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I would like to dedicate the fourth edition of the Core Curriculum to my family and friends, including my co-workers at Lutheran Medical Center in Wheat Ridge, Colorado, and all the contributing authors to this edition. A special thank you is extended to co-editor Pam Windle and all nursing colleagues whom I have encountered and have had the opportunity to share nursing stories. Without the support and encouragement of others, including family, it would have been difficult to update the material in this edition and to meet deadlines. You will note some changes in the fourth edition of the ASPAN PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I, and Phase II PACU Nursing, including the formatting, font size, and new punctuation based on Doland’s Medical Dictionary. It has been an experience of new changes, challenges, and opportunities. Thank you!
Lois Schick
I dedicate this book to all perianesthesia nurses, especially my former staff in the Post Anesthesia Care Unit (PACU), Day Surgery Center, CV Preop/PACU, Surgical Observation Unit and Endoscopy departments at St. Luke’s Medical Center, Houston, Texas, who for over 20 years consistently showed commitment in their daily practices, shared their knowledge, and provided me with their expertise and insights. Working with them to provide the best postoperative care management for all types of patients has been a great privilege and an honor. To David, my husband, my two children, Cynthia and Michael, my son-in-law, Jeremy, and my granddaughter, Natalia, for their understanding of my dedication and love of my career, and for their support and patience throughout this endeavor, as well as to my brothers Junior, Alan, Peter, and Philip, and sisters Elsie, Jane, Tina, and Brenda, and especially to my loving parents, Mary and Lorenzo, who believed in me! Thank you all!
Pamela E. Windle
CONTRIBUTORS
Maria Liza Anicoche, MSN, RN, ACNS-BC, CPAN, CAPA
NCIII, PACU
Johns Hopkins Hospital Baltimore, Maryland
Krista Paternostro Bower, MPA, CAE Chief Executive Officer, Administration American Board of Perianesthesia Nursing Certification, Inc. New York, New York
Courtney Brown, PhD, RN, CRNA Associate Director Didactic Education Nurse Anesthesia Program Wake Forest School of Medicine Winston-Salem, North Carolina
Matthew Byrne, PhD, RN, CNE Adjunct Professor, Nursing Saint Catherine University Saint Paul, Minnesota
Shelly L. Cannon, MSN, BSN, APRN, AGCNS-BC, CPAN, RN-BC
CNS Pain Management PACU, ERAS Coordinator
Lutheran Medical Center
Wheat Ridge, Colorado
Sarah Marie Independence Cartwright, DNP, MSN-PH, BAM, RN-BC, CAPA
Integrated Clinical Practice Strategist Anesthesiology and Perioperative Medicine Augusta University Augusta, Georgia
Theresa L. Clifford, MSN, RN, CPAN, CAPA, FASPAN
Manager Perioperative Services Mercy Hospital Portland, Maine
ASPAN Nurse Liaison for Special Projects
ASPAN Past President 2009–2010
Cherry Hill, New Jersey
Audrey E. Cook, MS, RN, CPAN, CAPA Perianesthesia
Children’s National Hospital Washington, District of Columbia
Amy Dempsey, MSN, BSN, RNC
Obstetrics Clinical Practice Specialist Women and Children’s Center
Assistant Dean for Simulation and Continuing Education College of Nursing and Health Professions
Drexel University
Philadelphia, Pennsylvania
ASPAN Past President 2002-2003
Cherry Hill, New Jersey
Pamela E. Windle, DNP, RN, NE-BC, CPAN, CAPA, FAAN, FASPAN
Perianesthesia Nurse Consultant
Nursing Program Manager
Harris Health System
Houston, Texas
ASPAN Past President 2006-2007
Cherry Hill, New Jersey
Vicki G. Yfantis, MSN, RN, CRNP, CPAN
President 2017–2020
American Board of Perianesthesia Nursing Certification, Inc.
New York, New York
Clinical Nurse Manager
Pre-Op, PACU, Pre-Surgical Testing
Suburban Hospital
Bethesda, Maryland
REVIEWERS
Sylvia J. Baker, MSN, RN, CPAN, FASPAN
Clinical Education Specialist
Mercy Health Rockford, Illinois
William Mark Enlow, DNP, NP, CRNA, DCC
Nurse Anesthetist
Department of Anesthesia Services Samaritan Medical Center Watertown, New York
Teresa Passig, BSN, RN, CPAN, CAPA, CCRN, CPHQ
Regulatory Consultant Orlando Health Orlando, Florida
Allan Schwartz, DDS, CRNA President Sedation Consult, LLC Columbia, Missouri
Associate Professor Department of Periodontics the Center for Advanced Dental Education St. Louis University St. Louis, Missouri
Sarah A. Sheets, MSN, CRNA Fort Collins, Colorado
The American Society of PeriAnesthesia Nurses (ASPAN) is pleased to offer the fourth edition of the PeriAnesthesia Nursing Core Curriculum. While professional practice and nursing knowledge are embedded in day-to-day practice, leadership in the development of care delivery models and constant collaboration in medicine have driven the need to update this essential text. This edition provides subject matter encompassed in the wide range of perianesthesia practice and has been created by clinical experts in perianesthesia nursing.
The core tenets in this curriculum are intended to provide guidance to cover the spectrum of perianesthesia nursing, from preoperative or preprocedural assessments and planning to day-of-surgery or procedure care, through Phase I, Phase II and Extended Levels of Care to include Enhanced Recovery After Surgery (ERAS). In addition, these concepts of practice are intended to offer guidance regardless of the location of that care. This includes the acute care setting, ambulatory or free-standing facilities, and office-based practices, to name a few. New topics are integrated throughout the text to reflect a growing body of evidence and to address emerging trends in care. New features in this edition include combining chapters and
streamlining content to create a more concise book. Education and discharge competences have been revised to address changes in ambulatory settings and patient discharge practices. Updated new content will include ERAS in multiple chapters, transgender care, Do Not Resuscitate/ Do Not Attempt Resuscitation/Do Not Intubate (DNR/ DNAR/DNI) and the impact of the latest technology on perianesthesia nurses.
ASPAN’s compelling vision is to be recognized as the leading organization for evidence-based perianesthesia nursing practice. The depth and value this edition will bring toward that goal is immense. As a core curriculum, it will provide guidance for nurses seeking certification, a map for creating unit-based competencies, a reference for clinical orientation of new staff and new perianesthesia nurses, and a resource for the fundamentals and standards of practice.
ASPAN offers this text as a comprehensive review for the assessment and care of patients of all ages presenting with a wide variety of medical findings, surgeries, and procedures in all phases and settings of perianesthesia care.
