Michael Kost, CRNA, MS Michael Kost, CRNA, MSN, is th

5/30/13
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Caring for the Postanesthesia Patient
CE115-60 :: 1.00 Hours
Authors:
Michael Kost, CRNA, MS
Michael Kost, CRNA, MSN, is the author of A Manual of Conscious Sedation. The author
has declared no real or perceived conflicts of interest that relate to this educational
activity.
Jan Odom-Forren, RIM, PhD, CPAN, FAAN
Jan Odom-Forren, RN, PhD, CPAN, FAAN, is a perianesthesia nursing consultant in
Louisville, Ky., and assistant professor at the University of Kentucky, Lexington, Ky. The
authors have declared no real or perceived conflicts of interest that relate to this
educational activity.
Objectives
The goals of this continuing education program are to update nurses' knowledge about the
care of post-anesthesia patients and to familiarize nurses with applicable The Joint
Commission standards. After you study the information presented here, you will be able to
• Name three important areas of concentration for assessing the post-anesthesia
patient.
• List two complications specific to regional anesthesia.
• Identify the etiologies of six complications of general anesthesia and their
treatments.
Nurses care for postoperative patients in post-anesthesia phase I or post-anesthesia
phase II, according to designations made by the American Society of PeriAnesthesia
Nurses. Nursing responsibilities during phase I focus on providing a transition for the
patient from a totally anesthetized state to care in the in-patient setting, phase II, or the
intensive care setting for continued care.1 Assessment in the post-anesthesia care unit
focuses on respiratory and cardiovascular systems and maintenance of a patent airway or
continued ventilatory support. The primary purpose of the PACU is critical assessment and
stabilization of post-anesthesia patients with an emphasis on prevention or treatment of
complications.2 Post-anesthesia patients often need continued intensive care and require
the nurse to possess critical thinking skills and complex nursing expertise. Post-anesthesia
phase II focuses on preparing the patient and family for care in the home or extended care
environment.1 Because of the complexity of care and increased patient responsibilities in
the immediate postoperative period, it's not surprising that The Joint Commission mandates
that an RN supervise perioperative nursing care, and that a sufficient number of qualified
staff are available to recover patients. 3
Assessing the Immediate Post-Anesthesia Patient
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Before patients are transferred from the operating room to the PACU, receiving nurses
need to know when they will arrive and what they will require, such as equipment for
ventilatory support or monitoring. The Joint Commission's standards require appropriate
physiological monitoring and resuscitative equipment be available, as well as equipment to
administer IV fluids, drugs, and blood and/or blood components, as necessary. 3 Upon
transfer, a thorough report from the anesthesia provider supplemented by the OR nurse
should include relevant preoperative information regarding patient status, including
emotional status; the surgical procedure performed; types of anesthesia and the drugs
used; length of anesthesia or sedation; any reversal agents; pain management
interventions; intraoperative estimated blood loss, surgical drain volume, and urine output;
IV fluid and blood products infused; any anesthetic and surgical complications that
occurred; vital signs, including pulse oximetry and temperature; and any co-existing
medical disorders.1 This report from the anesthesia provider to the PACU RN is a critical
patient handoff, and accurate information about the patient is essential. Standards from
the American Society of Anesthesiologists and the American Association of Nurse
Anesthetists require the anesthesia provider to supply a verbal patient report to the
responsible PACU nurse.4 ( Level A )/ 5 (Level A) -pne joint commission patient care standards
require that handoff communication provide for the opportunity for discussion between the
giver and receiver of care. 3
Expectations of The Joint Commission relative to monitoring of the post-anesthesia patient
include the following standards: 3
• The patient is assessed immediately after the procedure.
• Each patient's physiological status, mental status, and pain level are monitored.
• Monitoring is at a level consistent with the potential effect of the procedure and/or
sedation or anesthesia.
The nurse accepting the patient needs to complete an initial assessment that includes the
patient's level of consciousness, vital signs, oxygen saturation, end tidal CC"2 (if
applicable), heart and breath sounds, surgical site and drainage devices, and IV access
site so that any changes that occurred during transport can be identified immediately.
