Ambulatory Surgical Care

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Ambulatory Surgical Care, 3rd Edition

Angela Kramer, MBA, RN, CNOR, CASC, CPPS
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Ambulatory Surgical Care
3rd Edition
By
Angela Kramer, MBA, RN, CNOR, CASC, CPPS
Upon successful completion of this course, continuing education hours

will be awarded as follows:
Nurses: 20 Contact Hours*
*Western Schools is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s Commission
on Accreditation.
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ABOUT THE 3RD EDITION AUTHOR
Angela Kramer, MBA, RN, CNOR, CASC, CPPS, is the director of ambulatory
surgery for BayCare Health System in the Tampa Bay area of Florida. She earned
three board certifications through the Competency and Credentialing Institute, the
Board of Ambulatory Surgery Certification, and the Certification Board for
Professionals in Patient Safety. She is a certified nurse in the operating room, a
certified surgery center administrator, and a certified professional in patient safety.
Mrs. Kramer holds a Master of Business Administration degree with a concentration
in healthcare management. She is a member of the Florida Society of Ambulatory
Surgery Centers and sits on the association’s committee for education. She is also
a member of the National Patient Safety Foundation and the Ambulatory Surgery
Center Association.
Angela Kramer has disclosed that she has no significant financial or other
conflicts of interest pertaining to this course book.
ABOUT THE 1ST AND 2ND EDITION AUTHOR
Nance A. Seiple, RN, CRNA, MEd, is an independent medical communications

consultant based in suburban Chicago. A former nurse anesthesiology program
director and staff member of the American Association of Nurse Anesthetists
(AANA), she has extensive experience in the development and implementation of
educational programs. Ms. Seiple received her MEd from the College of Education,
Lehigh University. A member of the American Medical Writers Association and the
National Association of Science Writers™, her diverse publications include
Sedation and Analgesia for Outpatient Surgery and MRS to Treat Malignant
Tumors.
Nance A. Seiple has disclosed that she has no significant financial or

other conflicts of interest pertaining to this course book.
ABOUT THE PEER REVIEWER
Linnea Stewart, RN, BSN, has been working as a registered nurse in the
operating room (OR) for 15 years. She started in a hospital OR as most circulators
do but found her passion in nursing was in ambulatory surgery. Ms. Stewart has
performed every clinical role in the perioperative setting. For the past 6 years, she
has served as the perioperative nurse manager for two different ambulatory surgery
centers (ASCs). Before that position, she was a quality coordinator and a charge
nurse. Ms. Stewart recently relocated to Tennessee from Florida with her family and
is enjoying being a wife, mother, and PRN OR nurse at a local ASC in her spare
time.
Linnea Stewart has disclosed that she has no significant financial or other
conflicts of interest pertaining to this course book.
Nurse Planner: Patricia Hojnowski-Diaz, MS, MBA, RN
The planner who worked on this continuing education activity has

disclosed that she has no significant financial or other conflicts of interest
pertaining to this course book.
Copy Editor: Graphic World, Inc.

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Indexer: Dianne L. Schneider

Western Schools’ courses are designed to provide healthcare professionals with
the educational information they need to enhance their career development as well
as to work collaboratively on improving patient care. The information provided
within these course materials is the result of research and consultation with
prominent healthcare authorities and is, to the best of our knowledge, current and
accurate at the time of printing. However, course materials are provided with the
understanding that Western Schools is not engaged in offering legal, medical or
other professional advice.
Western Schools’ courses and course materials are not meant to act as a substitute
for seeking professional advice or conducting individual research. When the
information provided in course materials is applied to individual cases, all
recommendations must be considered in light of each case’s unique circumstances.
Western Schools’ course materials are intended solely for your use and not for the
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absolves itself of any responsibility for adverse consequences resulting from the
failure to seek medical, or other professional advice. Western Schools further
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Products (including brand names) mentioned or pictured in Western Schools’
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COPYRIGHT© 2017—S.C. Publishing. All Rights Reserved. No part(s)

of this material may be reprinted, reproduced, transmitted, stored in a
retrieval system, or otherwise utilized, in any form or by any means
electronic or mechanical, including photocopying or recording, now
existing or hereinafter invented, nor may any part of this course be used
for teaching without written permission from the publisher.
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PRETEST
Begin this course by completing the pretest. Compare your answers to

the answer key at the end of the pretest. Make note of the questions you
missed so that you can focus on those areas as you proceed to read the
entire course. To review the pretest questions you answered incorrectly,
you may also use your ebook reader’s search function to search the text
for a word or phrase from the correct answer (a, b, c, or d).
Note: Choose the one option that BEST answers each question.
1. What is one advantage of ambulatory surgery centers?

a. They offer a cost savings of 50% to 60%.
b. Transfer to the hospital for admission is common and acceptable.
c. They provide emergency surgery.
d. They are located in physicians’ offices.
2. During the preadmission interview, the ambulatory nurse learns the patient has
well-controlled diabetes mellitus and is a social drinker. Based on this
information, the nurse knows the patient most likely will be classified in the
American Society of Anesthesiologists’ (ASAs’) physical status classification as
a. ASA I.
b. ASA III.
c. ASA II.
d. ASA IV.
3. According to the Centers for Medicare and Medicaid Services (CMS), when
must the patient’s history and physical examination be updated by the physician
in the event of ambulatory surgery?
a. No more than 1 week before the day of surgery
b. On the day of surgery, before transfer to the operating or procedure room
c. No update is required if the history and physical were completed within the
last 30 days before the day of surgery.
d. Before the patient is scheduled for surgery
4. The preoperative nurse completes a deep vein thrombosis (DVT) assessment

on a 20-year-old, female patient scheduled for a 30-minute procedure under
general anesthesia. Upon review of the patient’s medical record the nurse notes
the patient does not take any prescription medications and has a history of three
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episodes of pharyngitis in the last year. The patient informs the nurse she is not
a smoker and does not have children. Based on this information, the nurse
knows the patient’s risk for DVT is
a. high.
b. going to require more information.
c. mid-range.
d. low.
5. Procedural sedation is defined as

a. a state of minimally depressed consciousness wherein the patient
independently maintains airway control and responds appropriately to
physical stimulation and verbal commands.
b. a state wherein the patient is unable to maintain control of the airway or
respond purposefully to external stimulation.
c. a loss of sensation in a particular area of the body.
d. an injection of a local anesthetic into the skin and subcutaneous tissue in
the area of the operative site.
6. During administration of a local anesthetic, the nurse suspects local anesthetic

systemic toxicity because the patient complains of
a. ringing in the ears, a metallic taste, and numbness around the mouth.
b. loss of sensation at the site of injection.
c. joint pain.
d. increased heart rate.
7. According to The Joint Commission (TJC), in what instance is site marking

required?
a. In cases in which bilateral structures will be extracted
b. Whenever the surgeon deems it necessary
c. When there is more than one possible body location for a procedure
d. Only when a right or left limb will be involved
8. The postanesthesia care unit (PACU) nurse receives a patient who is at risk for
hypertension What should the nurse do to keep this patient safe and optimize
this patient’s outcome?
a. Monitor the patient’s blood pressure every 5 minutes and obtain an order
from the physician for medication to control hypertension if needed.
b. Monitor the patient’s blood pressure every 60 minutes and obtain an order
for an IV fluid bolus.
c. Monitor the patient’s blood sugar and prepare to administer insulin.
d. Monitor the patient’s respiratory rate and depth every 30 minutes and turn
off the monitor alarms.
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9. Which of the following would qualify a postoperative patient to transition from

phase I of recovery to phase II of recovery?
a. The patient does not respond to verbal commands.
b. The patient cannot swallow.
c. There is significant bleeding at the surgical site.
d. There is no airway obstruction.
10. Thirty minutes after intravenous administration of an antibiotic, the patient

presents with urticaria, hypotension, bronchospasm, and nausea. The nurse
knows these symptoms are consistent with which of the following diagnoses?
a. Anaphylaxis
b. Malignant hyperthermia
c. Pulmonary embolism
d. Myocardial infarction
11. During a communication assessment, the patient states she speaks French to
her family but is also able to speak some English. What does the nurse do
next?
a. Arrange for a professional medical interpreter
b. Ask the patient which language she prefers to use during the
preadmission interview and during the ambulatory surgery visit
c. Cancel the case because no one on the ambulatory surgery team speaks
French
d. Ask the patient to bring a friend or family member to translate on the day
of surgery
12. The Centers for Medicare and Medicaid Services is involved in health care in
which of the following ways?
a. It is the largest payer, the principal regulator, and acts as a patient
advocate.
b. It offers high-interest loans to patients.
c. It manufactures medical devices and pharmaceuticals.
d. It operates medical schools and educates physicians who want to teach.
13. All of the following actions decrease patient safety in ambulatory surgery
organizations except
a. increasing communication and standardization in the operating room.
b. refraining from sharing information about sentinel events.
c. ensuring only members of the leadership team participate in safety
initiatives.
d. conducting root cause analyses that lead to placing blame on one person
or one group of people.
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14. Which of the following principles are employed to keep radiation exposure as
low as reasonable achievable (ALARA) during procedures that require use of
radiological technologies?
a. Time, distance, and shielding
b. Depth and positioning
c. Skin preparation and draping
d. Equipment management and hospital support
15. An ambulatory surgery nurse interested in a leadership role can serve in which
of the following leadership roles?
a. Chief of general surgery
b. Quality Assurance and Performance Improvement coordinator
c. Medical director
d. Chief of anesthesiology
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PRETEST KEY
1. A Chapter 1
2. C Chapter 2
3. B Chapter 3
4. D Chapter 3
5. A Chapter 4
6. A Chapter 6
7. C Chapter 7
8. A Chapter 8
9. D Chapter 9
10. A Chapter 10
11. B Chapter 11
12. A Chapter 12
13. A Chapter 13
14. A Chapter 14
15. B Chapter 15
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INTRODUCTION
COURSE OBJECTIVES
After completing this course, the learner will be able to:
1. Discuss the emergence, advantages, and challenges of ambulatory