The American Society of PeriAnesthesia Nurses (ASPAN)
PREFACE
The specialty of perianesthesia nursing is performed in a variety of settings. Once practiced only in the “recovery room,” nurses now care for perioperative and postprocedure patients in an array of surroundings—hospital-based and freestanding. Perianesthesia nursing encompasses caring for patients during the preanesthesia level of care (preadmission and day of surgery/procedure), in postanesthesia levels of care (Phase I, Phase II and Extended Care), ambulatory care settings, extended observation settings, and special procedure areas (e.g., endoscopy, radiology, cardiovascular, oncology), obstetric units, pain management services, and physician or dental offices. Nurses caring for perianesthesia patients need to possess a variety of skills and expertise. Patients undergoing operative and invasive procedures come to the facility either as a planned event or as an emergency. Being able to assess the patient, develop an individualized plan of care, implement the plan, and evaluate the results requires proficiency in perianesthesia nursing based on safety and evidenced-based practices. This book is divided into the following sections to address competencies:
• Professional Competencies
• Preoperative Assessment Competencies
• Life Span Competencies
• Perianesthesia Competencies
• System Competencies
• Education and Discharge Competencies
This text is also a resource for nurses preparing to take either the Certified Post Anesthesia Nurse (CPAN) or the
Certified Ambulatory PeriAnesthesia Nurse (CAPA) certification examination. Certification in one’s specialty is a way to promote quality of care to the general public, the nursing profession, and the individual nurse. When a nurse achieves certification in his or her specialty, this demonstrates commitment to his or her nursing career, provides tremendous personal satisfaction, and provides opportunities for career advancement.
The text uses an outline format to delineate areas of perianesthesia nursing practice. The text is not designed to be a complete study guide. The nurse must identify his or her own areas of strength and weakness, seek out additional resources, and develop an individualized study plan that will meet his or her needs. This book can be utilized as:
• A study guide for nurses new to the perianesthesia setting
• Development of an orientation plan for the PACU
• Development of perianesthesia nursing competencies
• A reference guide for student nurses rotating through the PACU
The chapter authors are experts in their fields of practice, and many of them are certified in their specialties. The information presented in this text is as accurate and current as possible. Each chapter has been reviewed to ensure accuracy. The development of this core curriculum was sponsored by and supported by the American Society of PeriAnesthesia Nurses (ASPAN).
Lois Schick and Pamela E. Windle
ACKNOWLEDGMENTS
The fourth edition of the Core Curriculum has been updated by combining chapters of like subjects to reflect evidence-based practice. Revisions were made to the surgical specialties chapters to combine care concepts. In this edition, from inception to its final reality, we encountered numerous challenges but none so monumental that they could not be overcome. We wish to thank the previous authors and our current authors who contributed chapters, as well as the reviewers who provided insightful suggestions and recommendations for updating each chapter in this edition. The time, energy, and dedication the authors and reviewers contributed is a reflection of their devotion to our nursing specialty.
Our sincere appreciation goes to Laura Selkirk, Senior Content Development Specialist at Elsevier, for her dedication in assisting us and each chapter author with any desired changes in their manuscript. She was always there with encouragement and words of kindness, keeping us on track to get the project done on time and to print, which is greatly appreciated. We extend our gratitude to the numerous other members of Elsevier’s team and thank them for bringing this project to fruition and to Doug Turner for getting the final proofs ready in a timely manner.
We could not have accomplished the rewrite of this book without the opportunity provided by the American Society of PeriAnesthesia Nurses (ASPAN) to recognize the continued need for an updated evidenced-based core curriculum. This text will assist the perianesthesia nurse in enhancing his or her knowledge and skills in preparation for taking their certification examination(s) and for providing comprehensive care to patients and families.
I continue to appreciate all the support given to me over the years from my eleven older siblings and their families particularly sisters Jean Newton, Lavonne Hougen, Henry Schick, and nurse friend Roma Schweinefus, who have
always been there to encourage and support me in all my life endeavors and during my nursing career. Thank you to the ASPAN Board of Directors for the opportunity to coedit the fourth edition of the Core Curriculum. I am indebted to co-editor Pam Windle and to Laura Selkirk and Doug Turner at Elsevier for their expertise and support during this time of writing.
Lois Schick
To all perianesthesia nurses, especially to my former staff in the PACU, Day Surgery Center, CV Preop/PACU, Endoscopy departments and Surgical Observation Unit at CHI St. Luke’s Medical Center, Houston, Texas, who for the past 20 years have consistently shown commitment in their daily practices, shared their knowledge, and provided me with their expertise. Working with them has been a great privilege and an honor. And to all the perianesthesia staff at Harris Health System and to all the TAPAN members whom I’ve mentored throughout the years, thank you!
A special thanks to my husband David, for his patience throughout this endeavor, and for his support and understanding of my dedication and love of my career. To my 2 children, Cynthia and Michael, Jeremy and Natalia, my brothers Junior, Alan, Peter, and Philip, and my sisters Elsie, Jane, Tina, and Brenda, and especially to my loving parents, Mary and Lorenzo, for their continual support and encouragement. Thank you also to my best friend and mentor, Lois Schick, for her continued assistance as coeditor, to Laura Selkirk and Doug Turner at Elsevier, who are always there for us. Lastly, to ASPAN, thank you for this wonderful opportunity and to all the authors for your contributions to this book! Thank you all!
Pamela E. Windle
SECTION ONE
Professional Competencies
1 Evolution of Perianesthesia Care, 1
Jan Odom-Forren and Theresa L. Clifford
2 Standards, Legal Issues, and Practice Settings, 10
Barbara Godden
3 Safety, Quality Improvement, and Regulatory and Accrediting Agencies, 26
Dina A. Krenzischek
4 Research and Evidence-Based Practice, 40
Susan Fetzer
SECTION TWO Preoperative Assessment Competencies
5 Preoperative Evaluation, 51
Sarah Marie Independence Cartwright
6 Preexisting Medical Conditions, 70
Lois Schick
7 Transcultural Nursing and Alternative Therapies, 88
Myrna Eileen Mamaril
8 The Developmentally and Physically Challenged Patient, 113
Theresa L. Clifford
SECTION THREE Life Span Competencies
9 The Pediatric Patient, 138
Myrna Eileen Mamaril
10 The Adolescent Patient, 181
Pamela E. Windle and Lois Schick
11 The Adult Patient, 194
Lois Schick
12 The Geriatric Patient, 205
Pamela E. Windle and Myrna Eileen Mamaril
SECTION FOUR
13 Fluid, Electrolyte, and Acid-Base Balance, 220
Kim A. Noble
14 Anesthesia, Moderate Sedation/Analgesia, 238
Courtney Brown
15 Thermoregulation, 287
Vallire D. Hooper
16 Postoperative/Postdischarge Nausea and Vomiting, 301
Jan Odom-Forren
17 Pain and Comfort, 312
Linda Wilson and H. Lynn Kane
SECTION FIVE System Competencies
18 Respiratory, 333
Rex A. Marley
19 Cardiovascular, 387
Deborah Johnson-Sasso
20 Neurological, 446
Pamela E. Windle
21 Endocrine, 499
Matthew Byrne
22 Gastrointestinal, 517
Denise O’Brien
23 General Surgery, 537
Maria Liza Anicoche and Myrna Eileen Mamaril
24 Hematology, 566
Pamela E. Windle and Sohrab Alexander Sardual
25 Renal/Genitourinary, 580
Kim A. Noble
26 Obstetrics and Gynecology, 613
Amy Dempsey
27 Ophthalmology, 660
Seema S. Hussain
28 Oral/Maxillofacial/Dental, 675
Denise O’Brien
29 Orthopedics and Podiatry, 686
Shelly L. Cannon
30 Otorhinolaryngology, 723
Rae Marshall
31 Peripheral Vascular Disease, 744
Maureen Lisberger
32 Plastic and Reconstruction, 770
Theresa L. Clifford
33 Bariatrics, 795
Kim A. Noble
34 Trauma, 817
Myrna Eileen Mamaril
35 Interventional Radiology and Special Procedures, 833
Amy Dooley and Valerie Aarne Grossman
36 Perianesthesia Complications, 843
Lois Schick
SECTION SIX
Education and Discharge Competencies
37 Postoperative/Postprocedure Assessment, 859
Maureen Frances McLaughlin
38 Discharge Criteria, Education, and Postprocedure Care, 896
Audrey E. Cook
Appendix A: Certification of Perianesthesia Nurses: The CPAN and CAPA Certification Programs, 908 Krista Paternostro Bower and Vasso G. Yfantis
Appendix B: Testing Concepts and Strategies, 914
Nancy O’Malley
OBJECTIVES
At the conclusion of this chapter, the reader will be able to do the following:
1. Describe three of the earliest recovery rooms.
2. Name the decade when recovery rooms became commonplace.
3. Name the one historical event that contributed most to the advent of recovery rooms.
4. Name three advances in medical technology that led to an increase in ambulatory surgeries.
5. List three reasons for consumer acceptance of ambulatory surgery.
6. Describe the development of the American Society of PeriAnesthesia Nurses (ASPAN), formerly known as the American Society of Post Anesthesia Nurses.
7. Describe three benefits brought to perianesthesia nursing by ASPAN.
I. Early Beginnings
A. Early beginnings of recovery room and ambulatory surgery
1. Trephining of the skull and amputations identified in the year 3500 BC, as evidenced by cave drawings
2. New Castle Infirmary, New Castle, England (1751): rooms reserved for dangerously ill or major surgery patients
3. Florence Nightingale, London, England (1863): separate rooms for patients to recover from immediate effects of anesthesia
4. Ambulatory surgeries performed at Glasgow Royal Hospital for Sick Children in Scotland from 1898 to 1908
a. Surgeries were performed on 8988 children
b. Surgeries included orthopedic problems, cleft lip and cleft palate, spina bifida, skull fracture, hernias, and others
c. None of the children required hospital admission
CHAPTER 1
Evolution of Perianesthesia Care
Jan Odom-Forren and Theresa L. Clifford
5. Information from Glasgow Hospital presented at a meeting of the British Medical Association in 1909
6. Twentieth century
a. First general anesthesia in ambulatory surgery at Sioux City, Iowa, in 1918
b. 1920s and 1930s: complexity of surgeries increased
c. 1923: Johns Hopkins Hospital, Baltimore, Maryland, three-bed neurosurgical recovery unit opened by Dandy and Firor
d. World War II: recovery units created to provide adequate level of nursing care during nursing shortage
e. 1942: Mayo Clinic, Rochester, Minnesota
f. 1944: New York Hospital
g. 1945: Ochsner Clinic, New Orleans, Louisiana
h. 1940s and 1950s: early ambulation after surgery came into acceptance
B. Value of recovery room demonstrated in improving surgical care
1. Anesthesia Study Commission of the Philadelphia County Medical Society report (1947) stated that one-third of preventable postsurgical deaths during an 11-year period could have been eliminated by improved postoperative nursing care
2. The Operating Room Committee for New York Hospital (1949) stated that adequate recovery room service was necessary for any hospital that provided surgical services
II. Acceptance and Decline of Recovery Rooms
A. Impact of changing technology on patient care
1. 1950s: more knowledge of common postanesthesia complications
2. 1950s and 1960s: growth of surgical intensive care and postoperative respiratory support
3. Expanding complex surgical procedures
4. Expanding technology led to outpatient complex surgeries
a. Microscopic surgeries abounded
b. New lasers were developed (yttrium argon gas, argon, and carbon dioxide)
c. New laparoscopic instruments facilitated shorter, less-invasive laparoscopic procedures
d. More endoscopic procedures performed as outpatient procedures
e. Video equipment and computer-assisted surgeries now performed
f. Fiber optics led to advances in ophthalmic surgeries, most performed in outpatient settings
5. Change in anesthesia techniques and medications
6. 1970s: recovery rooms managed routine postanesthesia patients, including ambulatory, routine, and critically ill patients receiving respiratory and circulatory support
7. Many diagnostic procedures done in ambulatory settings
a. X-ray procedures
b. Laboratory tests
c. Physical therapy
d. Cardiopulmonary tests
e. Pain blocks
B. Recovery rooms lose viability and identity
1. Staffing: shortage of skilled personnel
2. No organized body of knowledge pertinent to postanesthesia
a. Staff performance evaluated on the basis of trial and error
b. No territorial restrictions: sometimes considered an extension of the operating room
c. No established standards of care
III. Ambulatory Surgery Focus
A. Ambulatory surgery programs established
1. The nation’s first ambulatory surgery program opened at Butterworth Hospital in Grand Rapids, Michigan, in 1961, and staff performed 879 ambulatory surgeries between 1963 and 1964
2. A formal ambulatory surgery program began at the University of California, Los Angeles in 1962
3. In 1968, the Dudley Street Ambulatory Surgery Center opened in Providence, Rhode Island
4. The nation’s first freestanding surgery facility was opened in 1970, by Dr. Wallace Reed and Dr. John Ford in Phoenix, Arizona
a. In 1971, the American Medical Association endorsed the use of surgicenters
b. In 1974, the Society for the Advancement of Freestanding Ambulatory Surgery was formed, which was the precursor for the current Federated Ambulatory Surgery Association (FASA)
5. The American Society for Outpatient Surgeons (now known as American Association of Ambulatory Surgery Centers) was formed in 1978, leading to surgery being performed in doctors’ offices
a. The 1980s brought a shortage of inpatient hospital beds
b. In 1980, the Omnibus Budget Reconciliation Act authorized reimbursement for outpatient surgery
c. In 1981, the American College of Surgeons (ACS) approved the concept of ambulatory surgery units (ASUs) as preadmission units for scheduled inpatients
d. In 1983, Porterfield and Franklin advocated for office outpatient surgery
e. The Society for Ambulatory Anesthesia was formed in 1984
B. The ambulatory surgery concept proliferated in the 1980s
1. Hospital-affiliated ambulatory surgery accounted for 9.8 million operations (45%) performed within hospital settings by 1987
2. By 1988, there were 984 Medicare-participating freestanding ambulatory surgery centers in the United States
3. By 1988, the 984 freestanding outpatient surgery centers performed more than 1.5 million surgical operations
4. The list of approved procedures that can be conducted in surgery centers was expanded in 1987, by the Health Care Financing Administration (HCFA), now known as the Centers for Medicare and Medicaid Services
5. In 1989, HCFA revised the payment schedule for outpatient surgeries performed on Medicare patients
C. Freestanding recovery sites
1. In 1979, the first freestanding recovery care center opened in Phoenix, Arizona
a. Patients were transported directly to the recovery care center from hospital postanesthesia care units (PACUs), from ASUs, and from physicians’ offices
b. Some patients were transferred there from hospitals on their second or third postoperative day
2. The limits of stay for recovery care centers are defined by each state regulation
3. In the 1980s, the concept of 23-hour units led to guest services being developed for patients living more than 1 hour away from the site where the surgery was to be performed (hospital hotels; medical motels)
a. Freestanding medical motels are considered a comfortable, affordable, and convenient place to recuperate
b. Patients are cared for by family members
Table 1.1
Characteristics of Ambulatory and Inpatient Surgeries.