Subsequently, a complete system assessment is performed and postoperative orders
initiated. The report and assessment findings should be documented according to the
institution's policies and procedures.
Cardiopulmonary System: Maintenance of adequate gas exchange with adequate
ventilation is vital. The patient should have unlabored, quiet respirations with adequate
chest excursion; a respiratory rate of 16 to 20 breaths per minute is normal for an adult
(higher in children), but may be slower, particularly in a patient who has received opioids.
Patients should be encouraged to take deep breaths. The respiratory function should be
monitored, including oxygen saturation, and if available and appropriate, end-tidal carbon
dioxide levels.2 Generally, an oxygen saturation level measured with a pulse oximeter
should be higher than 92% to 94%, or the same as preoperative status.
The cardiac output and perfusion should be assessed and monitored by checking arterial
blood pressure for evidence of hypotension or hypertension — postoperative blood
pressure should be plus or minus 20% compared with the preoperative measurement;5
heart rate and rhythm for signs of dysrhythmias; and skin color and temperature, and
peripheral pulses for peripheral perfusion status. The fluid intake and output should be
reviewed for indications of possible hypovolemia or hypervolemia, and also for total fluids
infused, including blood products compared with urinary output, estimated blood loss, and
volume in surgical drains. Peripheral edema or jugular venous distention should be noted.
Numerous factors can alter cardiopulmonary function, including pain and residual
anesthetic affects, and the underlying cause needs to be identified to effectively resolve
the problem.
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Central Nervous System (CNS): CNS assessment includes evaluation of consciousness,
orientation, and behavior. Drugs used to produce general anesthesia cause
unconsciousness as well as amnesia and analgesia. The incidence of emergence delirium
ranges from 0% to 73.5%.7 Causes for emergence delirium include pre-existing cognitive
impairment, medication, pain, bladder distention, or cerebral hypoxia with the older patient
at a greater risk.7'8 In a recent study, the risk factors for emergence delirium in 1,868
adult patients were premedication with benzodiazepines, induction of anesthesia with
etomidate, younger and older age (below 40 and over 64), higher postoperative pain
scores (NRS 6-10) and musculoskeletal surgery.9 ( Level B) Young children also frequently
experience delirium.8'10 The patient exhibits restlessness, confusion, and disorientation,
and may be combative, uncooperative, or uninhibited during this time. Although the
delirium does not last long, it's important to promote the patient's safety as well as that of
the healthcare professional by remaining calm, speaking softly, and reassuring and
orienting the patient.7'8'10 Drug therapy may be necessary to resolve the agitation, such
as a benzodiazepine or physostigmine, which reverses agitation caused by atropine (an
anticholinergic drug).10 However, before drug therapy is considered, other causes of
delirium should be identified and corrected, such as hypoxia, hypercarbia, hypothermia,
gastric dilatation, and urinary retention.8'10
Temperature: Hypothermia, a core temperature below 36 C, is a common, but adverse,
side effect of anesthesia.11'12 Every patient should be assessed for hypothermia and
warming initiated for any hypothermic patient.11 Infants and the elderly are more
susceptible to hypothermia because of immaturity and diminished sensitivity of
temperature regulating mechanisms.10 The reduced metabolic rate caused by hypothermia
can prolong the effects of anesthetics and delay recovery, while the associated shivering
increases oxygen consumption10 four to five times, increasing the risk for angina and
dysrhythmias in patients with cardiovascular disease. Postoperative shivering is controlled
by using IV fluid warmers, skin surface warming devices such as forced warm air devices,
and drugs such as meperidine (25 mg IV).10"12 In the PACU, hypothermic patients should
continue to have an assessment of temperature at least hourly, assessment of thermal
comfort and passive thermal care measures, such as a warmed blanket. Hypothermic
patients should have an application of forced-air warming and consideration of additional
adjuvant measures such as warmed intravenous fluids and humidified warm oxygen.12 ( Level
A),13 (Level A)
Anesthetic Techniques
Surgery within ORs can be performed under a variety of anesthetic techniques. Three
concepts are integral to a comprehensive understanding of these methods and their
effects on postoperative patients. Analgesia is defined as the lack of normal pain
sensation.14 Amnesia, an essential element of general anesthesia and a desired element of
regional and sedation techniques, is the absence of awareness of stimuli and events.15
Anesthesia, a partial or complete loss of sensation with or without loss of
consciousness,can be achieved by the use of regional or general techniques.14
Many procedures are performed with IV sedation and local anesthesia that is injected at
the surgical site, commonly referred to as monitored anesthesia care or local standby with
sedation. Opioids and/or benzodiazepines and IV anesthetic agents, such as propofol
(Diprivan), provide an anxiolytic and analgesic state while the surgeon provides local
anesthesia.