surgical care.
2. Describe the process implemented to assess patients before admission to
ensure appropriateness for the ambulatory surgery setting.
3. Identify preoperative patient assessment requirements performed by

physicians, anesthesia providers, and nurses.
4. Recognize the various anesthetic agents and techniques used in the

ambulatory setting, and explain how to ensure proper intraoperative
patient care related to patient safety and advocacy, including widely
accepted infection prevention techniques and safety protocols.
5. Discuss common interventions used during postprocedure care to
promote patient comfort and safety.
6. Identify the various aspects of nursing care needed for the safe transition
of the patient from the immediate postoperative recovery phase to
discharge from the facility.
7. Recognize serious complications and emergencies that may occur during
ambulatory surgery and anesthesia.
8. Identify unique considerations relative to pediatric, geriatric, and special

needs populations in the ambulatory surgical setting.
9. Identify influential ambulatory surgery regulatory agencies and

professional associations, and articulate their purposes.
10. Explain how risk management, patient safety, quality assessment, and
performance improvement are integral parts of ambulatory surgical
nursing care.
11. Explain ancillary support services, special procedures, and the use of
special equipment in ambulatory surgery organizations.
12. Explain ambulatory surgery leadership and governance, including its
structure and common committees.
A
mbulatory surgery, also known as outpatient, same-day, or 1-day surgery,
exists for the purpose of providing surgical services to patients not requiring
inpatient hospitalization and in which the expected duration of services
would not exceed 24 hours following an admission. It is cost effective for the
patient, third-party payers, and government agencies. The patient is spared the
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stress and time commitment of hospitalization, usually benefits from a more rapid
recovery period, and has a reduced risk of acquiring a hospital-related infection.
Hospital outpatient departments, free-standing ambulatory surgery centers, and
office-based surgery suites have grown in volume exponentially since the 1970s as
a result of technological advances in surgery, anesthesia, and medications;
expansion of managed care, including Medicare and Medicaid; and patient and
physician acceptance. This growth presents opportunities and challenges for
healthcare clinicians and providers practicing in this demanding environment.
Ambulatory surgery staff members work as a team with the patient’s physician
and the patient to provide safe, efficient, and streamlined care. Ambulatory surgery
offers an evidence-based approach to perioperative care while maximizing
convenience and safety. Although emergencies rarely occur in the ambulatory
environment, preparation for these events is continuous. Federal and state
regulations prompt ambulatory surgery teams to consistently focus on quality
assurance, performance improvement, and risk management in an effort to ensure
reliable patient safety.
The intent of this course is to provide the learner with information focused on
the unique specialty of ambulatory surgical care. Ambulatory surgery is an exciting
area of practice that offers clinicians variety and growth opportunities. Although this
course will assist nurses who are new to ambulatory surgical care or considering
entering ambulatory surgical care, it will also provide up-to-date information
relevant to the skills and practices of nurses already working in the ambulatory
setting.
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CHAPTER 1
OVERVIEW OF AMBULATORY
SURGERY
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to discuss the
emergence, advantages, and challenges of ambulatory surgical care.
CHAPTER OBJECTIVES
A
fter completing this chapter, the learner will be able to:
1. Summarize the history and evolution of ambulatory surgery.

2. Differentiate between the types of ambulatory surgery facilities and list their
advantages and challenges.
3. Discuss the various roles found in the ambulatory surgery setting.

4. Examine the areas of inventory management and revenue cycle and list
ways nurses may be involved.
5. Explain financial considerations that play a factor in the ambulatory surgery
environment.
6. Identify trends expected to influence ambulatory surgery in the future.
INTRODUCTION
I
n the midst of controversy surrounding the high costs of health care, ambulatory
surgery has emerged as an example of a safe, low-cost alternative to hospital
inpatient care. Before 1970, almost all surgeries were performed in the hospital
setting, and patients typically spent several days recovering in a hospital room.
Advances in surgical technology as well as the development of shorter acting
anesthetics and ancillary drugs have facilitated the performance of elective
procedures in ambulatory surgical settings. Ambulatory surgery offers patients a
value-added process approach to elective surgery through consistent processes
and consistent results. In 2011, more than 5,300 ambulatory surgery centers
(ASCs) in the United States performed 23 million surgeries annually (Ambulatory
Surgery Center Association [ASCA], n.d.d). At the time of publication of this course,
the Centers for Medicare and Medicaid Services (CMS) had granted approval for
ASCs to perform more than 3,800 different procedures (ASCA, n.d.a).
Ambulatory surgery nurses are constantly communicating with patients,
families, peers, physicians, intradepartmental staff members, business office staff,
and outside entities in an effort to coordinate a care episode that may last a few
minutes to a few hours. The ambulatory setting is often fast-paced, making it critical
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for each nurse to be focused on safety and diligent in protecting the health of
patients. The nurse works side by side with surgeons, anesthesia care providers,
licensed independent providers, and surgical technicians to assure the best
possible outcome for each patient.
The passage of the Patient Protection and Affordable Care Act in 2010 has
been followed by challenges to control healthcare costs while maintaining quality.
Ambulatory surgery settings are well positioned to meet the challenge because
they strive to perform elective procedures efficiently and without variation. The
business office staff is trained to analyze each clinical and administrative supply for
the best price and the best quality before approving purchase. The ambulatory
surgery staff work as a team to eliminate waste.
HISTORY AND EVOLUTION OF AMBULATORY CARE
N
ow widely accepted, even mandated by third-party payers for certain
procedures, the concept of ambulatory surgery was slow to gain
appreciation and acceptance.
As early as 1910, when 21 days of bed rest was routinely prescribed
convalescence after inguinal herniorrhaphy, Drs. Emil Ries of Chicago and Herman
Boldt of New York, both gynecologic surgeons, advocated early ambulation
following laparotomy and pelvic surgery. Dr. Ries noted that patients who were
allowed out of bed between 24 and 48 hours and were discharged in less than a
week did not have the muscular weakness and listlessness characteristic of longer
postoperative confinement (Brieger, 1983). Nevertheless, this premise failed to gain
support in the surgical community.
In February 1918, the first outpatient general anesthesia case in the United
States was successfully administered by Ralph Waters, an anesthesiologist at the
Downtown Anesthesia Clinic he established in an office building in Sioux City, Iowa.
Local surgeons performed relatively minor procedures there such as setting
fractures, draining abscesses, and performing dental surgery. In a paper he
presented later that year at a medical meeting in Indianapolis, Waters commented
that costs for outpatient surgery were considerably less than costs for similar
procedures done in a hospital.
Still, the concept of ambulatory, or outpatient, surgery was largely ignored for
several decades.
By the 1950s, socialized health care in the United Kingdom was causing
extraordinary delays of up to 2 years for elective surgery. This situation led some
surgeons to recognize that ambulatory surgery, which was being successfully used
on children, could be equally applicable to many adult procedures. As a result, a
pivotal study by J. A. Stallworthy, the well-known Oxford gynecologist who
advocated decreasing postoperative hospitalization, was published in The Lancet in
1960. It was titled “Hotels or Hospitals?” (Small, 1998).
In the United States, ambulatory surgery gained momentum in the 1960s and
hospital-based or affiliated facilities began to be established. One of the keys to this
growth was the acceptance of the idea that anesthesia could be safely
administered in an ambulatory setting. Anesthesiologists David Cohen and John
Dillon championed the premise that judicious patient assessment and selection,
combined with safe anesthetic and surgical techniques, led to successful
ambulatory surgical procedures. They were instrumental in the opening of one of
the earliest, widely publicized units at the Center for Health Services at the
University of California at Los Angeles (UCLA) in 1962.
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By 1966, The Journal of the American Medical Association (JAMA) stated that it
was possible to conduct a program of anesthesia for outpatient surgery without
compromising patient safety. In 1968, a United States National Advisory Committee
on Health Facilities report advocated experiments to help decrease healthcare
costs (Federated Ambulatory Surgery Association, 1998).
In 1970, the first successful freestanding ambulatory surgery center (ASC) was
opened in Phoenix, Arizona. The Surgicenter, founded by anesthesiologists
Wallace Reed and John Ford in conjunction with a nurse, Sharon Schafer
(DeFazio-Quinn, 1997), served as a model for future outpatient surgery centers.
The success, acceptance, and promotion of the Surgicenter were key factors in the
rapid expansion of ambulatory surgical facilities during the decade (Small, 1998).
Later that year, a second ASC opened, and more than 5,700 surgeries were
performed at these two centers during the year.
The American Medical Association (AMA) passed a resolution in 1971 that
endorsed the concept of outpatient surgery under general and local anesthesia for
selected procedures and patients. In 1973, the American Society of
Anesthesiologists (ASA) published Guidelines for Ambulatory Surgery Facilities
(ASCA, n.d.c).
In 1972, the Department of Health, Education, and Welfare received a mandate
from Congress to do a feasibility study for reimbursing freestanding ambulatory
surgery facilities. Done by the Orkland Corporation, the study confirmed that
surgery could be accomplished safely and less expensively in freestanding facilities
on an outpatient basis. By 1974, a contract was signed for a Medicare
demonstration project with six surgery centers. Sixty-seven surgery centers were
operating in the United States by 1976 (ASCA, n.d.c).
Major medical and surgical advances were made during the decades since
1950, and as technology proliferated, so too did health care costs. Federally funded
Medicare and Medicaid programs added more monetary stimulation for expansion
of health care services until, in the 1970s, concerns about escalating costs started
to be addressed. The recognition that safe health care had to be delivered more
economically spurred the growth of ambulatory care programs through the 1980s
and well beyond the passage of the Patient Protection and Affordable Care Act of
2010.
More than 900 ASCs opened during the decade of the 1980s, bringing the total
number to 1,200. The number of ASCs has increased commensurately with the
expansion of Medicare procedures approved for an ASC setting. In 1982, the
federal government began approving Medicare payments for patients having
surgery in ASCs. At that time there were approximately 200 covered procedures.
According to Koenig, Doherty, Dreyfus, and Xanthopoulous (2009) in 1981, the vast
majority (93%) of outpatient surgeries were performed in hospital outpatient
departments (HOPDs). The share of surgeries performed in HOPDs (or hospital-
owned facilities) fell to 45% by 2005, with the volume of surgeries performed in
freestanding ASCs increasing almost four-fold (Koenig et al., 2009). As of July
2015, Medicare has approved more than 3,800 procedures to be performed as
appropriate in ASCs (ASCA, 2015). The majority of surgeries performed in the
United States now take place in outpatient settings (Munnich & Parente, 2014).
Ambulatory procedures represented over 60% of all surgeries in the United States
in 2011, up from 19% in 1981 (Munnich & Parente, 2014).
Based on 2011 Medicare data, the most commonly performed procedures in the
Medicare population occur in ophthalmology (30%), gastroenterology (14%),
orthopedics (15%), pain management (10%), plastic (8%), urology (5%), and other
procedures (18%; see Figure 1-1).
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A 2012 survey of 201 freestanding ASCs across the country – representing