CHARACTERISTICS
Adapted from Steiner CA, Karaca Z, Moore BJ, et al: Surgeries in hospital-based ambulatory surgery and hospital inpatient settings, 2014: Statistical brief #223, Agency for Healthcare Research and Quality, 2017, revised February 2018.
c. Home health nurses make visits, or a nurse is stationed onsite
4. Data from the National Center for Health Statistics Data Center, 1996
a. An estimated 31.5 million surgical and nonsurgical procedures were performed during 20.8 million ambulatory visits in 1996
b. An estimated 17.5 million (84%) of the ambulatory surgery visits were in hospitals, and 3.3 million (16%) were in freestanding centers in 1996
c. In 2000, 63% of all surgeries were performed in outpatient settings
5. In 2005, there were more than 4200 ambulatory surgery centers, which provided more than 12 million surgeries annually
6. Nearly 64% of all surgeries in the United States are performed in the ambulatory setting, including approximately 22 million surgeries (Table 1.1)
D. Economics of ambulatory surgery
1. Cost control, a primary force in the development of ambulatory surgery
a. In 1988, 58% of surgery centers contracted with health maintenance organizations, and 52% with preferred provider organizations
b. In 1990, the American Hospital Association reported that more than 50% of all hospitalbased surgical procedures were done on an outpatient basis
c. In the 1990s, 23 home observation units (recovery centers) were established in the United States
d. The percentage of outpatient procedures approved for payment under Medicare increased (1) In 1982, 450 procedures were approved (2) By the early 1990s, 2500 procedures were approved
(3) On July 1, 2003, 282 more approved procedures were added
e. Third-party payers require many surgeries to be performed in an ambulatory setting, to avoid the cost of hospitalization
f. Many freestanding centers have contractual arrangements with managed care plans, rehabilitation centers, and nursing homes
g. Outpatient facilities eliminate the costs of cafeteria, laundry, and the need for 24-hour staffing
h. Outpatient procedures eliminate unnecessary lab, x-ray, and electrocardiogram services
i. Patients recovering in 23-hour units are considered nonhospitalized for purposes of reimbursement by Medicare and third-party payers
E. Legislation encouraged growth of ambulatory centers
1. Relaxation of legislation began to occur in the 1980s
2. By 1987, the Omnibus Budget Reconciliation Act provided for less reimbursement to hospitals, providing rates equal to those for ambulatory surgery centers
3. The Omnibus Budget Reconciliation Act of 1989 again increased the reimbursement rates for assigned surgical procedures in ambulatory centers
4. Ambulatory centers became certified by accepted certifying agencies
F. Consumer acceptance of ambulatory surgery
1. Awareness
a. Increased marketing led to increased consumer awareness
b. Greater awareness led to greater demand for surgery in ambulatory settings
c. Consumers saw more physician involvement in ambulatory settings
d. Patient consumers felt more involved and took part in decisions
e. Few problems were seen with quality of care
2. Convenience
a. Flexible hours
b. Early admission and same-day discharge
c. Less time lost from work
d. Units easily accessible
3. Wellness philosophy well accepted
a. Patients could walk to the operating room
b. Patients could recover on stretchers or in recliners
c. Parents could remain with children during induction; parents and sometimes families could be present postoperatively
d. Patients were able to keep dentures, eyeglasses, and hearing aids with them
e. Patients felt more involved in decision making for their care
f. Family visitation encouraged in phase I PACUs
4. Reimbursement
a. Reimbursement provided by Medicare for outpatient procedures for the elderly made ambulatory surgery a viable alternative
b. Employers were paying less, and consumers found ambulatory settings less expensive, making outpatient surgery an attractive option
IV. Emergence of Organized Recovery Room Groups
A. The need to identify a special body of knowledge and skills required for practice
1. Groups form to develop educational opportunities
a. Nineteen groups were organized in the United States
b. The Florida Society of Anesthesiologists initiated a yearly seminar in 1969
(1) Attended by nurses from United States and Canada (2) Dr. Frank McKechnie: supporter of recovery room nurses
2. Series of seminars sponsored by American Society of Anesthesiologists (ASA) in the 1970s
a. Supported by solid attendance and strong interest from nurses in the specialty
b. Interest shown in development of recovery room nursing organization
B. Local and state organizations form a national group
1. Regional nursing representatives met with ASA Care Team to organize a national postanesthesia nurses’ association
2. Goals established
a. Education for postanesthesia nurses
b. Recognition of postanesthesia nursing as a specialty
3. 1979: steering committee formed
a. Selection of name: American Society of Post Anesthesia Nurses (ASPAN)
b. Preparation of bylaws
c. Incorporation
d. First ASPAN president: Ina Pipkin, RN, from Seattle, Washington
4. First meeting of board of directors held October 1980, in Orlando, Florida
5. April 1982: charter for component status granted to Alabama and Florida
V. First years (October 1980 to April 1982)
A. Financial development
1. ASA grant for legal expenses
2. Membership dues
B. Internal organization developed
1. Committees appointed
2. Newsletter, Breathline, begun in 1981
3. Membership increased
a. First national conference planned
b. Regional educational meetings held
VI. ASPAN Developments
A. Publications
1. 1981: Breathline (ASPAN’s newsletter)
2. 1983: Guidelines for Standards of Care
3. 1984: Post Anesthesia Nursing Review for Certification
4. 1986: Standards of Nursing Practice
5. 1986: Journal of Post Anesthesia Nursing (JoPAN)
6. 1986: Redi-Ref, ed 1
7. 1990: Fifty Years of Progress in Post Anesthesia Nursing 1940–1990
8. 1991: Standards of Post Anesthesia Nursing Practice
9. 1991: Core Curriculum for Post Anesthesia Nursing Practice, ed 2
10. 1992: Standards of Post Anesthesia Nursing Practice
11. 1992: ASPAN Resource Manual
12. 1993: Postanesthesia and Ambulatory Surgery Nursing Update (Saunders, publisher)
13. 1994: Pediatrics added to Redi-Ref
14. 1994: ASPAN Resource Manual published in collaboration with American Board of Post Anesthesia Nursing
15. 1994: Ambulatory Post Anesthesia Nursing Outline: Content for Certification
16. 1995: Core Curriculum for Post Anesthesia Nursing Practice, ed 3
17. 1995: Standards of Perianesthesia Nursing Practice
18. 1996: Certification Review for Perianesthesia Nursing
19. 1996: Research Primer
20. 1997: Competency Based Orientation and Credentialing Program, ed 1
21. 1998: Redi-Ref, ed 2
22. 1998: Standards of Perianesthesia Nursing Practice—new additions
a. Guidelines for preadmission phase (1) Preadmission
(2) Day of surgery/procedure