Regional anesthesia includes spinal, epidural, and caudal anesthesia. This type of
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anesthesia interrupts the patient's sensory, motor, and sympathetic nervous system
impulse transmissions at the selected surgical site.16 Used in conjunction with IV sedation,
regional anesthesia can provide an effective alternative to general anesthesia in certain
procedures on extremities or the lower abdomen. The drug used and the site of drug
installation affects the intensity of blockade, as well as the adverse reactions and the
level and duration of anesthesia.15
Postoperative care of patients with regional anesthesia includes assessment of the
sensory and motor function in the area of the block. The return of motor function should
be documented based on the patient's ability to progressively move toes, feet, legs, and
thighs. Return of sensory function is demonstrated by the ability to distinguish sensations
of cold (alcohol swab) or touch (small gauge needle pricks). Patients with a "high"
sensory/motor block (spinal/epidural) may complain of numbness and tingling of the hands
and may exhibit signs of labored respirations. Anesthesia-induced hypotension is due to
vasodilatation caused by the sympathetic blockade that leads to decreased venous return
and cardiac output. These patients need continuous assessment, including oxygenation
and ventilation and vascular volume status, while supplemental oxygen is provided and
venous return is increased using IV fluids and positioning. Patients who are having
difficulty breathing or who have a reduction in oxygen saturation may require endotracheal
intubation and ventilatory support, and those whose hypotension persists may need a
sympat ho mimetic drug, such as ephedrine. Assessment for other causes of the
hypotension, such as bleeding from the operative site, should also occur. 16
General anesthesia produces unconsciousness, amnesia, analgesia, skeletal muscle
relaxation, and control of sympathetic response to noxious stimuli.15 A combination of
drugs, administered as inhalants or intravenously, is used to achieve adequate surgical
anesthesia. Nurses can anticipate potential problems if they know which agents have been
used during the surgical procedure.
Opioids include morphine — the prototype to which all others are compared — fentanyl
(Sublimaze), remifentanil (Ultiva), sufentanil (Sufenta), alfentanil (Alfenta), and
hydromorphone (Dilaudid). Fentanyl is 75 to 125 times more potent than morphine;
remifentanil has an analgesic potency similar to fentanyl, and sufentanil is five to 10 times
more potent than fentanyl.17 Alfentanil is one-fifth to one-tenth as potent as fentanyl,
which makes it a popular IV adjunct in outpatient settings because of its rapid onset and
short duration of action. Opioids produce analgesia, euphoria, and sedation. Morphine
reduces blood pressure due to vagal-induced bradycardia and histamine release, reactions
not seen with other opioids such as fentanyl.17 Hydromorphone, similar to morphine, has
seen a renewed popularity in the PACU. It has a rapid onset of action and virtual lack of
active metabolites after breakdown in the liver.17 Due to the potential for histamine
release, morphine is contraindicated for the asthmatic patient. Other adverse effects,
including somnolence, urinary retention, nausea and vomiting, and respiratory depression
(which may be reversed with naloxone), are common to all opioids. Meperidine (Demerol) is
not typically used for long-term pain management due to its metabolite, normeperidine,
which causes CNS excitability.17 The reversal agent for opioids is naloxone, which can
reverse side effects such as respiratory depression.