more than 1.2 million cases – found that gastroenterology and orthopedic
procedures accounted for 27% and 17%, respectively, of all cases performed.
These, together with ophthalmology, pain management, general surgery, and
otolaryngology, comprised more than 90% of the total case volume. Associated
revenues in each category per case were orthopedics, $2,618; GI, $788;
ophthalmology, $1,273; pain management, $840; general surgery, $1,795; and
otolaryngology, $1,849 (VMG Health, 2013).
TYPES OF AMBULATORY SURGICAL FACILITIES

mbulatory surgical facilities can be divided into three types: HOPDs, freestanding
A
ASCs, or office-based surgery suites.
Hospital Outpatient Departments
The earliest ambulatory surgeries were performed in hospital-based facilities.

Scheduling and administration were commingled with inpatient surgery. Crowded
inpatient surgery schedules or emergencies impacted, and usually took precedence
over, outpatient procedures, leading to frustration for staff, patients, and surgeons.
However, the hospital setting provided a major advantage because resources such
as expensive equipment, central billing processing, and laboratory and pharmacy
services could be utilized as needed.
The development of departments dedicated to outpatient surgery within
hospitals has allowed patients and healthcare providers to continue to benefit from
the advantages offered by a hospital setting while capitalizing on certain efficiencies
such as reliable scheduling, cost savings, and on-site health care experts. An
advantage for the patient in a hospital-based outpatient surgery department is the
availability of overnight admission if necessary. For this reason, surgical procedures
of greater magnitude can be performed in this setting. HOPDs exist in the hub of
the hospital, and physicians have the ability to quickly consult a variety of
specialists as needed. Some surgeons find practicing in HOPDs alongside hospital
inpatient departments allows them to efficiently handle a variety of patient needs
while delivering continuous patient-centered care. Many insurance companies will
cover certain surgical procedures only on an outpatient basis unless the surgeon
certifies the patient will require a more intensive level of postoperative care
because of an underlying medical condition. If the surgeon is unable to conclude
that inpatient care will not be required after an elective surgical procedure, he or
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she may choose to perform the procedure in an HOPD and then assess the patient
postoperatively for extended care needs.
Hospital outpatient departments employ clinical staff who have knowledge of
many different surgical procedures. HOPDs may offer new nurses a very
comprehensive orientation and preceptorship by devoting a specified amount of
time to training in each service line. Intradepartmental and interdepartmental
relations offer HOPD clinical staff great support and opportunities to learn and grow
in their chosen professions. The patients in a typical hospital setting will vary
greatly. Some patients may be very healthy and, therefore, will be discharged home
as planned a couple of hours after surgery. Other patients may be at high risk for
complications and require close monitoring for many hours or admission to an
inpatient unit. Nurses working in an HOPD can generally expect to have a variety of
shifts, handle on-call requirements, and work some holidays and weekends.
Ambulatory Surgery Centers
ASCs are healthcare facilities designed to offer patients elective surgeries and
procedures outside of the hospital setting. ASCs provide care to mostly healthy
patients who are expected to be discharged home a couple of hours after their
procedure is complete. Patients treated in the ASC are not expected to be
transferred to a hospital after surgery is complete.
The first ASCs were created and developed by physicians who saw an
opportunity to establish a high-quality, cost-effective alternative to hospital surgical
services. Faced with challenges such as scheduling delays, limited operating room
availability, slow operating room turnover times, and frustrations with hospital
budgets and policies, physicians were looking for a better way – and they found it in
ASCs. Today, physicians continue to be one of the driving forces behind the
development of ASCs. The ASC offers physicians increased control over their
surgery schedule, teams of specially trained and highly skilled staff, the assurance
that equipment and supplies used are best suited to their technique, and facility
designs tailored to their specialties and to the needs of their patients (ASCA, n.d.c).
The ASC offers patients a cost savings of 50% to 60%, almost zero risk for facility-
acquired infection, and a comfortable environment.
ASC clinical staff members must work as a team to maintain efficient patient
flow. Communication among departments is imperative while striving to meet
patient’s needs. The ASC setting is a streamlined, focused environment that is
often fast-paced. Despite this reality, each team member must be concerned about
assessing the patient properly and implementing timely safety and comfort
measures as appropriate. Nurses who work in an ASC are usually cross-trained to
wear many hats throughout the day, do not get bored with repetition, work at a high
energy level, and must possess a strict adherence to quality when it comes to
patient care by maintaining sterility and providing customer service. New nurses
are not usually hired into ASCs. In addition to the reasons listed, Sigsby, Selzer,
and Wilson (2006) found that new nurses think the acuity of patients is limited and
that the procedures are repetitive and, therefore, mundane. Nurses working in the
ASC can generally expect a Monday through Friday schedule with weekends and
holidays off. Freestanding ASCs provide ease of parking, a less-complicated
campus to maneuver, less opportunity for delays in the surgical schedule, and a
staff that has a single focus on ambulatory procedures. Freestanding surgery
centers are versatile in the scope of services and convenience provided to patients.
According to a study by the U.S. Department of Health and Human Services Office
of the Inspector General, Medicare patients prefer ASCs to hospitals for outpatient
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surgical and diagnostic procedures. Among reasons for this preference was less
waiting time, less crowded and more comfortable environments, lower costs, less
paperwork, and a more convenient location and parking (ASCA, n.d.c). Effective
May 18, 2009, Medicare defines an ASC as “any distinct entity that operates
exclusively for the purpose of providing surgical services to patients not requiring
hospitalization and in which the expected duration of services would not exceed 24
hours following an admission” (Centers for Medicare and Medicaid Services, 2015,
April 15).
Office-Based Surgery Suites
The growth in the volume and complexity of office-based surgical procedures