b. Guidelines for phase III (addresses ongoing care for those patients requiring extended observations/interventions after transfer/discharge from phase I or phase II)
c. 1998 Position statements approved:
(1) “Minimum Staffing in Phase I PACU”
(2) “Registered Nurse Use of Unlicensed Assistive Personnel”
(3) “Intensive Care Unit (ICU) Overflow Patients”
23. 1999: Core Curriculum for Ambulatory Perianesthesia Nursing Practice
24. 1999: Core Curriculum for Perianesthesia Nursing Practice, ed 4
25. 1999 Position statements
a. “Fast Tracking”
b. “Pain Management”
c. “On Call/Work Schedule”
26. 2000 Standards included a “Joint Position Statement on ICU Overflow Patients,” developed by ASPAN, American Association of Critical Care Nurses (AACN), and ASA’s Anesthesia Care Team Committee and Committee on Critical Care Medicine and Trauma Medicine
27. 2001: Competency Based Orientation and Credentialing Program for the Unlicensed Assistive Personnel in the Perianesthesia Setting, ed 1
28. 2002: Standards included position statement on the “Nursing Shortage”
29. 2003: Competency Based Orientation and Credentialing Program, ed 2
30. 2003: Prevention of Unplanned Perioperative Hypothermia Guidelines
31. 2003: Pain and Comfort Clinical Practice Guidelines and Resource Manual
32. 2003 Position Statements approved included:
a. “Medical/Surgical Overflow Patients in the PACU and Ambulatory Care Unit”
b. “Visitation in Phase I Level of Care”
c. “Smallpox Vaccination Programs”
33. 2003: Breathline approved for online access
34. 2004: Redi-Ref, ed 3
35. 2004: PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing, ed 1
36. August 2005: ASPAN’s Evidence-Based Practice Model introduced
37. 2006: Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV
38. 2006–2008 Standards of PeriAnesthesia Nursing Practice—new additions
a. “The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery”
b. Position statements approved:
(1) “Safe Medication Administration”
(2) “Cultural Diversity and Sensitivity in Perianesthesia Nursing Practice” (3) “Perianesthesia Safety”
39. December 2007: ASPAN’s Safety Model introduced, “Perianesthesia Nursing’s Essential Role in Safe Practice,” published in Journal of PeriAnesthesia Nursing (JoPAN)
40. 2007: Competency Based Orientation and Credentialing Program for the Unlicensed Assistive Personnel in the Perianesthesia Setting, ed 2
41. February 2008: ASPAN’s Perianesthesia Data Elements (PDE) Model introduced
42. 2008–2010 Standards of PeriAnesthesia Nursing Practice
a. “Smallpox Vaccination Program” position statement retired
b. Position statements approved: (1) “The Geriatric Patient” (2) “Advocacy”
43. 2009: A Competency Based Orientation and Credentialing Program for the Registered Nurse in the PeriAnesthesia Setting, ed 2
44. 2009: ASPAN PDE
45. 2009: ASPAN Safety Toolkit
46. 2009: Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia
47. 2009: Additional position statements
a. “The Pediatric Patient”
b. “The Workplace Violence”
48. 2009: “Go Green” initiatives
a. Breathline—only available online
b. ASPAN educational syllabus—only available online
49. 2010: ASPAN Bylaws and Representative Assembly Standard Procedures (updated version)
50. 2010: 2010 Redi-Ref for Perianesthesia Practices, ed 4
51. 2010–2012 ASPAN Standards
a. Name changes to include practice recommendations
b. Position statement approved: (1) “Substance Abuse in Perianesthesia Practice”
52. 2012–2014 ASPAN Standards
a. Format and name changed to include interpretive statements
b. Approved “Principles of Perianesthesia Safe Practice”
c. New Practice Recommendations: (1) “Obstructive Sleep Apnea in the Adult Patient”
53. 2013: Additional position statement
a. “Social Media and Perianesthesia Practice”
54. 2015–2017: ASPAN Standards
a. Additional practice recommendation: (1) “The Prevention of Unwanted Sedation in the Adult Patient”
b. Additional position statements:
(1) “Care of the Perinatal Patient”
(2) “Nurse of the Future: Minimum Bachelor of Science in Nursing (BSN) Requirement for Practice”
55. 2014: A Competency Based Orientation and Credentialing Program for the Registered Nurse in the PeriAnesthesia Setting, 2014 ed.
56. 2015: 2015 Redi-Ref for Perianesthesia Practices, ed 5
57. 2016: A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the PeriAnesthesia Setting, 2016 ed.
58. 2016: PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing, ed 3
59. 2017: A Competency Based Orientation and Credentialing Program for the Unlicensed Assistive Personnel in the PeriAnesthesia Setting, 2017 ed
60. 2017–2018: ASPAN Standards
a. Additional position statements:
(1) “Alarm Management”
(2) “Acuity Based Staffing for Phase I”
(3) “Air Quality and Occupational Hazard Exposure Prevention”
61. 2017: Certification Review for PeriAnesthesia Nursing, ed 4
62. 2019–2020: ASPAN Standards
a. Additional position statements:
(1) “Opioid Stewardship in Perianesthesia Practice”
1. 1985: American Board of Post Anesthesia Nursing Certification (ABPANC) established (see Appendix A)
2. Certification examination developed to recognize knowledge and skill of practitioners
3. November 1986: certification examination first administered, 172 nurses certified
4. Annual CPAN and CAPA recognition day at national conference
5. 1991: certification examination expanded to include ambulatory surgery nurses who work in preoperative and phase II areas
6. 1993–1994: separate certification examinations under development for phase I PACU nurses and ambulatory postanesthesia nurses—CPAN and CAPA designations
7. November 1994: CAPA examination first administered
8. 1996: name changed to American Board of PeriAnesthesia Nursing Certification (ABPANC)
9. 1998: 4191 CPANs, 1183 CPANs, and 100 with dual certification
10. 2003: 3921 CPANs, 1730 CPANs, and 202 with dual certification
11. 2006 Advocacy Award created to recognize publicly the CPAN and/or CAPA certified nurse who exemplifies leadership as a patient advocate
12. 2006 Shining Star Award created to recognize ASPAN components for supporting and encouraging certification at the local level
13. 2008: 5371 CPANs, 3210 CAPAs, and 297 with dual certification
14. 2008: the American Nurses Credentialing Center (ANCC) and the American Nurses Association (ANA) designated March 19 as National Certified Nurses Day
15. 2009: Computer-based testing for CPAN and CAPA underway
16. 2013: 6670 CPANs, 4302 CAPAs, and 494 with dual certification
17. 2014: 6958 CPANs, 4542 CAPAs, and 550 with dual certification
18. 2017–2018: 7439 CPANs, 5141 CAPAs, and 676 with dual certification
19. Spring 2019: 6977 CPANs, 4866 CAPAs, 808 with dual certification
C. Education
1. 1982: national conference and annual educational program started
2. Regional core curriculum workshops (2-day program available)
3. Regional ambulatory surgery workshops
4. Regional interpersonal and leadership skills workshops
5. ASPAN videotapes, overviews of postanesthesia nursing
6. 1993: national ASPAN Lecture Series established
7. 1993: joint ASPAN/Association of periOperative Registered Nurses (AORN) Ambulatory Surgery Symposium