Benzodiazepines produce amnesia. Diazepam (Valium) use is limited since the introduction
of midazolam (Versed), which is shorter-acting and water-soluble, causing less venous
irritation. Adverse effects may include delayed awakening, somnolence, disorientation,
amnesia, and postoperative respiratory depression, especially if used in conjunction with
opioids. Flumazenil (Romazicon), a benzodiazepine antagonist, may be used to reverse
significant adverse effects such as respiratory depression.
Barbiturates, including sodium thiopental (Pentothal) and methohexital (Brevital), have
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been a mainstay of IV anesthetic practice for more than 50 years. These hypnotic
producing drugs are used for induction or sedation and have a low incidence of
postoperative nausea and vomiting. Large or repeated doses intraoperatively may prolong
the drug's effects postoperatively, causing delayed awakening, somnolence, hypotension,
and respiratory depression. Barbiturates do not provide adequate analgesia and must be
supplemented for pain control.18 Propofol (Diprivan), a sedative hypnotic, produces dosedependent depression of the CNS. Approximately twice as potent as sodium pentothal, it
may be used for sedation or induction and maintenance of general anesthesia. Other CNS
depressants such as opioids increase propofol's hypnotic effect. Adverse effects include
hypotension, which is more pronounced if the patient is elderly or has poor left ventricular
function — fluid resuscitation and vasopressor therapy may be required.18 Etomidate,
another sedative hypnotic, is frequently used as an alternative to propofol and
barbiturates for emergency surgery when volume resuscitation is ongoing and for patients
with cardiac disease.18 It has less of an effect on blood pressure, heart rate, myocardial
contractility, and cardiac output, compared to the other sedative hypnotic drugs.18
Involuntary muscle contractions or tremors are adverse effects, and nausea and vomiting
are more common postoperatively than with thiopental or propofol.
Neuromuscular blocking agents (NMBA) are used principally to relax and paralyze skeletal
muscles, facilitating endotracheal intubation and muscle retraction in the surgical field.19
They do not possess analgesic, amnesic, or anesthetic properties, and are classified
according to how they act upon the neuromuscular junction, depolarizing or
nondepolarizing. Succinylcholine (Anectine) is the only depolarizing NMBA currently
available in the U.S., and there is no reversal agent for this drug.20 Nondepolarizing NMBAs
include intermediate acting rocuronium (Zemuron), vecuronium (Norcuron), cisatracurium
(Nimbex), and atracurium (Tracrium); and long-acting pancuronium (Pavulon). Adverse
effects may include cardiac dysrhythmias, postblockade myalgia, prolonged blockade, and
persistent weakness. 20 There are also certain drugs, such as local anesthetics, antibiotics,
antidysrhythmics, and diuretics that can potentiate the effects of NMBA, contributing to a
prolonged recovery.20 The most serious postoperative complication is inadequate reversal,
which may result in short jerky attempts at respiration with little or no gas exchange.
Patients exhibit uncoordinated "floppy fish" gasps for air. Nurses need to assess
respiratory rate, oxygen saturation level, and tidal volume and report findings to the
anesthesia provider. Reversal agents for nondepolarizing NMBA, neostigmine, edrophonium,
or pyridostigmine, may be given if needed.19'20 It's recommended that an anticholinergic is
given with the NMBA to prevent bradycardia, bronchoconstriction, and hypotension, which
are adverse effects of these reversal agents; atropine is given with edrophonium or
glycopyrrolate with neostigmine or pyridostigmine.19'20 When the supine patient can lift his
head off the bed and hold it for five seconds, neuromuscular blockade recovery is
considered adequate.
Inhalation anesthetics, halothane, isoflurane, desflurane, and sevoflurane are used for
general anesthesia. In addition to depressing the central nervous system, these drugs
depress baroreceptor sensitivity and myocardial and respiratory function. Nurses need to
frequently assess blood pressure; cardiac rhythm; peripheral perfusion; and respiratory
rate, rhythm, and depth.15
General Anesthesia Postoperative Complications
Respiratory depression (reduced tidal volume, respiratory rate, and 62 saturation) may
result from residual drug effects. Inadequate reversal of muscle relaxants reduces tidal
volume; if unresolved by additional reversal agents, reintubation may be necessary.