has offered a new way for surgeons to deliver health care. From 1995 to 2005, the
number of office-based procedures doubled to 10 million procedures per year
(Shapiro et al., 2014). The growth of office-based surgery is a result of economic
variables, as well as improved surgical techniques and anesthetic drugs suitable for
the office environment.
The shift to the office setting raises many issues around safety. For example,
private offices may have fewer resources than other surgical care settings and
often have less staff and equipment available for procedural and anesthetic
complications. State regulatory agencies are shifting their focus to office-based
surgery suites and requiring them to be appropriately credentialed or accredited,
sometimes restricting the types of procedures performed in such settings. Office-
based surgery suites often provide a cost savings to the patient and convenience to
the surgeon. This one-stop shop model can be efficient and safe for smaller
procedures, including some dental cases.
Office-based surgery staff may be required to fulfill a variety of roles that are
much different from the usual acute care or ambulatory surgery setting. A nurse in
the office may also assist in the surgery suite in between registering patients for
surgical consultation. Nurses working in an office-based surgery environment can
generally expect a Monday through Friday schedule with weekends and holidays
off. Office-based surgery suite nurses should not be novice nurses but rather expert
nurses comfortable working autonomously with a small team of healthcare
providers.
ROLES IN AMBULATORY SURGERY
E
ach patient in the ambulatory surgery setting is supported by a team that
contributes to patient care by fulfilling their roles as assigned. Ambulatory
surgery relies heavily on strong teams because intradepartmental
relationships are crucial to delivering the best possible patient outcome.
Within the business office of an ambulatory surgery setting there are staff to
schedule procedures, verify insurance coverage, prepare and review medical
record documents, and review anticipated supply needs. These office staff,
sometimes called patient account representatives or patient financial
representatives, may communicate directly with the patients regarding their
financial responsibility for the procedures scheduled and assist them with a
payment plan as dictated by facility policy. They also work with the physician’s
business office staff to ensure optimal scheduling of cases. Patients can expect one
of these team members to greet them on the day of their surgery and assist them
with completing various financial forms related to insurance, patient privacy, patient
rights and responsibilities, and other important notifications and policies. These
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team members usually report to the ambulatory surgery administrator or director

who may or may not have clinical credentials.
The administrator, sometimes referred to as the director, works closely with the
business office staff and oversees the day-to-day business functions of the
ambulatory surgery setting. In many instances, the administrator will have clinical
credentials, such as registered nurse (RN) or physician’s assistant (PA), but this is
usually not required. The administrator may oversee accounts payable, accounts
receivable, medical records, governance, risk management, and business
development. The administrator also helps develop policies and procedures in the
clinical areas, as well as the business area, and works closely with those
responsible for revenue cycle management.
Upon admission to the preoperative area, the patient can expect to be assessed
and prepared for surgery by an RN. A licensed practical nurse or patient care
technician may also participate in preparing the patient, but an RN is required to
oversee and verify the admission assessment of the patient.
The surgical team in the operating room is traditionally composed of an RN who
fulfills the role of circulator and patient advocate, a surgical technician who assists
the surgeon, an anesthesia care provider who administers anesthesia and monitors
patient sedation, and a physician who performs the procedure(s). The physician
performing the procedure may prefer to partner with a physician assistant who
works closely with the surgical technician and physician during the surgical case.
The postanesthesia care unit (PACU), or recovery room, is traditionally staffed
with RNs. Some facilities may also employ licensed practical nurses and patient
care technicians to assist the RN. The patients in this unit require constant
monitoring, and critical thinking skills by the nurse are imperative. The Centers for
Medicare and Medicaid Services (CMS) requires personnel trained in the use of
emergency equipment and in cardiopulmonary resuscitation must be available
whenever there is a patient in the facility (Centers for Medicare and Medicaid
Services, 2015, April 15).
Ambulatory surgery facilities must ensure that their nursing service is directed
under the leadership of an RN (Centers for Medicare and Medicaid Services, 2015,
April 15). Most often, this is handled through a nurse manager or clinical manager
role. The RN in this leadership role ensures the implementation of approved
policies and procedures in the clinical areas of the ambulatory surgery facility. The
manager works closely with the administrator to facilitate smooth day-to-day
operation of the facility.
INVENTORY MANAGEMENT
A
mbulatory surgical facilities can be either for-profit or not-for-profit entities.
Regardless of this designation, all healthcare personnel have a role in
inventory management and a responsibility to use resources wisely. Most
ambulatory surgery facilities designate a team member to manage inventory in the
center. Smaller facilities may enlist a surgical technician, patient care technician,
nurse, or business office employee to handle these duties before or after surgery
cases are complete for the day. Larger facilities may employee a full-time materials
manager or coordinator. In all cases, astute supply analysis and vigorous
preference card management is the basis for a financially sound ambulatory
surgery facility and the goal of the inventory designee.
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The administrator of the facility typically works closely with those involved in
supply analysis. Supplies requested by the physician and nurse are vetted for
quality first, and then for financial implications. The shared goal is to provide the
highest quality items with the best cost savings while never compromising patient
care. This can be done by working closely with vendor representatives, nurses, and
physicians in an effort to reduce waste while optimizing patient outcomes. For
example, if a physician requests a new suture that is three times more expensive
than the suture currently used, the administrator or inventory designee may contact
other vendors with a comparative suture and implement a trial period of use. The
cost of the suture incurred by the facility should be discussed with the physician so
an informed decision can be made. Blindly approving purchases without analysis is
discouraged in the ambulatory surgery setting. Rather, thoughtful supply purchases
are supported by education, trial, and review by those affected. While hospitals may
be able to form supply chain committees, smaller ASCs and office-based surgery
suites rely on a few key stakeholders to manage inventory and product analysis.
When evaluating products, stakeholders should start with the clinical criteria.
Decisions based on clinical criteria include a review for safety and health risk
issues, quality improvement potential in patient outcomes, cost effectiveness, and
overall quality of the product (Brusco, 2012b). Any ambulatory staff person can
initiate an analysis, and nurses often have the greatest insight as to what is needed
to provide optimal care. An example is provided in Case Study 1-1.
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Ambulatory surgery facilities should maintain accurate preference cards

individualized to each utilizing physician. Preference cards should be updated and
saved any time a change in necessary supplies for a case is made. Accurate
preference cards allow the surgery administrator to track costs and make important
decisions about purchases and future strategies. Preference cards are also used
as a form of communication among ambulatory surgery team members. An
accurate preference card enables any clinical team member to set up a case with
all the necessary supplies needed in the operating room and available to the
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physician. This eliminates waste and undesirable traffic in and out of the operating
room collecting supplies after the case has started. The circulating RN is able to
focus on the patient’s care.
THE REVENUE CYCLE
T
he revenue cycle begins with patient registration and ends when all charges
are paid in full. Collection of precise and accurate information helps to
expedite the process. Depending on the type of facility, nurses may be
asked to assist with gathering required information, which is then passed on to
various staff including certified professional coders and billers.
Current facility payments from third-party payers such as private insurance
companies and government insurers are based on a fee-for-service model. A
surgical procedure is identified on a bill by a corresponding code, known as a
Current Procedural Terminology (CPT) code. CPTs are alphanumeric codes that
represent the services that are provided to a patient in an ambulatory surgery
facility. CPTs are used by third-party payers and outpatient healthcare facilities to
provide appropriate outpatient reimbursement assignment. The appropriate CPT
code is typically assigned by a certified professional coder during their
postoperative review of the medical record. The CPT code is linked to contractually
negotiated and agreed upon reimbursement fees because of the ambulatory
surgery facility. Reimbursement is not linked to the expenses incurred by the facility
but, rather, it is linked to the procedure(s) performed. This incentivizes the facility to
carefully control costs to realize a larger profit margin. The future revenue system
will be at least partially based on the fee-for-performance model in which facility
reimbursement will be linked to designated quality measures and patient
experience ratings, as well as the CPT code.
In conjunction with CPT codes are ICD-10 codes. ICD-10 codes are used to
classify diagnoses on claims submitted to third-party payers. ICD-10 is the World
Health Organization’s disease classification system and is known as the standard
diagnostic tool for epidemiology, health management, and clinical purposes. It is
used by healthcare providers, researchers, health information managers and
coders, health information technology workers, policy makers, insurers, and patient
organizations to classify diseases and other health problems recorded in health and
vital records (Bourdon, 2014). ICD-10 represents the 10th revision and is made up
of two parts: ICD-10-CM (Clinical Modification), which is for diagnosis coding and is
used in all U.S. healthcare settings, and ICD-10-PCS (Procedure Coding System),
which is for inpatient procedure coding and is only used in U.S. inpatient hospital
settings (Bourdon, 2014). Although the October 2015 transition from ICD-9 to ICD-
10 was a resource-laden, costly venture, the revised code sets offer a level of detail
that allows for more accurate medical diagnoses, data capture, and analytics that
should contribute to enhanced patient care and improved analysis and reporting for
tracking diseases and medical outcomes (Bourdon, 2014).
Ambulatory surgery billing is increasingly becoming more complicated because
of continuously changing regulations; therefore, leaders frequently review their own
practices in search of opportunities for improvement. The increase in the volume of
high-deductible health insurance plans has led to a movement toward price
transparency as consumers become more invested in their out-of-pocket
healthcare costs. The intricacies of billing for procedures completed in the surgery
facility are challenging. Professional billers must be in constant contact with third-
party payers and the ambulatory surgery facility to ensure accuracy, as well as
proper and timely payment to the surgery facility. Many ambulatory surgery facilities
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outsource this task to dedicated billing companies or handle it in-house with a