8. 1994: cosponsored Governmental Affairs Workshop with American Association of Nurse Anesthetists (AANA), AORN, and the American Veterans Association of Nurse Anesthetists
9. September 1994: sponsored first Volunteer Leadership Institute in Richmond, Virginia
10. 1997: patient education videos on general anesthesia, conscious sedation, and regional anesthesia developed
11. Continuing education articles available in JoPAN
12. 1998: Consensus Conference for Perioperative Normothermia held in Bethesda, Maryland
13. 2001: Consensus Conference for Pain and Comfort held in Nashville, Tennessee
14. 2008: second consensus meeting for normothermia guidelines held in St. Louis, Missouri
15. 2011: on-demand programming initiated
D. Specialty representation
1. Member of National Federation for Specialty Nursing Organizations (NFSNO) since June 1983
a. 1990: Federation presidents invited for Nurses Day Luncheon given by Barbara Bush at the White House with ASPAN President attending
2. Member of National Organization Liaison Forum (NOLF)
3. Established official liaison with ASA
4. Official liaisons with following organizations
a. Society of Gastroenterology Nurses and Associates
b. Society of Critical Care Medicine
c. FASA
5. Increased networking with the following
a. AANA
b. AORN
c. AACN
6. 1992: organizational affiliate of ANA
7. 1994–1996: ASPAN elected to NFSNO Executive Board
8. 1994: ASPAN elected to NOLF Board
9. 1994: ASPAN represented at AORN Perioperative World Conference in Adelaide, Australia
10. Nursing Summit held in Chicago—a coalition of all nursing leadership to discuss Nursing’s Agenda for Healthcare Reform
11. September 2000: ASPAN started the first Component Development Institute, focusing on leadership, education, research, clinical practice, and advocacy
12. Fall 2002: ASPAN president represented at the 10th Congress of the Cuban Nursing Society and the first Colloquium on Natural and Traditional Medicine in Havana, Cuba
13. 2003: NOLF and NFSNO combine to form new organization of the Alliance: Nursing Organizations Alliance (NOA)
14. 2003: ASPAN begins partnership with the British Anaesthetic and Recovery Nurses Association (BARNA), and seven ASPAN delegates attended the BARNA Conference
15. 2004: ASPAN collaborates with the AANA, American Association of Surgical Physician Assistants, ACS, ASA, AORN, and the Association of Surgical Technologists to form the Council on Surgical and Perioperative Safety (CSPS), dedicated to promote a culture of patient safety and a caring perioperative workplace environment
16. July 2006: ASPAN represented at the Nursing Terminology Summit, Nashville, Tennessee
17. September 2006: ASPAN represented at the first summit of the newly formed Society for Perioperative Assessment and Quality Improvement
18. October 2006: ASPAN president is invited to attend the ACS in Chicago
19. October 2007: ASPAN president participated in the Irish Anaesthetic and Recovery Nurses Association Conference and began a partnership in Waterford, Ireland
20. October 2011: Inaugural International Conference for PeriAnesthesia Nurses held in Toronto, Canada
21. September 2013: International Conference for PeriAnesthesia Nurses held in Dublin, Ireland
22. September 2015: International Collaboration of PeriAnaesthesia Nurses held in Copenhagen, Denmark
23. November 2017: International Collaboration of PeriAnaesthesia Nurses held in Sydney, Australia
24. November 2019: International Collaboration of PeriAnaesthesia Nurses held in Cancun, Mexico
E. Other highlights
1. 1983: members encouraged to change name from recovery room to PACU
2. 1989: postanesthesia nurse awareness week established
3. 1989: definition of immediate postanesthesia nursing expanded to include preoperative and phase II areas to incorporate ambulatory nurses working in those areas
4. 1989: presidential award established
5. 1989: AACN formally recognized postanesthesia nursing as a critical care specialty
6. 1991: clinical excellence and outstanding achievement awards established
7. 1991: ASPAN becomes an ANA approver and provider of continuing education
8. 1992–1993: research committee offers grants and conducts the first Delphi study to establish postanesthesia and ambulatory surgery nursing priorities
9. 1993: ASPAN Foundation established with first board of trustees
10. 1993: organizational task force appointed to look at size and structure of ASPAN Board, dues structure, and membership voting
11. 1994: approved concept of specialty practice groups
12. 1994: Ontario, Canada, becomes ASPAN’s first affiliate member
13. 1994: online communication by means of the internet, between officers and national office
14. 1995: change of ASPAN’s name to American Society of PeriAnesthesia Nurses approved, effective July 1, 1996
15. 1995: funds for first scholarship awards donated by the ASPAN Foundation
16. 1996: one dues structure initiated (one payment includes national and component membership)
17. 1996: ASPAN website created (www.aspan.org)
18. 1996: Journal of Post Anesthesia Nursing name changed to Journal of PeriAnesthesia Nursing
19. April 10, 1997: newly structured board of directors met for first time in Denver, Colorado, after the ASPAN Conference
20. 1997: ASPAN Foundation receives seat, and ASPAN member attends AANA Foundation Research Scholars Program
21. April 21, 1998: first meeting of the ASPAN Representative Assembly at National Conference in Philadelphia
22. 2006–2007: ASPAN Safe Staffing Group conducted a multidisciplinary meeting and developed an ASPAN Fatigue Checklist as a guide for members
23. 2007: ASPAN Research Committee conducted the second Delphi study for ASPAN members’ research priorities
24. 2009: ASPAN joined social media with a Facebook page, Twitter, LinkedIn, and Pinterest
25. 2013: ASPAN introduces Standards to digital libraries
26. 2018: Established the Fellows of the American Society of PeriAnesthesia Nurses (FASPAN) program with 17 inaugural inductees
27. Membership highlights
a. 1998: ASPAN membership is more than 10,000 with 40 components
36. Katrina Bickerstaff, 2017; Energizing Generations: The Race to Distinction!
37. Susan Russell, 2018; Detecting Greatness: The Proof is in Our Practice
38. Regina Hoefner-Notz, 2019; Leading With Knowledge; Serving With Heart
39. Amy Dooley, 2020. Celebrate Strengths, Elevate Practice
Bibliography
American Society of Post Anesthesia Nurses: Fifty years of progress in post anesthesia nursing 1940–1990, Richmond, 1990, The Society.
American Society of Post Anesthesia Nurses: ASPAN resource manual, Richmond, 1992, The Society.
Barone CP, Pablo CS, Barone GW: A history of the PACU, J Perianesth Nurs 19(4):237–241, 2003.
Bendixen H, Kinney J: History of intensive care: American College of Surgeons. In Kinney JM, Bendixen HH, Powers Jr SR, editors: Manual of surgical intensive care, Philadelphia, 1977, WB Saunders, pp 3–35.
Burden N: Outpatient surgery: a view through history, J Perianesth Nurs 20(6):435–437, 2005.