Residual opioids primarily diminish respiratory rate, and patients may require naloxone
(Narcan) titrated to reverse opioid depression. On occasion, reduced tidal volume and 02
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saturation result from pain and splinting, and may improve with opioid analgesia. Because
patients who have had general anesthesia have had some interference with their
respiratory processes, most experts suggest these patients should receive supplemental
oxygen during the recovery period.21
Upper airway obstruction can also result from relaxation of the pharyngeal musculature due
to residual drug effects. The patient should be observed for signs of obstruction, such as
snoring, nasal flaring, and sternal retractions.6 Raising the head of the bed, if not
contraindicated, or performing a simple jaw lift or mandible thrust, is often sufficient to
bring the tongue forward and relieve the upper airway obstruction. If this is ineffective, a
nasal airway can be inserted. If a nasal airway is contraindicated by a history of epistaxis,
cranial surgery, facial fractures, or a low platelet count, an oral airway may be inserted if
the patient is unconscious; 6 stimulation of the patient's gag reflex may cause vomiting,
increasing the risk for aspiration. If upper airway obstruction is not relieved immediately,
the anesthesia provider should be notified to assess for reintubation.
Mechanical obstacles, such as teeth, vomitus, or hematomas may also cause obstruction.
Patients who have had head and neck surgery need continuous assessment for airway
patency. Hemorrhage and/or clot formation at the surgical site may require further surgical
exploration. An emergency tracheostomy setup needs to be at the bedside for these
patients if signs and symptoms indicate respiratory distress.22
Laryngospasm, which may result in complete closure of the vocal cords and inability of the
patient to ventilate, requires immediate assistance from anesthesia personnel. Those at
risk for laryngospasm include patients with chronic pulmonary disease, those who smoke,
those with a history of asthma, or those who had a difficult intubation. Patients will often
display "rocking" abdominal respirations with no air exchange. Initial treatment is positive
pressure ventilation using a bag valve mask device with 100% 02- The anesthesia provider
will give a nonparalyzing dose of succinylcholine (about one-tenth of the full intubating
dose) if this maneuver is unsuccessful. Reintubation may be a last resort.10
Hypotension is commonly caused by hypovolemia from hemorrhage, insensible (third space)
losses, or inadequate fluid replacement. But hypotension can also be caused by decreased
systemic vascular resistance and myocardial contractility, which are residual effects of
anesthetic agents.8 Arterial hypoxemia, cardiac dysrhythmias, pulmonary embolism,
pneumothorax, and cardiac tamponade can also lead to hypotension.8
Treating hypotension depends upon its etiology; however, oxygen therapy is usually a
standard treatment regardless of cause. Assessment starts with an evaluation of fluid
status, including a thorough review of estimated intraoperative blood loss and fluid
replacement, urine output, and postoperative bleeding at the wound site and from surgical
drains. If blood loss is suspected, hemoglobin and hematocrit levels should be checked.
Evidence of bleeding and a low hematocrit level are signs of inadequate surgical
hemostasis, and the surgeon should be notified. Based on a patient's cardiovascular
status, fluid challenges of 200 cc to 500 cc may restore blood pressure to baseline values
if hypovolemia is present.10 Other etiologies require further assessment and specific
treatments.
Hypertension in the immediate postoperative period is often due to the sensation of pain
as the patient emerges from anesthesia.8 However, it may result from hypoxemia,
hypercarbia, a full bladder, hypothermia with arterial and venous constriction, fluid
overload, and the administration of exogenous sympathomimetic agents, such as ephedrine
or neosynephrine.10 As with hypotension, the etiology of hypertension determines
treatment. First, the nurse should assess such factors as airway and ventilation,
unrelieved pain, or the presence of a full bladder. Correction and treatment of one or more
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of these factors may return the patient's blood pressure to baseline value. Patients may
need to be reassured, have their fears allayed, have analgesics administered for pain, their
bladders emptied, and be encouraged to deeply breathe and cough. Patients with preexisting hypertension, who often exhibit wide ranges of blood pressure postoperatively,
need to be carefully returned to baseline values with antihypertensive medications,
calcium channel blockers, or vasodilators.