billing manager who oversees several professional billers and coders. The CMS-
1500 form is the standard paper claim form used to bill fee-for-service (FFS)
insurers when a paper claim is allowed. An example is below in Figure 1-2. Data
elements in the CMS uniform electronic billing specifications and most other
insurers are consistent with the paper form so that one processing system can
handle both. Ambulatory surgery team members play an important role in the
revenue cycle by submitting accurate claims, maintaining current knowledge of
billing policies, and ensuring all documentation required to support the medical
need for the service rendered is complete and submitted in a timely manner.
FINANCIAL CONSIDERATIONS
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n the United States, ambulatory surgery was born of the need for cost containment.
Healthcare costs continue to outpace inflation, which makes options to costly
I
hospitalization imperative. Cost outcomes for ambulatory surgery are typically
assessed by comparing the inpatient versus outpatient costs of a particular
procedure. To establish the total societal cost, the amount of time away from
normal daily activity plus the dollar value of the time expended by nonprofessional
caregivers must be considered.
Ambulatory surgery facilities have been able to provide quality care more
economically than the inpatient hospital environment because they have low
overhead costs and they focus on one area: treating ambulatory patients efficiently.
On average, procedures performed in an ASC cost 58% less than the same
procedure performed in a hospital outpatient department (HOPD; Fulton & Kim,
2013). This savings is passed on to patients in the form of decreased copays and
coinsurance payments. For example, in 2015, a Medicare beneficiary typically
would pay $290 coinsurance for a cataract extraction in a hospital, but the
coinsurance payment due to an ASC would be $118. The ASC is reimbursed a total
average of $1,050 for a tonsillectomy compared to a hospital reimbursement of an
average of $1,659 (ASCA, n.d.a). Similarly, cataract surgery reimbursement to an
ASC averaged $915, compared with $1,445 in a hospital, and an inguinal
herniorrhaphy done in an ASC reimbursed $1,398 versus $2,208 in a hospital
(ASCA, n.d.a). During the four-year period from 2008 to 2011, ASCs saved the
Medicare program and its beneficiaries $7.5 billion (Fulton & Kim, 2013).
Freestanding ambulatory surgery centers spend less on supplies, staffing, and
other support areas that hospitals have to maintain because of the varied services
they offer. Third-party payers, government and private commercial payers alike,
negotiate with ASCs for lower reimbursement because it is known the ASCs spend
less per patient as opposed to the hospital. A formula calculation in the CMS
reimbursement policy could jeopardize the savings ASCs provide to patients. CMS
uses two different factors to update ASC and HOPD reimbursement – despite the
fact that the two settings provide the same surgical services. ASC payments are
updated based on the Consumer Price Index for All Urban Consumers (CPI-U) and
measures changes in the costs of all consumer goods. HOPD rates, meanwhile,
are updated in the hospital market basket, which specifically measures changes in
the costs of providing health care, and so more accurately reflects the increased
costs that outpatient facilities face (Fulton & Kim, 2013).
THE FUTURE OF AMBULATORY SURGERY
F
reestanding ambulatory surgery centers provide a low-cost, efficient
alternative to hospitals for outpatient surgeries (Munnich & Parente, 2014).
Researchers from the University of Louisville and the University of
Minnesota examined data for 52,000 surgical visits at 437 ambulatory surgery
facilities over 4 years and found procedures performed in freestanding ambulatory
surgery centers take 31.8 fewer minutes than those performed in hospitals – a 25%
difference in the mean procedure time (Munnich & Parente, 2014). With the number
of outpatient procedures performed consistently rising over the past 35 years,
ambulatory surgery centers are a proven efficient way to meet future growth in
outpatient surgery demands (Munnich & Parente, 2014).
Facilities are now being designed to meet the needs of the patient by offering
high-tech robotic surgical services for procedures that previously were typically
complicated and expensive inpatient procedures. These device-intensive cases can
often be done in freestanding ambulatory surgery centers away from the maze of
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the main hospital campus. Some procedures may require an extended length of
stay of 23 hours in a private recovery suite in order to allow the patient to remain
monitored and treated for pain and then sent home to fully recover. Many health
officials and policy makers now acknowledge these new methods as acceptable,
even desirable, as evidenced by the 35 U.S. states that allow ASCs to admit
patients for up to 23 hours and 59 minutes.
SUMMARY
U
.S. Representatives Devin Nunes (R-CA) and John Larson (D-CT) in the
House and Senator Mike Crapo (R-ID) in the Senate have introduced H.R.
1453, the Ambulatory Surgical Center Quality and Access Act of 2015, to
ensure that the Medicare program and its beneficiaries continue to enjoy the high
level of care and cost savings that the more than 5,300 ASCs across the nation
provide (ASCA, n.d.d). The Ambulatory Surgical Center Quality and Access Act of
2015 would move the ASC reimbursement plan from the CPI-U to the hospital
market basket update, which better measures the cost of health care. By
establishing affordable and safe outpatient surgery, ambulatory surgery is the
leader in the evolution of promising new avenues for health care delivery
improvement. The aggressive use of minimally invasive surgical techniques has
shifted procedures to the ambulatory surgery environment. Cardiac surgery and
total joint replacement surgery, two of the most costly inpatient procedures, are
already increasing on an outpatient basis. Expansion of microsurgery is occurring,
and improved imaging techniques have offered new venues. For example,
innovations in magnetic resonance imaging have increased early surgical
interventions in cancer care. As the number of older adults continue to increase, so
too will the number of ambulatory endoscopic, ophthalmic, and arthroscopic
procedures. Toward that end, the availability of portable diagnostic and treatment
equipment, including imaging devices and lasers, has made procedures previously
reserved for the hospital setting currently accessible in the ambulatory setting.
Nurses who choose to practice in the ambulatory surgery setting now have
access to a growing environment rich with opportunity. Ambulatory surgery nurses
care for patients and their significant others in an environment that is efficient,
pleasant, and sometimes varied. The nurse in this setting will find there are
opportunities to contribute beyond nursing care by becoming involved in business
management, inventory, product analysis, team building, and much more. Along
those lines, there are several professional organizations and resources that will be
discussed later in this course to assist the nurse in learning more about ambulatory
surgery.
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EXAM QUESTIONS
CHAPTER 1
This is for your reference only. To complete the exam, login to your
account at http://www.westernschools.com
Questions 1–8
1. All of the following concepts led to the acceptance of ambulatory surgery except
a. acceptance of the idea that anesthesia could be safely administered in an
ambulatory setting.
b. judicious patient assessment and selection.
c. confirmation that surgery could be accomplished safely and less
expensively in freestanding facilities on an outpatient basis.
d. support from the American Hospital Association.
2. Mr. Smith needs surgery to remove his gallbladder. His physician, Dr. Klien,
often performs this procedure in an ambulatory surgery center. Dr. Klien notes
Mr. Smith may need to be monitored for a day or two after his surgery because
of his current health status but also may be well enough to be discharged home
after a few hours in recovery. Dr. Klien will not be able to make a decision about
discharge planning until Mr. Smith has had surgery and has been assessed in
the postanesthesia care unit. Where is the best place for Mr. Smith to have
surgery?
a. A hospital outpatient department
b. An ambulatory surgery center
c. A hospital inpatient department
d. The physician’s office surgery suite
3. What is the average cost savings to a patient who has surgery in an ambulatory
surgery center when compared to a hospital outpatient department?
a. 20% to 30%
b. 50% to 60%
c. 0
d. 10% to 20%
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4. What activities generally occur in an ambulatory surgery business office?

a. Scheduling, insurance verification, and financial counseling
b. The informed consent process
c. Patient care activities
d. The universal protocol
5. How can an ambulatory surgery nurse contribute to inventory management?

a. Nurses should not be involved in inventory management.
b. The nurse can compromise patient care to receive the lowest cost
supplies available.
c. The nurse assists with the maintenance of accurate preference cards.
d. The nurse recommends the purchase of the most expensive supplies
regardless of quality.
6. Reimbursement to the ambulatory surgery facility is linked to

a. the Current Procedural Terminology code.
b. expenses incurred by the facility.
c. patient experience measurements.
d. the total length of time of the case.
7. Ambulatory surgery center payments from the Centers for Medicare and
Medicaid Services are updated based on
a. the hospital market basket.
b. changes in the costs of providing health care.
c. ambulatory surgery performance.
d. the consumer price index for all urban consumers.
8. In the future, experts predict the volume of ambulatory surgeries done in the
U.S. will
a. decrease.
b. increase.
c. stay the same.
d. shift back to the hospital inpatient arena.
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CHAPTER 2
PATIENT SELECTION AND

ASSESSMENT
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to describe the process
implemented to assess patients before admission to ensure
appropriateness for the ambulatory surgery setting.
CHAPTER OBJECTIVES
A
1. Discuss appropriate ambulatory surgery procedures and patients.