Dunn F, Shupp M: The recovery room: a wartime economy, Am J Nurs 43(3):279–281, 1943.
Feeley TW, Macario A: The postanesthesia care unit. In ed 6, Miller R, editor: Anesthesia. New York, 2004, Churchill Livingstone.
Fetzer SJ: Practice characteristics of the dual certificant: CPAN/ CAPA, J Perianesth Nurs 12(4):240–244, 1997.
Frost E, editor: Post anesthesia care unit: current practices, ed 2, St. Louis, 1990, Mosby.
Krenzischek D, Clifford TL, Windle PE, et al.: Patient safety: perianesthesia nursing’s essential role in safe practice, J Perianesth Nurs 22(6):385–392, 2007.
Litwack K: Post anesthesia care nursing, ed 2, St. Louis, 1995, Mosby.
Luczun ME: Postanesthesia nursing: past, present, and future, J Post Anesth Nurs 5(4):282–285, 1990.
Mamaril ME, Ross JM, Krenzischek D, et al.: The ASPAN’s EBP conceptual model: framework for perianesthesia practice and research, J Perianesth Nurs 21(3):157–167, 2006.
Niebuhr BH, Muenzen P: Foundation for newly revised CPAN and CAPA certification examinations, J Perianesth Nurs 16(3):163–173, 2001.
Odom-Forren J: Drain’s Perianesthesia Nursing: a critical care approach, ed 7, St. Louis, 2018, Elsevier.
Russo A, Elixhauser A, Steiner C, Wier L: Hospital-based ambulatory surgery, 2007. Washington, DC, 2010, Agency for Healthcare Research and Quality.
Ruth H, Haugen F, Grove DD: Anesthesia study commission, J Am Med Assoc 135(14):881–884, 1947.
Schneider M: Trends in postanesthesia nursing, J Post Anesth Nurs 2(3):183–188, 1987.
Wetchler BV: Anesthesia for ambulatory surgery, ed 2, Philadelphia, 1990, Lippincott.
CHAPTER 2
Standards, Legal Issues, and Practice Settings
Barbara Godden
OBJECTIVES
At the conclusion of this chapter, the reader will be able to do the following:
1. Describe the importance of standards as they relate to perianesthesia nursing practice.
2. Discuss the contents of the American Society of PeriAnesthesia Nurses (ASPAN) Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.
3. Define the scope of practice for perianesthesia nursing.
4. Describe the preanesthesia phase of care.
5. Explain the three phases of postanesthesia care.
6. List three inpatient and three outpatient settings where perianesthesia nursing care is delivered.
7. Define competency-based practice.
8. Identify important ethical principles.
9. List the steps for ethical decision making.
10. Identify five common causes of nursing liability.
11. Describe the four elements of negligence.
12. Discuss phases of litigation that can occur with a malpractice suit.
13. Differentiate between a policy and a procedure.
14. Name three agencies or organizations that influence perianesthesia policies and procedures.
15. Identify policies and procedures that define practice in perianesthesia nursing settings.
I. Definition of Standard
A. Established by authority, custom, or general consent
B. Model for quality or quantity
C. Standardized for everyone
D. Determined by what a reasonably prudent nurse acting under the same circumstance would do
E. Describes the responsibilities for which the nursing profession is accountable
F. Provides direction for professional nursing practice
G. Framework for the evaluation of care
H. Minimal requirements that define an acceptable level of care
II. Evolution of Nursing Standards
A. Before 1950
1. Florence Nightingale
2. Her early treatments were used as standards
B. Code of Ethics published by the American Nurses Association (ANA) in 1950
1. Nursing care without prejudice
2. Confidential care
3. Safe care
C. Standards of professional nursing practice
1. Pertain to general or specialty practice
2. First generic nursing standards in 1973 by the ANA Congress for Nursing Practice
3. Specialty standards followed beginning in 1974
III. Sources of Standards
A. Accrediting organizations
2. The Joint Commission (TJC)
1. Centers for Medicare and Medicaid Services (CMS)
3. Healthcare Facilities Accreditation Program (HFAP)
4. Det Norske Veritas (DNV)
5. Center for Improvement in Healthcare Quality (CIHQ)
6. National Committee for Quality Assurance (NCQA)
7. Accreditation Association for Ambulatory Health Care (AAAHC)
8. American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF)
B. State Nurse Practice Act and Board of Nursing Rules
C. Federal agency guidelines and regulations
1. Agency for Healthcare Research and Quality (AHRQ)
2. Occupational Safety and Health Administration (OSHA)
D. American Nurses Association (ANA)
1. Magnet Environments for Professional Nursing Practice
E. ASPAN or other national specialty organizations
F. Hospital or ambulatory surgery facility rules and procedures
G. State Board of Nursing
H. Nursing texts and articles
I. Common practice
J. Determined by expert witnesses for judicial system
1. Essential in professional negligence cases
IV. Standard Criteria
A. Standard: authoritative statement articulated and disseminated by the profession by which the quality of practice, service, or education can be judged
B. Rationale: delineates the importance to perianesthesia practice
C. Outcome: measures the results of activity (per TJC, care should meet the same standards of practice wherever the care is provided)
D. Criteria: describes principles and actual activities used in implementing practices to meet the standard
V. ANA Standards of Nursing Practice
A. Original standards published in 1973—updated as changes in practice occur
B. Applies to all registered nurses (RNs) in clinical practice
C. Standards of practice: describe a competent level of nursing care
1. Assessment: collect pertinent patient health information
2. Diagnosis: analyze assessment data to determine nursing diagnosis
4. Planning: develop a plan of care specific for the patient
5. Implementation: implement the identified plan
6. Evaluation: evaluate progress toward outcomes
D. Standards of professional performance: describe a competent level of behavior in the professional role
1. Quality of practice: enhances quality and effectiveness of nursing practice
2. Education: acquires knowledge and competency related to current practice
3. Professional practice evaluation: evaluates one’s own nursing practice
4. Collegiality: interacts with professional peers and colleagues
5. Collaboration: collaborates with patient, family, and others
6. Ethics: integrates ethics into all aspects of performance
7. Research: integrates and disseminates research findings into practice
8. Resource utilization: considers factors related to safety, effectiveness, cost, and impact on practice
9. Leadership: provides leadership in the practice setting
VI. Agency for Healthcare Research and Quality (AHRQ)
A. Established in 1989
B. Goals to enhance the quality, appropriateness, and effectiveness of health care and to ensure efficient implementation and evaluation
C. Standard of practice: patients will receive care according to the standard
D. Guideline: to guide practitioners, patients, and consumers in health care decisions
E. First guidelines in 1992: Acute Pain Management goals:
1. Reduce the incidence and severity of patients’ acute postoperative or post-traumatic pain
2. Educate patients about the need to communicate unrelieved pain
3. Implement proactive and multimodal interventions
4. Enhance patient comfort and satisfaction
5. Contribute to fewer postoperative complications and shorter lengths of stay
VII. 2019–2020 Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements
A. ASPAN history of standards (see Chapter 1 for additional information)
1. 1983: Guidelines for Standards of Care published