Aspiration may occur in patients recovering from general anesthesia and IV sedation when
airway reflexes are impaired. Patients most commonly aspirate gastric contents, which can
result in severe pneumonitis and bronchospasm with resultant hypoxemia. Some signs
include wheezing, sustained coughing, and laryngospasm. Pulmonary infiltrates may appear
on the chest X-ray immediately or within 24 hours of the event.10'23 Postoperative
aspiration is life-threatening, and patients demonstrating an inability to maintain a patent
airway or the absence of pharyngeal or laryngeal reflexes require immediate intervention by
anesthesia personnel. Postoperative endotracheal intubation may be required to protect
the airway from gastric contents or foreign materials.
Skeletal muscle pain, especially in the neck, abdomen, and back, may occur from the use
of the depolarizing muscle relaxant succinylcholine. The discomfort is thought to be due to
muscle damage caused by unsynchronized contractions of the skeletal muscles
(fasciculations) associated with generalized depolarization.19 Patients who exhibit skeletal
muscle myalgia postoperatively should be reassured that the duration of this pain is
generally short, dissipating within 24 to 48 hours. Treatment of myalgia includes
analgesics, such as acetaminophen (Tylenol).
Nausea and vomiting is one of the most common postoperative problems, affecting 20% to
30% of patients.8 Primary risk factors fall into three categories — patient-specific,
anesthetic-related, and surgery-related. A patient with risk factors, including female
gender, non-smoking history, use of opioids, and history of post-operative nausea and
vomiting (PONV), or motion sickness, has an 80% chance of having PONV, with each risk
factor increasing the risk of PONV.
Measures to prevent and treat PONV include the use of pharmacologic agents. Serotonin
antagonists (5-HT3 receptor antagonists) prevent and relieve nausea and vomiting by
blocking a chemical called serotonin, which is produced in the brain and the stomach.
Dopamine receptor agents, such as prochlorperazine (Compazine) and droperidol, block the
dopamine (D2) receptor sites. Droperidol was a common treatment until the FDA black box
warning regarding possible dysrhythmias. Promethazine or diphenhydramine can be given to
block the histamine receptor sites. Glycopyrrolate or scopolamine patches can be used for
the muscarinic receptors. Dexamethasone (Decadron) has been used effectively, especially
in combination with a serotonin or dopamine-blocking agent. Metoclopramide blocks D2
receptor sites and enhances gastric emptying. The newest drug is apretitant, which
targets the neurokinin 1 (NK-1) receptors and is available orally for prophylaxis of
PONV.24'25 CLeveLA)
Other measures to reduce nausea and vomiting are the administration of oxygen,
analgesics, decreased stimulation and movement of the patient, adequate hydration,
aromatherapy, and P6 acupoint stimulation with acupuncture or acupressure
techniques.8'25'25 The nurse should work together as a team with the anesthesia provider
to follow multidisciplinary guidelines instituted to guide the care of post-anesthesia
patients.25 (LeyeLA)
Discharge Criteria from the Post-Anesthesia Care Unit
The Joint Commission's standards require patients to be discharged from the PACU by a
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licensed independent practitioner or according to rigorously applied criteria approved by
the medical staff. 3 An example of such criteria follows:
• A patent airway.
• Adequate tidal volume, respiratory rate, and oxygen saturation with or without
supplemental oxygenation.
• Stable vital signs for an established period of time based on the procedure and
anesthesia technique.
• Alertness when stimulated (able to be aroused and capable to summon help from the
nursing staff).
• A tolerable level of pain, which is variable for each individual patient. Patients should
not be discharged immediately after an initial dose of opioid.
• Adequate return of motor and sensory function (patients who have received regional
anesthesia with supplemental sedation).
Instead, a numeric scoring system previously approved by the department of anesthesia
may be used to determine patient readiness for discharge from the PACU.6 The most
common scoring system for the Phase I PACU patient in use presently is the Aldrete
scoring system. Activity, respiration, circulation, consciousness, and oxygen saturation
level are scored from 1 to 2, with a total score of 8 to 10 as acceptable for PACU
discharge.
