the clinical team about the status of blood oxygenation.

What is the purpose of capnography? a. To monitor exhaled carbon dioxide b. To monitor blood oxygenation c. To monitor nitrous oxide volume d. To monitor oxygen volume

Best defined as the administration of incremental doses of an intravenous or inhalation drug over time until a desired effect is reached

What is titration?

- tidal volume - time baseline was reached - amount of gases administered - duration of sedation - length of oxygenation period - client's response

What should be documented when using N2O?

At the termination of the procedure, the patient should be placed on 100% oxygen for at least 5 minutes to avoid diffusion hypoxia

What should be done after terminating the N2O procedure?

20% - The initial introduction of nitrous oxide should not exceed 20%. - 30%, 40%, and 50% are flow rates that may be used during sedation, but not for initial introduction of nitrous. - Rarely should a percentage higher than 50% nitrous oxide be used. - Most patients will attain an appropriate level of sedation with less than 50% N2O. - Once the 50% marker is reached, care must be taken, as exceeding this amount, especially with a child, is considered moderate sedation by definition. - A smaller percentage of patients require more nitrous oxide; however the decision to exceed 50% N2O should be carefully considered.

When introducing nitrous oxide, the initial amount should not exceed which of the following amounts? a. 30% b. 20% c. 50% d. 40%

No loss of gag reflex - Little or no gagging is a sign of nitrous oxide-oxygen sedation. - Normal eye reaction and pupil size, normal blood pressure and pulse, and the ability to answer questions are also signs of nitrous oxide-oxygen sedation.

Which of the following is not a sign of a desirable level of sedation? a. Ability to answer questions b. Normal blood pressure and pulse c. Normal eye reaction and pupil size d. No loss of gag reflex

Normal reaction of pupils - A symptom is reported by the patient and is subjective. - A sign can be observed by the clinician. - The normal reaction of pupils is observed by the clinician and is termed a sign. - Tingling of the arms and legs, a feeling of warmth, and decreased awareness of time are all reported by the patient and are termed symptoms.

Which of the following is not a symptom of nitrous oxide oxidation sedation? a. Feeling of warmth b. Normal reaction of pupils c. Tingling in arms and legs d. Decreased awareness of time

Controlled cardiovascular disease - The patient who has controlled cardiovascular disease is typically a candidate for N2O O2 sedation. - Patients with chronic bronchitis and emphysema utilize less oxygen naturally as a sequela of their condition. - Giving such a patient more than the normal amount of oxygen could cause the body to think it does not need to respire, thus initiating a respiratory crisis like dyspnea, difficulty breathing, or apnea, which is not breathing at all. - The use of halogenated gases for vitreoretinal surgery poses a contraindication for N2O O2 sedation for such a time as determined by the ophthalmologist. - Some ear surgeries can be problematic as pressure could build in the tympanic cavity. - Again, a medical consultation is advised as to the length of time needed to postpone N2O O2 sedation.

Which of the following is not contraindicated for use of nitrous oxide-oxygen sedation? a. Recent ear surgery b. Recent eye surgery c. Controlled cardiovascular disease d. Chronic bronchitis

N2O has an effect on all sensations, such as hearing, touch, pain and warmth - Clients under the influence of N2O may key in to distant background sounds, such as music or the conversation in the next room, rather than close sounds

While an adequate amount of oxygen is being delivered concurrently, what does N2O effect?

N2O has no effect on the heart rate, blood pressure, liver, or kidneys as long as an adequate amount of oxygen is delivered concurrently

While an adequate amount of oxygen is being delivered concurrently, what does N2O have no effect on?

This oxygenation period is essential to prevent tissue hypoxia, characterized by headache and upset stomach, on completion of the sedation procedure.

Why is the oxygenation period after N2O administration so important?

3 to 5 minutes - Approximately 3 to 5 minutes is required by the brain to process each dose of nitrous. - After adjusting the flow rate observe the patient for response, until the proper signs and symptoms are observed. - 1 to 2 minutes does not allow the brain to process the dose of nitrous. - Waiting 6 to 12 minutes is not necessary.

You have just increased your patient's nitrous oxide level, how long will you observe your patient before increasing the level again? a. 1 to 2 minutes b. 10 to 12 minutes c. 3 to 5 minutes d. 6 to 8 minutes

Give the patient 100% oxygen, decrease nitrous oxide. - If a patient indicates nausea, lower the nitrous oxide concentration, and place the patient immediately on 100% oxygen. - This change alone may help alleviate the feeling. - If vomiting occurs, have the patient turn to the side and use a waste basket while being ready with suction. - It is important to avoid aspiration of the vomitus into the lungs to prevent an emergency situation. - Sitting the patient up without setting oxygen to 100% and lowering the nitrous oxide will not stop the nausea. - Increasing the nitrous oxide content and lowering the oxygen level will have the opposite effect and will increase the nausea and chance for vomiting.

Your patient is feeling nauseated while you are deep scaling in Quadrant 3. You are using nitrous oxide-oxygen sedation. What should you do? a. Give the patient 100% oxygen, decrease nitrous oxide. b. Lay the patient on their side. c. Sit the patient up. d. Increase the nitrous content, lower the oxygen level.

40% - Nitrous oxide should be added in increments of 5% to 10% at a time, adjusting the flow rate and waiting a few minutes to observe the patient for a response, until the proper signs and symptoms are observed. - Adding more than 10% of nitrous at a time may provide more deeper sedation than is needed and cause nausea.

Your patient is receiving 30% nitrous oxide and is still anxious and has a hypersensitive gag reflex. What is the highest percentage of nitrous oxide you can administer to your patient at this time? a. 40% b. 60% c. 45% d. 50%