2. 1986: Standards of Nursing Practice published
3. 1989: definition expanded to include preoperative and phase II areas
4. 1991: Standards of Post Anesthesia Nursing Practice published; included data for initial, ongoing, and discharge assessment for phase I and phase II
5. 1992: Standards of Post Anesthesia Nursing Practice published
6. 1995: Standards of Perianesthesia Nursing Practice published; included preanesthesia, preprocedural, phase I and phase II postanesthesia information
7. 1998: Standards of Perianesthesia Nursing Practice, revised; included the addition of postanesthesia phase III for patients requiring extended observation
8. 2000–2010: Standards of Perianesthesia Nursing Practice, revised every 2 years
9. 2010–2012: Perianesthesia Nursing Standards and Practice Recommendations; some resources changed to be entitled Practice Recommendations
10. 2012–2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements; Interpretive statements added for frequently asked questions
11. 2015–2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, revised and updated
12. 2017–2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, revised and updated
13. 2019–2020 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, revised and updated
B. Scope of perianesthesia nursing practice
1. Cultural, developmental, and age-specific assessment, diagnosis, intervention, and evaluation of individuals within the perianesthesia continuum
2. Nursing practice is systematic, integrative, and holistic and includes:
a. Nursing process
b. Critical thinking
c. Clinical decision making
d. Inquiry
3. The scope of practice includes, but is not limited to, the following:
a. Preanesthesia level of care
(1) Preadmission
(2) Day of surgery/procedure
b. Postanesthesia levels of care
(1) Phase I
(2) Phase II
(3) Extended care
C. Perianesthesia nursing practice occurs in, but may not be limited to, the following environments:
1. Hospital settings (inpatients and outpatients)
a. Preadmission assessment/testing unit
b. Preoperative/preprocedural holding area
c. Postanesthesia care unit
d. Same-day surgery units
e. Extended observation
f. Obstetrical units
g. Emergency department
h. Special procedure areas
(1) Interventional and diagnostic radiology
(2) Endoscopy/gastrointestinal (GI) procedures
(3) Cardiac catheterization lab
(4) Electroconvulsive therapy (ECT)
(5) Pain management clinic
(6) Oncology
2. Outpatient settings
a. Ambulatory surgery unit
(1) Hospital based
(2) Free-standing center
b. Areas where procedural sedation/analgesia is required
(1) Interventional and diagnostic radiology
(2) Endoscopy/GI procedures
(3) Cardiac catheterization
(4) ECT
(5) Pain management clinic
(6) Oncology
(7) Urgent care centers
c. Office-based settings
(1) Dental
(2) Dermatology
(3) Ophthalmology
(4) Plastic surgery
D. Perianesthesia nursing encompasses the following continuum of care:
1. Preanesthesia phase
a. Preadmission: preparation, interviewing, assessment, identification of potential or actual problems, and education
b. Day of surgery/procedure: assessment, validation of existing information; coordination of care (sometimes patients need radiology procedure before going to the OR), preparation and completion of required documents, reinforcement of preoperative teaching, and review of discharge instructions
3. Postanesthesia phase II: prepare the patient/significant other for home or extended care environment, discharge teaching
4. Extended care (formerly phase III): provide ongoing care for patients requiring extended observation/ intervention after discharge from phase I or phase II
5. Care of the patient and family/significant other along the perianesthesia continuum
a. Physical
b. Psychological
c. Educational
d. Cultural
e. Spiritual
E. Perianesthesia nursing practice is based on knowledge of:
1. Physiological and psychological responses
2. Vulnerability of patients subjected to the following:
a. Sedation/analgesia
b. Anesthetic agents and techniques
c. Specific surgical or procedural interventions
3. Principles of age-specific medical-surgical nursing and critical care nursing
4. Evidence-based practice (EBP)
F. Perianesthesia nursing roles encompass:
1. Clinical practice
2. Education
3. Research
4. Management
5. Administration
6. Consultation
7. Advocacy
G. The scope of perianesthesia nursing practice is regulated by:
1. Hospital or facility policies and procedures
2. State and federal regulatory agencies
3. National accreditation organizations
4. Professional nursing organizations
H. Perianesthesia nursing interacts with other professional groups to advance the delivery of quality care. These groups include, but may not be limited to, the following:
1. Alliance for Nursing Informatics (ANI)
2. Ambulatory Surgery Center Association (ASCA)
3. American Academy of Ambulatory Care Nursing (AAACN)
4. American Academy of Anesthesiologists Assistants (AAAA)
5. American Association of Colleges of Nursing (AACN)
6. American Association of Critical Care Nurses (AACN)
7. American Association of Neuroscience Nurses (AANN)
8. American Association of Nurse Anesthetists (AANA)
9. American Association of Nurse Practitioners (AANP)
10. American Board of PeriAnesthesia Nursing Certification (ABPANC)
11. American College of Surgeons—John A, Hartford Foundation (ACS-JAHF) Geriatric Program
12. American College of Surgeons (ACS)
13. American Medical Informatics Association (AMIA)
14. American Nurses Association (ANA)
15. American Nursing Informatics Association (ANIA)
16. American Organization of Nurse Executives (AONE)
17. American Society for Pain Management Nursing (ASPMN)
18. American Society of Anesthesiologists (ASA)
19. American Society of Plastic Surgical Nurses (ASPSN)
20. Americans for Nursing Shortage Relief (ANSR)
21. Anesthesia Patient Safety Foundation (APSF)
22. Association for Radiologic & Imaging Nursing (ARIN)
23. Association for Vascular Access (AVA)
24. Association of Anesthesia Clinical Directors (AACD)
25. Association of periOperative Registered Nurses (AORN)
26. Association of Women’s Health, Obstetric and Neonatal Nurses ((AWHONN)
27. British Anaesthetic and Recovery Nurses Association (BARNA)
28. Council on Surgical and Perioperative Safety (CSPS)
29. Enhanced Recovery After Surgery (ERAS)
30. International Collaboration of PeriAnaesthesia Nurses (ICPAN)
31. Irish Anaesthetic and Recovery Nurses Association (IARNA)
32. National Association of Clinical Nurse Specialists (NACNS)
33. National Association of PeriAnesthesia Nurses of Canada (NAPANc)
34. National League for Nursing (NLN)
35. Nursing Community Forum
36. Nursing Organizations Alliance (NOA)
37. Pain Action Alliance to Implement a National Strategy (PAINS)
38. Society for Ambulatory Anesthesia (SAMBA)
39. Society for Office Based Anesthesia (SOBA)
40. Society for Perioperative Assessment and Quality Improvement (SPAQI)
41. Society of Anesthesia and Sleep Medicine (SASM)
42. Society of Gastroenterology Nurses and Associates (SGNA)
43. Society of Pediatric Nurses (SPN)
44. Surgical Pain Consortium (SPC)
45. The Joint Commission (TJC)
I. Perianesthesia Principles for Ethical Practice
1. Specific context in which to apply the ANA Code of Ethics
2. Moral commitment to uphold values and ethical obligations related to perianesthesia nursing
3. Strive to ensure:
a. Competency
(1) Maintains personal accountability
(2) Participates in professional continuing education
(3) Adheres to ASPAN’s standards
(4) Complies with institutional policies and procedures