2. Identify essential components of preadmission patient assessments.
3. Describe preadmission testing considerations and articulate requirements

related to preadmission patient notification.
4. Assess patient and caregiver learning needs.
INTRODUCTION
T
horough and comprehensive preadmission assessment of the prospective
ambulatory surgical patient is essential for perioperative management and
positive outcomes. Similarly, the importance of teaching patients before
surgery about what to expect after surgery should not be overlooked. The collection
of pertinent patient data prior to admission assists in the provision of patient
education, helps to establish nursing goals, and facilitates the development of a
relevant plan of care in an ongoing and systematic manner. In addition, the
preadmission timeframe allows the opportunity for addressing the following key
goals:
1. To provide for a collaborated effort to gather information about the patient’s

condition
2. To plan individualized care based on the patient’s needs and applicable
nursing diagnoses
3. To orient and educate the patients and family members and/or responsible
adults to the surgical routine
4. To decrease the anxiety and fears of the patients and their families
5. To increase communication among all members of the multidisciplinary

surgical team, patient, and family
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6. To identify and reduce potential complicating factors specific to the individual

patient and planned surgical/anesthesia interventions.
7. To provide the opportunity for the patient to discuss issues with care
providers and to ask questions
8. To ensure completeness of the medical record for both business and clinical
needs
9. To meet regulatory requirements for prenotification of patients related to
physician ownership of the surgery center, if applicable, advance directive
policy, and patient rights and responsibilities
THE SELECTION PROCESS
W
hen ambulatory surgery became popular, eligible patients were limited to
those qualifying as American Society of Anesthesiologists (ASA) class I
and class II, according to the ASA physical status classification (see
Table 2-1). Increasingly, medically stable class III patients became recognized as
suitable for ambulatory surgery. In selected cases, physically less stable patients
may also be candidates for outpatient procedures. Patient and procedure selection
begins in the surgeon’s office and extends to ambulatory surgery clinical policies,
nurse assessment, and anesthesia provider assessment. Preadmission
management options for ambulatory surgical patients are no longer restricted to a
preoperative consultation with an anesthesiologist. Options now include several
tools ranging from nurse-led, prescreening telephone interviews to in-office
questionnaires to web-based assessment sites.
<TABLE 2-1 WILL BE VIEWABLE AFTER PURCHASE>
The American Society of Anesthesiologists (ASA) has designed and used a

patient physical status classification, the ASA class, for more than 50 years. This
assessment tool is reflective of a patient’s comorbid status and general fitness for
undergoing anesthesia as well as surgery. It has been shown to accurately predict
perioperative morbidity and mortality (Enestvedt, Eisen, Holub, & Lieberman,
2013).
TYPES OF SURGERY
E
ffective January 1, 2008 and confirmed on November 30, 2011 by the
Centers for Medicare and Medicaid Services, covered ambulatory surgery
center procedures are those procedures that would not be expected to pose
a significant safety risk to a patient when performed in an ambulatory surgery
center (ASC) and for which standard medical practice dictates that the beneficiary
would not typically be expected to require active medical monitoring and care at
midnight following the procedure. Covered surgical procedures do not include those
surgical procedures that
1. generally result in extensive blood loss,
2. require major or prolonged invasion of body cavities,
3. directly involve major blood vessels,
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4. are generally emergent or life-threatening in nature,
5. commonly require systemic thrombolytic therapy,

6. are designated as requiring inpatient care, and
7. can only be reported using an unlisted Current Procedural Terminology
(CPT) code.
Ambulatory surgery settings usually maintain a list of procedures that have been
approved by leadership as appropriate for the environment based on the above
guideline, evidence-based research, patient safety, available equipment, staffing
models, and third-party reimbursement.
PATIENT SELECTION
W
hether a patient is appropriate for ambulatory surgery is a medical
decision made by the physicians involved in care. The preadmission
assessment nurse is responsible for gathering information about the
patient’s medical and surgical history that will then be used by the involved
physicians to determine if the patient is an appropriate ambulatory surgery
candidate. In many facilities, a medical oversight committee, often referred to as
the medical executive committee, leadership, or the board of directors, may
develop a standard, guideline, or policy about patient appropriateness based on the
particular ambulatory setting and evidence-based research.
The incidence of unanticipated hospital admission following ambulatory surgery
was found to be higher in the older population, defined as greater than 40 years
old, according to Whippey, Kostandoff, Paul, Ma, J., Thabane, and Ma, H. K.
(2013). They found the following factors were associated with an increased
likelihood of unplanned hospital admission: ASA classes II-IV, increased body mass
index (BMI), and the Mallampati 2 classification (discussed in Chapter 3). The
following conditions were found to have a higher incidence of unplanned hospital
admission: diabetes, hypertension, ischemic heart disease, psychiatric illness,
sleep apnea, and thyroid disease (Whippey et al., 2013). No specific medication
class was associated with an increased likelihood of unanticipated admission.
Adult patients typically considered appropriate for ambulatory surgery include
healthy patients without systemic disease and those with stable chronic conditions
such as well-controlled diabetes or stable cardiac or pulmonary disease. Many
ASCs have generally deemed the following categories as inappropriate for
ambulatory surgery, though individual variances requested by attending physicians
may be referred to the ASC’s anesthesia director and/or medical director for
consideration:
1. Unstable ASA III or ASA IV and patients known to require post op ventilation
2. Acute intoxication
3. Infants at risk for apnea, children who are febrile or dehydrated
4. Age limits if defined in each ASC’s Plan of Care
5. Known recent exposure to chicken pox or other highly communicable

disease
6. Active communicable disease or those who exhibit signs and symptoms of
infection known or suspected to spread through droplet or airborne
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transmission (e.g., tuberculosis, chicken pox, measles, disseminated herpes

zoster, active respiratory methicillin-resistant Staphylococcus aureus
[MRSA], respiratory infections, meningitis, severe acute respiratory
syndrome [SARS], etc.)
7. Inadequate home support available (home health nurses may be used in

some cases if agreeable to the anesthesiologist and surgeon)
8. Patients being scheduled for a percutaneous liver biopsy or other procedure

determined to be inappropriate for the freestanding setting
9. Patients at increased perioperative risk from obstructive sleep apnea (OSA),
including but not limited to tonsillectomies in children less than 3 years of age
Pediatric Considerations
Physiologic status is more of a determining factor of an appropriate candidate

for ambulatory surgery than is chronologic age. With the exception of infants who
were born prematurely – experts believe acceptable postconception age for
outpatient surgery varies from 44 weeks to 60 weeks – extremes of age are no
longer considered a contraindication to ambulatory surgery if the patient is healthy.
The safe and efficient scheduling of pediatric outpatient surgery requires the ability
to identify appropriate candidates and anticipate postoperative needs. Age,
postoperative nausea and vomiting (PONV), and oxygen desaturation are the major
factors associated with a prolonged stay in the Postanesthesia Care Unit (PACU;
Edler, Mariano, Golianu, Kuan, & Pentcheva, 2007). Consideration of these factors
should take place prior to scheduling high-risk pediatric patients for ambulatory
surgery. Focused efforts to decrease the risks of PONV and oxygen desaturation,
such as multidrug antiemetic prophylaxis, meticulous airway management by
skilled anesthesiologists and PACU nurses, provision of supplemental oxygen, and
routine use of dexamethasone to decrease airway edema, can improve outcomes
in pediatric surgical outpatients (Edler et al., 2007). It is preferred that children are
assessed as close to the day of surgery as possible to evaluate them for infectious
diseases such as upper respiratory infections.
There is considerable controversy concerning tonsillectomies and
adenoidectomies (T & A) performed in an outpatient setting because 3% of these
patients experience postoperative bleeding, some of whom require transfusion and
reoperation.
Medical criteria for pediatric ambulatory tonsillectomy include
1. a patient who is 3 years old or older,
2. a patient who is classified as ASA class I or II,
3. a patient who is free of comorbidity liable to exacerbate the respiratory risks,

and
4. a patient who is free of hemostasis abnormality.
Inpatient admission is recommended in the case of one or more of the following

criteria:
1. clinical criteria for perioperative respiratory risk present,

2. hemostasis abnormality, and
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3. respiratory difficulty on anesthesia induction or at awakening in the recovery

room. (Transfer from ambulatory to inpatient surgery is then recommended.)
(Lescanne et al., 2012)

In very young children, posttonsillectomy breathing problems, nausea, and
vomiting leading to dehydration are additional concerns. After tonsillectomy and
adenoidectomy, patients also may be prone to laryngospasm, so adequate
postoperative monitoring is essential (Drain, 2008). Surgical location must be
decided on a case-by-case basis after careful evaluation. Decisions are influenced
by the type of ambulatory facility, the skill and resources of those caring for the
patient, postoperative resources, and community standards.
The preadmission nurse should confirm the availability of appropriately sized
medical equipment for pediatric patients, including blood pressure cuffs and
surgical tourniquets. Facilities treating pediatric patients should have cribs with
padded side rails and appropriate distraction toys (such as stuffed animals)
available.
Geriatric Considerations
When reviewing an elderly patient’s medical and surgical history, the

preadmission nurse should consider the risks of the proposed operative procedure,
the planned anesthesia and analgesia regimen, and any underlying medical
conditions (White et al., 2012). Risk reduction strategies for the elderly outpatient
involve optimization of coexisting diseases. Benefits of ambulatory surgery for the
elderly surgical population include a reduction in respiratory and intubation-related
events and the relative reduction of postoperative complications such as pain,
PONV, and facility-acquired infection (White et al., 2012). The preadmission nurse
should carefully assess this patient’s at-home support network to ensure adequate
assistance is available for at least 24 hours postoperatively. All postoperative
patients are at risk for falls related to the ongoing effects of anesthesia, but many
geriatric patients are at heightened risk related to ongoing physical issues,
including arthritis and previous extremity injuries.
Obstructive Sleep Apnea
Eligibility for ambulatory for surgery should be decided on a case-by-case basis.

