Role of the perianesthesia nurse in the preoperative evaluation, preadmission testing, and preanesthesia evaluation setting

The preanesthesia evaluation establishes the initial contact of the perianesthesia nurse with the patient and the patient’s support persons. This initial contact is crucial because it establishes the baseline trust the patient will have in the care provided to them during this vulnerable time. The purpose of this preoperative evaluation is to identify potential complications that can arise during the scheduled event, provide an opportunity for patient education, and establish guidelines in preparation for the procedure. The goal of the preoperative phase is to provide a complete picture of the patient relevant to the procedure while providing education that will allow the patient to have decreased anxiety regarding the perianesthesia care.¹

The preanesthesia evaluation can occur in several ways depending on the clinical enterprise from which the patient is receiving care. The assessment is a historical assessment that can be conducted in person, by telephone interview, or via a computer-based patient questionnaire application. This historical assessment is a full system review, psychosocial assessment, functional assessment, as well as medication reconciliation and learning needs assessment. A brief physical examination of heart and lung sounds as well as airway evaluation can also occur if the interview is conducted in person. Preanesthetic testing to include laboratory studies, cardiac studies, radiology examinations, and other tests, as deemed necessary per patient condition and physician orders, can also be completed at this time.

The perianesthesia nurse, in the preanesthesia evaluation period, acts as a liaison between multiple providers to obtain data that provide a complete picture of the patient’s clinical presentation. The nurse can work with offsite physician offices to obtain referral records and test results. Competency-based orientation programs provide the perianesthesia nurse the judgment to complete the initial review of the documentation and send for further review or recommend additional testing as necessary. Partnering with other providers allows for the optimization of the risk stratification of the preanesthetic patient while reducing costs associated with redundant testing.

The patient population that the perianesthesia nurse encounters during this phase depends on the area of practice. Each specialty patient population brings challenges to the perianesthesia nurse and allows for further specialization within the field of perianesthesia nursing. The patient population can vary from pediatric to geriatric. Pediatric perianesthesia nurses face challenges with their patient populations that are different from, but just as challenging as, the geriatric population. Perianesthesia nurses in the nontraditional care areas also face challenges of limited resources and specialized assessments. For example, perianesthesia nurses in the pain management clinic area may be more aware of patient coping mechanisms related to chronic pain conditions that are not expressed in the general population.

The effects of the preanesthesia evaluation are multifaceted. The patient who is adequately prepared for the procedure has a better postprocedure outcome.⁴ Information gathered during this phase is communicated forward to the next phase of care, which allows each subsequent perianesthesia care provider to follow the established plan of care while adapting the plan to meet each patient’s individual circumstance or concern.⁴ For example, patients identified in the preanesthesia evaluation as having a family history of malignant hyperthermia will have their anesthesia plans altered to reflect that information. Likewise, patients identified as having risk factors for postoperative nausea and vomiting will be given appropriate premedication to prevent nausea postprocedure. The effects of the preanesthesia evaluation are evidenced by patient readiness for the operative experience and further evidenced by limited incidences of patient complications during subsequent phases of perianesthesia care. Verifying historical assessment information with current physical status potentiates patient safety by addressing needs such as medication reconciliation, fall risk assessments and interventions, side or site verification of planned procedure, potential for compliance of instructions, and discharge planning assessments.¹

Role of the perianesthesia nurse in ambulatory surgery and preoperative holding

The ambulatory surgery unit and preoperative holding areas provide the perianesthesia nurse the opportunity to interact with the patient and the patient’s family or other support persons before the procedure. This time period may be surreal for the patient and the family with heightened anxiety as the level of vulnerability increases.³ The perianesthesia nurse in this phase provides competent care including an assessment to identify any changes from the preanesthetic evaluation, pain and anxiety control, advocacy, and clinical skills such as intravenous line insertion and medication management. The perianesthesia nurse uses therapeutic communication skills with the patients and their families to ensure a calming environment and patient readiness for the scheduled procedure.

