Pasero Opioid-induced Sedation Scale (POSS) with Interventions* S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed

What is POSS? An evidence based validated assessment tool An assessment that is specific for identifying excess(undesired) opioid-induced sedation from pain medications. Provides guidance to the nurse in determining whether or not it is safe …

Developed by Chris Pasero, a renowned pain management nurse, this scale helps in monitoring and managing opioid-induced sedation effectively. By utilizing the POSS, nurses can identify potential risks, provide timely interventions, and ensure patient safety during opioid administration.

Sedation Scale (POSS) • POSS is for monitoring and early detection of unintended sedation with opioid administration • Sedation usually precedes respiratory depression

For adults experiencing respiratory depression give intravenous naloxone very slowly while observing patient response (“titrate to effect”).

sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. 1 Pain Assessment and Pharmacologic Management, by C. Pasero and M. McCa˜ery, 2011, St. Louis, MO: Mosby/Elsevier.

Pasero Opioid-Induced Sedation Scale (POSS) What is the role of the nurse? Assess POSS prior to administering opioids POSS S, 1, or 2 •Give the opioid medication •Sign Documentation •Reassess pain within 1 hour (POSS Response box will require a pain score, POSS level, and functional ability reassessment) POSS 3 or 4 •Hold the opioid ...

Early identification of unacceptable levels of opioid-induced sedation and appropriate intervention can PREVENT opioid-related respiratory depression. When to Use POSS? Where is POSS located? “What did you eat for breakfast today?” How to Assess the Sleeping Patient? Click on the Pain tab to document the POSS assessment.

• Use POSS to assess sedation prior to and after administering opioids and perform interventions as applicable • Monitor for desaturation or apnea • Monitor for hypercarbia • Position in semi-upright position if not contraindicated • Administer supplemental O2 as indicated or ordered

Pasero Opioid -Induced Sedation Scale (POSS) with Interventions A validated and reliable sedation scale for assessing and reporting opioid induced sedation. Registered Nurses' Association of Ontario.