ASA class III patients may be suitable for outpatient procedures if the concurrent
systemic disease is well controlled. Morbidly obese patients present potential
airway maintenance problems and typically have numerous medical concerns,
including sleep apnea. However, for short procedures with cautious anesthetic
management, ambulatory surgery may be acceptable.
As the number of overweight individuals increases, so too does the incidence of
OSA, which develops in children as well as adults. OSA may affect every phase of
the perioperative experience. OSA is a relatively common sleep-related breathing
disorder that is associated with daytime sleepiness, neurocognitive dysfunction,
cardiovascular disorders, and metabolic dysfunction. The prevalence of OSA is
increasing and is reported to be higher in the surgical population than in the general
population (Joshi, Ankichetty, Gan, & Chung, 2012). With the increase in
prevalence of OSA as well as the increase in surgical procedures performed on an
outpatient basis, surgical staff will increasingly manage patients with OSA in the
ambulatory setting.
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The appropriateness of ambulatory surgery for patients with OSA remains

controversial because of the concerns of increased perioperative complications.
Usually, patients with a known diagnosis of OSA and optimized comorbid medical
conditions may be considered for ambulatory surgery, especially if they are able to
use a continuous positive airway pressure (CPAP) device in the postoperative
period (Joshi et al., 2012). The Society for Ambulatory Anesthesia states general
anesthesia patients who do not have a diagnosis of OSA should be screened using
the STOP-Bang questionnaire (Table 2-2). The preadmission nurse can ask the
patient these questions during the preadmission interview. Patients who answer
“yes” to three or more questions are at high risk for OSA but are still candidates for
ambulatory surgery if comorbid conditions are optimized and if postoperative pain
can be managed predominantly with nonopioid analgesic techniques. OSA patients
with nonoptimized comorbid medical conditions may not be good candidates for
ambulatory surgery. Patients who use CPAP therapy should be asked to bring their
device on the day of surgery for possible postoperative use.
The preadmission nurse should be familiar with the weight limits of the facility’s
stretchers, operating room tables, and wheelchairs, which are established by the
manufacturer of these items. The nurse should also assure the availability of
appropriately sized blood pressure cuffs and surgical tourniquets.
Patients at Risk for Malignant Hyperthermia
Appropriateness of a patient with a personal or family history of malignant

hyperthermia (MH) is another topic of controversy. Any patient may present with an
unexpected MH reaction after anesthesia has begun. Risk for MH is best predicted
by a family history of MH or suspicious episodes during previous general
anesthesia. There is no medically valid reason why known MH-susceptible patients
cannot undergo general anesthesia in an ambulatory environment as long as the
anesthesia machine is properly prepared and a nontriggering anesthetic technique
such as total intravenous anesthesia (TIVA) is used. In these patients, surgery with
nontriggering agents is safe; prophylactic dantrolene premedication is not
necessary, and postoperative discharge times do not need to be increased for
monitoring of delayed MH presentation (Litman & Joshi, 2014).
PREADMISSION PATIENT ASSESSMENT
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dequate preadmission assessment of the prospective ambulatory surgical

patient is essential for optimal perioperative management and outcome. By
identifying existing or potential areas of concern, the goal of having the
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patient in the best possible health consistent with his or her physical status at the
time of surgery may be achieved. In addition to gathering the necessary
information, the nurse’s role focuses on preparing the patient physically and
emotionally.
Assessment and evaluation may be accomplished by a patient visit to the facility
prior to the day of surgery, an office visit, a telephone interview, a written
questionnaire, a computer-aided survey (e.g., One Medical Passport) completed by
the patient, or surgical and anesthetic assessment done the morning of surgery.
Assessment is best performed sufficiently in advance of the scheduled surgery
to allow time for investigation of areas of concern, obtaining previous medical
records and consultations if needed. Telephone interviews are frequently used by
ambulatory facilities. It is important for the telephone interview to be conducted at
least 1 to 2 days in advance of the scheduled surgery. It should be conducted by a
registered nurse who can evaluate the patient for appropriateness for ambulatory
surgery and identify the need for any tests that could not be performed the day of
surgery. The perioperative nurse should review results of preprocedure diagnostic
tests and notify the surgeon and anesthesiologist of any questionable
abnormalities. Ambulatory surgery patients should be assessed as a hospitalized
patient would be, relative to the surgical procedure and patient’s physical condition,
but also special attention should be focused on same-day discharge planning. The
best disease screening procedures continue to be a carefully performed physical
examination along with a detailed history. Based on the results, laboratory testing
may then be ordered. See Table 2-3.
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The nurse’s assessment should consider the patient’s emotional status,