This phase of perianesthesia care can occur in any clinical practice site before the procedure. Hospital-based ambulatory settings can provide care for patients from same-day outpatient procedures to complex cases requiring lengthy postoperative admissions. The preprocedure perianesthesia nurse can promote the safety of the patient by verifying patient compliance and identifying any alteration from preanesthetic instructions, such as validation of NPO status. The perianesthesia nurse also reviews relevant preoperative testing results, current orders, completion of medication reconciliation to include last dose date and time verification, comfort and safety needs, and verification of discharge planning such as validation of the postprocedure driver and care provider.¹

The patient population under the care of the perianesthesia nurse depends on the provider’s scope of care. In addition to the patient, this care period will include the patient’s support structure of family members, friends, clergy, and other support providers. These additional support persons (e.g., family or friends) can provide relief from anxiety for the patient and may be able to provide the perianesthesia nurse with additional information the patient is unable to share because of heightened anxiety. It is important to note that, during all interactions with the patient and the patient’s support system, the perianesthesia nurse’s interaction must maintain patient privacy and respect.

After obtaining the day-of-procedure assessment update and initiating patient care preparation orders, the perianesthesia nurse hands off care. The critical thinking and interpretation of the assessment by the perianesthesia nurse is essential, as is the communication of this assessment along with any changes or concerns, to the procedure nurse who will be involved with the immediate care of the patient during the procedure. This vital communication provides the patient with the best opportunity for a safe, successful anesthetic event. While the patient is receiving care, the perianesthesia nurse continues to support the patient’s family.

Role of the perianesthesia nurse in the post anesthesia care unit phase I recovery

The perianesthesia nurse in phase I recovery cares for patients in the PACU and provides care for patients who have completed their anesthetic event. The PACU is a critical care environment; therefore it is designed to provide active line-of-sight monitoring of patients who have undergone a general anesthetic. Phase I recovery is available in all areas for care after a general anesthetic, such as hospital-based surgery units, ambulatory surgery clinics, and office-based procedure areas. Because these patients have had their basic life-sustaining reflexes suppressed during their anesthetics, it is imperative for the perianesthesia nurse in this setting to be acutely aware of changes in the patient’s status, such as a sudden oxygen desaturation possibly indicating a loss of airway. Phase I status is determined by the patient condition, rather than location of care.¹

During this critical care period, the patient is acutely monitored and evaluated for subtle changes indicating a change in homeostasis. As the patient recovers from the anesthetic, the patient is vulnerable, uncertain of location, and often in pain. The perianesthesia nurse offers reassurance; assesses for pain and other physical indicators; and provides medication, monitoring, and additional comfort measures. Using therapeutic communication techniques, the perianesthesia nurse guides the patient through the experience, allowing the patient to express any needs. The perianesthesia nurse communicates frequently with the patient’s support members, providing condition updates. The perianesthesia nurse also communicates frequently with the physician or anesthesia care provider to ensure an optimal continuum of care.

The perianesthesia nursing assessment includes integration of relevant preoperative information, such as patient comorbidities. Understanding the patient’s anesthetic technique and potential consequences, such as airway management or resedation potential is critical to the patient’s safe recovery. The perianesthesia nurse obtains information from the anesthesia provider regarding technique, length, and drugs administered to include reversal agents. Cardiovascular, pulmonary, and neurologic assessments are completed to validate return to baseline values following the administration of anesthetic agents. The critical aspect of this assessment cannot be understated. The PACU nurse is the primary care provider who uses critical care skills and training to detect early subtle changes that could become catastrophic without intervention. The PACU nurse assesses the patient for pain and discomfort using a variety of pain scales from an observational scale for sedated patients to the numeric scale for those who are more alert and able to answer questions. The patient’s procedure will dictate additional assessments for wound assessment, potential for hypovolemia owing to hemorrhage, alteration in maintenance of normothermia, as well as additional physical assessments such as peripheral pulse verification. A thorough skin integrity assessment should also be performed to verify continued integrity of skin structures or identify concerns with skin integrity from the operative procedure or positioning.¹