The post-anesthesia caregiver should give a full report of the intraoperative course of
events and post-anesthesia phase to the nurse assuming care of the patient after
discharge from the post-anesthesia care unit, again allowing for an opportunity to ask and
respond to questions.2
Patients may receive anesthesia through a variety of techniques in the surgical suite.
Regardless of the technique, they all require careful postoperative monitoring and
assessment. With the advent of new technology and pharmacological adjuncts, morbidity
associated with the administration of anesthesia has dropped dramatically. Postoperative
monitoring and recovery of the patient is still a time for careful assessment and skilled
intervention. Effective collaboration between anesthesia and nursing services promotes
quality patient care and positive surgical outcomes.
Gannett Education guarantees this educational activity is free from bias.
References
1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and
Practice Recommendations 2010-2012. Cherry Hill, NJ: ASPAN; 2010.
2. Schick L. Assessment and monitoring of the perianesthesia patient. In: Drain CB, OdomForren J. Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis, MO:
Saunders Elsevier; 2009: 360-389.
3. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive
Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: The Joint
Commission; March 2011.
4. Standards for Post-anesthesia Care. American Society of Anesthesiologists Web site.
http://www.a5aha.org/For-Healthcare-Professionals/Standards-Guidelines-andStatements.aspx. Updated October 21, 2009. Accessed June 20, 2011.
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5. Scope and Standards for Nurse Anesthesia Practice. American Association of Nurse
Anesthetists Web site, http://www.aana.com/Resources.aspx?id=24799. Updated 2005.
Accessed June 20, 2011.
6. Odom-Forren J. Postoperative patient care and pain management. In: Rothrock JC.
Alexander's Care of the Patient in Surgery. 14th ed. St Louis, MO: Mosby; 2011: 267-293.
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interventions. J Perianesthes Nurs. 2002; 17(6):384-392.
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Per/anesthesia Nursing: A Critical Care Approach. 5th ed. St Louis, MO: Saunders Elsevier;
2009: 403-424.
9. Radtke FM, Franck M, Hagemann L, Seeling M, Wernecke KD, Spies CD. Risk factors for
inadequate emergence after anesthesia: emergence delirium and hypoactive emergence.
Minerva Anestesiol. 2010;76(6): 394-403.
10. Schick L. Perianesthesia complications. In: Schick L Windle PE, eds. PeriAnesthesia
Nursing Core Curriculum: Preprocedure Phase I and Phase II PACU Nursing. 2nd ed. St.
Louis, MO: Saunders Elsevier; 2010: 571-596.
11. Hooper VD. Care of the patient with thermal imbalance. In: Drain CB, Odom-Forren J.
Perianesthesia Nursing: A Critical Care Approach. 5th ed. St Louis, MO: Saunders Elsevier;
2009: 748-759.
12. Hooper VD, Chard R, Clifford T, et al. ASPAN's evidence-based clinical practice
guideline for the promotion of perioperative normothermia: second edition. J Perianesth
Nurs. 2010;25(6):346-365.
'•*,
13. Hooper V. Thermoregulation issues. In Stannard D, Krenzischek DA, eds. PeriAnesthesia
Nursing Care: A Bedside Guide for Safe Recovery. Sudbury, MA: Jones & Bartlett; 2012:
55-60.
14. Venes D, Taber CW, eds. Tabor's Cyclopedic Medical Dictionary. 20th ed. Philadelphia,
PA: FA Davis; 2005.
15. Drain CB. Inhalation Agents. In: Drain CB, Odom-Forren J. PeriAnesthesia Nursing: A
Critical Care Approach. 5th ed. St Louis, MO: Saunders Elsevier; 2009: 281-292.
16. Davis TC. Regional anesthesia. In: Drain CB, Odom-Forren J. PeriAnesthesia Nursing: A
Critical Care Approach. 5th ed. St Louis, MO: Saunders Elsevier; 2009: 344-351.
17. Drain CB. Opioid intravenous anesthetics. In Drain CB, Odom-Forren J. PeriAnesthesia
Nursing: A Critical Care Approach. 5th ed. St Louis, MO: Saunders Elsevier; 2009: 305317.
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