As in any critical care nursing unit, the PACU nurse may care for patients who need a ventilator, requiring hemodynamic intravenous medication administration and intensive cardiac monitoring. If the requirements of the phase I recovery for the institution includes care and management of these most critical patients, appropriate competencies—to include patient assessment and intervention, advanced cardiac monitoring skills, advanced hemodynamic medication administration, and advanced pulmonary care, such as ventilator management skills—must be included in the competency-based orientation program for the phase I PACU nurse.

Communication with the anesthesia care team to understand the patient’s emotional status preprocedure will allow the perianesthesia nurse to provide the appropriate emotional support to the emerging patient who will have anxiety because of the surgical event, surgical findings, and general loss of control. Patients who experience preprocedure heightened levels of anxiety often emerge from anesthesia in the PACU with continued expressions of anxiety and may lash out as a result of anxiety, fear, or pain.

The patient population receiving care by the perianesthesia nurse in the PACU depends on the organization’s scope of care and can include patients from the pediatric age group to patients in the geriatric population. Changing dynamics toward open visitation in the PACU allow for this care period to include the patient’s support structure of family members, friends, clergy, and other support providers. These individuals may give the perianesthesia nurse additional support by helping to relieve patient anxiety during this postanesthesia experience and sharing an understanding of the patient’s normal response to pain and other stimuli, as these responses may still be depressed from the anesthetic (see Chapter 3). ASPAN has developed a position statement specifically targeting patient visitation in the PACU.¹

The acuity of inpatient cases has increased significantly. In addition, the increasing age of the population in the United States means that many surgical patients have a number of concomitant chronic problems, such as chronic obstructive lung disease, diabetes mellitus, and chronic heart conditions. The provision of quality care in the PACU necessitates a strong, knowledgeable clinician with excellent skills using critical thinking to the fullest while supporting patients, their families, and other caregivers.

In many institutions, discharge from PACU Phase I occurs when the patient has met predetermined discharge criteria established in conjunction with the anesthesia providers and medical staff in lieu of individual orders.¹ The phase I perianesthesia nurse’s critical judgment and skill is crucial because many patients are not seen and evaluated by a physician or anesthesia provider before leaving this intense monitoring setting. Items for consideration to determine discharge eligibility include airway patency, independent and dependent respiratory function, and gas exchange as validated by oxygen saturation. The patient’s ability to maintain cardiac and hemodynamic stability, normothermia, expected level of consciousness, and sensory–motor function should be assessed. Further assessments include pain and comfort status, postoperative nausea and vomiting, and emotional status.¹ Patency of lines, completion of medication administration, and wound integrity are also considered when determining discharge eligibility. When the patient is deemed eligible for discharge to the next level of care, the patient is discharged from phase I to either an inpatient hospital bed or to phase II recovery in anticipation of discharge to home.¹

In an effort at cost containment, hospitals have increased the use of the PACU. In the critical care setting, highly skilled perianesthesia nursing staff and proximity to anesthesia providers has made the PACU a prime location for special procedures, such as electroconvulsive therapy (ECT), elective cardioversion, and endoscopic examination.¹ In addition, the PACU is often used for services such as pain clinics for block placement; as preoperative holding areas (for both inpatient and outpatient services); as a recovery area for remote procedure patients from areas such as interventional radiology and cardiology; and as an overflow unit when intensive care unit or inpatient beds are full.¹ Although some of these changes seem to create less than optimal conditions for patient care, the creative collaboration of all health care practitioners can meet the challenges of the rapidly changing health care environment. PACUs have the unique opportunity to be innovative and creative in implementation of methods to meet these challenges while continuing to support the operating room schedule and surgical PACU patients within the organizational and operational structure of the unit.¹

Role of the perianesthesia nurse in the postanesthesia phase II recovery

Patients who have met discharge criteria for phase I recovery are transferred to phase II recovery where they continue to respond to interventions aimed at recovering from the anesthetic agents. Assessment of the phase II patient continues as with the phase I patient. Validation of hemodynamic stability is monitored as the patient’s activity level increases. Thermoregulation monitoring continues. Verification of the patient’s ability to swallow before the administration of diet or medications by mouth is completed. Of note, the patients in this phase of recovery may have less fluctuation in their vital signs as their condition stabilizes toward baseline. They may be more vocal regarding pain management needs or postoperative nausea. Their families are more involved with their care as they are more alert and responsive to stimuli. These patients often alter their position from lying to sitting and consume clear liquids.¹

The patients in phase II recovery are preparing for discharge to home following their anesthesia event. Verification of emotional readiness for discharge of both the patient and caregiver is to be completed by the phase II perianesthesia nurse, because concerns not previously identified can occur in this postoperative period. Continued discharge teaching that includes home care instructions are given to both the patient and the care provider, to include contact numbers for further information. Should the perianesthesia nurse encounter any concerns with a safe discharge, the perianesthesia nurse should escalate the concerns to the physician provider for additional intervention.¹

The phase II setting may be present in an ambulatory surgery setting, or it may be a chair recovery area in an office-based procedure suite. As with phase I recovery, the patient’s condition dictates the level of recovery more than the physical location.¹ Monitoring needs in phase II care are less intense because the patient should be at or near baseline before leaving the phase I setting.

As with previous areas, the patient population receiving care from the perianesthesia nurse is dependent on the provider’s scope of care, pediatric through geriatric. In the phase II setting, discharge education and validation of understanding is completed with the patient and their support structure of family members, friends, clergy, and other support providers.

Role of the perianesthesia nurse in the fast-tracking of recovery patients to phase II

Fast-tracking has become a popular concept in the PACU. Fast-tracking involves admission of patients from the operating room directly to phase II and the bypass of phase I for both the ambulatory and inpatient.¹ These patients must meet discharge criteria for phase I before leaving the operating room, and as such, policies and procedures on fast-tracking should be developed collaboratively with the involvement of nursing and anesthesia personnel.¹ Policies should address patient selection and criteria for direct admission to phase II (inpatient floor), patient monitoring, and outpatient discharge. Nurses in the phase II unit must be competent to handle any unexpected outcome that may be a direct result of fast-tracking.

ASPAN supports the use of fast-tracking within the bounds of safe patient care.¹ Patient selection before fast-tracking is vital to decrease potential complications. Appropriate candidates include those who have motivation to progress the postoperative care, short-acting anesthetic agents, limited preexisting comorbidities, and collaborative care teams who communicate well with one another. Criteria for discharge from the operating room should include level of consciousness (awake or easily aroused), hemodynamic stability (towards baseline), appropriate gas exchange (patient maintaining oxygen saturation on room air), limited pain, nausea, and stable wound site (no active bleeding). Phase II is a level of care, not a physical place. As a result, before fast-tracking the patient needs clinical assessments, and potential outcomes should be assessed and honored.¹

Role of the perianesthesia nurse in extended observation

Following the assessment of the patient in phase II, some patients do not meet discharge criteria related to continued pain or nausea management needs or social indications, such as no appropriate transportation available. These patients can receive care in an extended observation unit maintained under the perianesthesia department. In this setting, the patient continues to be monitored for hemodynamics, respiratory and circulatory stability, and pain control. Additional assessment for skin integrity to include the surgical site and dressing are completed and documented. The perianesthesia nurse provides emotional support and communication with the patient and any support members present. Administration of medications, diet, and treatments can occur. The patient’s safety is maintained through fall risk assessments and additional risk identifiers. These patients continue to have their discharge needs managed by the perianesthesia nurse, who then contacts appropriate resources to help facilitate discharge to the next level of care.¹