cognitive ability, and social or cultural influences. The alert preadmission nurse will
document noted physical or mental impairments or disabilities; communication
limitations; mobility limitations; and prostheses used, including hearing aids and
contact lenses. If a patient has a pacemaker, the type should be documented on
the patient’s chart. A growing number of surgical patients present to the operating
room with implantable cardioverter defibrillators (ICDs). In most cases, ICD function
should be suspended for many surgical procedures to avoid inappropriate, and
possibly harmful, ICD shocks triggered by electromagnetic interference (Rodriguez-
Blanco, Souki, Tamayo, & Candiotti, 2013). An alternative to reprogramming the
ICD is the temporary use of a magnet to suspend its function. The preadmission
nurse should inform the patient’s anesthesia provider about the presence of the
ICD and the magnet’s availability. The nurse should also ascertain the
manufacturer and model number of the ICD to clarify with the company
representative how to ensure that the ICD is again functioning correctly after the
procedure and prior to discharge from the facility.
Skillful interviewing techniques and the ability to discern what the patient may
have neglected to mention may make the difference between a safe and uneventful
ambulatory surgical experience and an emergency. This is especially true with
elderly patients who may not want to admit that they do not understand, do not hear
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well, or have forgotten certain information. How the question is phrased is often the
key to patient response. Specific questions asked in a pleasant, nonthreatening,
and unhurried manner are most effective. The preadmission nurse will be most
successful in obtaining important information from the patient by asking open-
ended questions.
Conversational questions may provide valuable insights. For example, in talking
with patients with known systemic diseases, questions about sports and hobbies
(e.g., gardening), may provide a gauge of exercise tolerance, functional physiologic
reserve, and stress tolerance. The presence of stairs in the home or estimates of
housework performed may provide similar insight. For smokers, a discussion of
morning routine and smoking habits facilitates an estimation of the degree of
chronic respiratory compromise and may also lead to discovery of cessation
adjuncts the patient is using but neglected to mention.
Questions about allergies or side effects to medications require a more direct
approach. Patients tend to describe nausea and other gastrointestinal upsets
secondary to medications as allergies rather than side effects. Side effects involve
unpleasant or adverse reactions. The World Health Organization characterizes
allergic reactions as hives, pruritus, skin wheals, edema, wheezing,
bronchospasms, hypotension, or circulatory collapse caused by an over-response
of the immune system (McAuley, 2012). Neuromuscular blocking agents (NMBAs)
and antibiotics are the most common drugs triggering perioperative anaphylaxis.
Although many clinicians believe that certain food allergies present an issue with
the use of propofol, there is no evidence to contraindicate propofol in egg-allergic,
soy-allergic or peanut-allergic patients (Dewachter, Mouton-Faivre, Castells, &
Hepner, 2011). Latex sensitivity should be specifically addressed. If the patient is
not aware of latex sensitivity, he or she should be asked about redness, itching, or
swelling after wearing rubber gloves; dental, vaginal, or rectal examinations; or
blowing up balloons. A positive response warrants further investigation, and the
surgeon and anesthesia provider should be notified. Additionally, the ambulatory
surgery staff should be prepared to establish a latex-safe environment. A history of
any fruit allergy may indicate possible latex sensitivity (American Association of
Nurse Anesthetists, 2014).
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It is a myth that an allergy to seafood increases the risk of iodine allergy, and it
is unclear how they became linked and associated with allergic reactions
(Schabelman & Witting, 2010). Iodine is not and cannot be an allergen as it is found
throughout our bodies in thyroid hormones and amino acids. Iodine is added to
most of the salt used in the United States as a public health measure to prevent
iodine deficiency. Without iodine in the body, a person cannot survive. Due to its
antiseptic properties, iodine is used in many medicinal compounds, for example,
povidone-iodine skin prep. Patients who experience reactions to these products are
reacting to allergens in the solution, not to the iodine. Nurses should not ask
whether patients are allergic to shellfish or iodine because this information has no
relevance to radiocontrast allergies. This questioning perpetuates the myth of an
association between shellfish, iodine, and contrast agents. Instead, the nurse
should use open-ended questioning techniques and ask the patient whether he or
she has any allergies.
The World Health Organization defines an adverse drug reaction (ADR) as
“a noxious and unintended response to a drug that occurs at a dose
normally used in man.” Included in the many types of ADRs are
hypersensitivity drug reactions. Hypersensitivity reactions are divided into
two categories: (1) allergic drug reactions that result from an over-
response of the immune system, and (2) adverse drug effects that
resemble allergic reactions in their clinical presentation but are not proven
to be immune mediated. Examples of immune-mediated allergic reactions
include anaphylaxis from penicillins, Stevens-Johnson syndrome from
sulfonamides, allopurinol hypersensitivity syndrome, and serum sickness
from phenytoin. Examples of nonimmune hypersensitivity reactions include
shock after radiocontrast media, aspirin-induced asthma, opiate-related
urticaria, and vancomycin-induced red man syndrome. Hypersensitivity
reactions represent about one third of all ADRs. Between 10% to 20% of
hospitalized patients are affected by ADRs (McAuley, 2012).
Patients are often unclear about previous procedures; they may believe they
had general anesthesia when in fact they slept after sedation and regional
anesthesia. The type of procedure and description of events are significant
indications of what questions healthcare providers should ask patients during their
assessments. However, prolonged or incapacitating nausea and vomiting is not
usually forgotten. Patients should be questioned about recovery from previous
anesthetics and procedures so that precautions may be taken to avoid repetition of
any adverse effects. Broad generalizations, such as an allergy to antibiotics or
sleeping pills, must be defined.
Similarly, the patient should be specifically asked about a personal or family
history of MH. In addition to general questions about complications associated with
previous surgeries and anesthesia, the patient should be asked whether there has
ever been an incident of unexplained high fever after anesthesia and whether there
are any muscular problems or diseases that run in the patient’s family. Positive
answers warrant in-depth investigation; previous medical records should be
obtained, and the surgeon and anesthesia provider should be notified.
Medication history is especially important to ensure patient safety throughout
the perioperative continuum of care. Medication checklists for the patient to
complete are helpful as is the practice of having the patient bring all current
medications, if there is a preoperative visit. In a study spanning 7 years,
researchers compiled more than 11,000 case reports of medication errors. From
this analysis, the researchers established the incidence of harm at 4.96% in the
perioperative continuum, which compared unfavorably with the national reported
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incidence of harm of 1.3% (Hicks, Wanzer, & Denholm, 2012). When examining
only pediatric patients, the incidence of harm was noted at 16.7% (Hicks, Wanzer,
& Denholm, 2012). With the increasing popularity of homeopathic and herbal
medications, all adults should be specifically questioned about medications they
purchase without a prescription, including aspirin and nonsteroidal anti-
inflammatory drugs (NSAIDs) such as ibuprofen, which may cause clotting
abnormalities. Additionally, the nurse should prompt the patient to try to remember
all medication products they take such as patches, creams, eye drops, inhalers,
shots, herbal or mineral supplements, and vitamins.
Some vitamins and nutritional supplements, including vitamin E, fish oils, and
garlic, decrease platelet aggregation and increase bleeding times. The most
dangerous herbal related perioperative events are bleeding, cardiovascular
instability, or prolongation of anesthetic effect. The five most popular herbal
supplements used in the United States are gingko biloba, St. John’s wort, ginseng,
garlic, and echinacea. All of these may produce adverse effects during surgery and
anesthesia. Most surgery-related side effects can be avoided by stopping herbal
supplements at least two weeks prior to surgery and during the postoperative
period while prescription medications such as blood thinners or antibiotics are
being used (Mohan & Lahiri, 2014). However, the hazards of abruptly discontinuing
any supplement must be considered. Discontinuation could produce symptoms
similar to those that occur when alcohol or narcotics are suddenly withdrawn. There
is little definitive scientific information available, but, as an example, a possible
dangerous situation could occur if St. John’s wort is suddenly discontinued.
Because the herb is known to decrease the amount of other drugs and medications
in the body, the concentration of St. John’s Wort could quickly rise to toxic levels.
Patients must be urged to be honest about substance abuse or recreational
drug and/or alcohol use. Explaining the dangerous consequences of not doing so
may prove effective. For example, a patient who uses cocaine could suffer fatal
dysrhythmias if the surgeon injects epinephrine (as in the use of a local anesthetic
with epinephrine) during the procedure. Checklists or questionnaires tend to elicit
more honest responses than direct questioning. Additionally, assuring patients that
their answers are considered confidential and that questions are only asked to
assure their personal safety may increase cooperation.
Medication reconciliation is a major focus in The Joint Commission’s National
Patient Safety Goals. Although there is continued controversy about the
interpretation and implementation process for the medication standard, the intent is
an important safety measure. On admission, during transfer to another caregiver,
and upon discharge, all the patient’s medications should be reviewed in the context
of other medications being administered or prescribed to avoid duplication or
inadvertent adverse interactions. A list of medications should be compiled including
those medications the patient reported taking prior to the procedure and any new
medications prescribed immediately after the procedure. The list should be given to
the patient postoperatively. The intent is for the list to be shared by the patient with
the pharmacist and primary physician, at a minimum, and other medical providers
as appropriate. See Figure.
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PREADMISSION TESTING
A
mbulatory facilities may have protocols for minimum testing information and
laboratory values required before admission. These parameters may
include hemoglobin and hematocrit, basic metabolic profile (BMP),
complete blood count (CBC), oxygen saturation, chest x-ray, or electrocardiogram
(ECG). For a geriatric patient, blood urea nitrogen (BUN) results may be beneficial.
Obtaining a potassium level is advisable for patients on diuretics because
hypokalemia may cause dangerous dysrhythmias, especially if hypoxemia
develops during surgery or in the PACU. Females of childbearing age should be
asked about the possibility of pregnancy, and their last menstrual period should be
documented. If there is any question of pregnancy, facilities should require testing
prior to surgery.
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A battery of unnecessary tests is not cost effective and may increase patient
anxiety. According to Patey, Islam, Francis, Bryson, and Grimshaw (2012), many
preoperative tests are ordered routinely for apparently healthy patients without any
clinical indication, and the subsequent test results are rarely used. Patey et al.
found unnecessary testing may lead physicians to pursue and treat borderline and
false-positive laboratory abnormalities. Preadmission tests should be ordered
based on the patient’s health status, drug therapy, and with consideration to the
proposed surgical intervention.
Several standard-setting organizations, such as the American College of
Physicians (ACP), the American College of Surgeons (ACS), and the ASA, have
developed recommendations for preoperative patient assessment. According to the
ASA, appropriate indications for ordering tests include the identification of specific
clinical indicators or risk factors such as age, preexisting disease, or magnitude of
the surgical procedure. A chest x-ray and ECG may be necessary only if warranted
by the patient’s history or age. Additionally, previous tests showing normal results
may be acceptable. A chest x-ray within 1 year, ECG within 6 months, or blood
tests done within 6 weeks prior to surgery may be satisfactory if there has been no
intervening clinical event. CMS mandates a history and physical exam must be
completed no more than 30 days prior to the day of surgery and must be reviewed
and updated on the day of the procedure by the physician performing the
procedure (Centers for Medicare and Medicaid Services, 2015, April 15).
The preadmission assessment of pediatric patients should include birth history
and developmental stage. Height and weight in kilograms should be documented.
Head circumference of infants is another facet that may be part of the preadmission
assessment in some institutions. A 2013 study that included 3,693 pediatric
patients concluded that routine blood tests performed preoperatively for pediatric
outpatient surgery were unnecessary (Erdoğan, Balcı, Karaman, Karaman, &
Çavuşoğlu, 2013).
Figure 2-2 is an example of standing orders the preadmission nurse may refer
to when assessing a patient prior to admission to the ambulatory surgery setting.
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PREADMISSION PATIENT NOTIFICATION
I
n 2008, CMS mandated all ambulatory surgery center patients receive
information in writing, and verbally, detailing the surgery center’s patient’s bill of
rights and responsibilities, physician ownership status, if applicable, and
advance directive policy prior to the date of service. After a brief period of lobbying,
this requirement was changed to allow for same-day scheduling of ambulatory
surgery cases as long as the patient receives the outlined information prior to
admission to the ASC. The preadmission nurse is well positioned to assist the
patient with this information and to answer questions about rights, responsibilities,
physician ownership, and advance directives.
Patient Rights and Responsibilities
In December 1991, the Patient Self-Determination Act (PSDA) became effective

stipulating that individuals receiving medical care be given written information about
their rights according to the laws of their state of residence in order to make
informed decisions about that care. This information includes the right to accept or
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refuse medical or surgical care. The act also specifies the right to initiate advance
directives, such as living wills and durable power of attorney (Berrio & Levesque,
1996). Thereafter, many states enacted consumer protection laws relative to
managed care. Recognizing the importance of protecting the privacy of health
information because of the rapid evolution of health information systems, congress
passed the Health Insurance Portability and Accountability Act (HIPAA), which
became law in August 1996.
The following year, President Bill Clinton created the President’s Advisory
Commission on Consumer Protection and Quality in the Health Care Industry that
developed a Patient’s Bill of Rights, whose principles were adopted by many health
plans. Additionally, the Office for Civil Rights enforces the federal law that protects
the privacy of health information along with civil rights in health care and social
services. Congress passed a Patient’s Bill of Rights in 2001, but it was vetoed by
President George W. Bush.
The American Hospital Association (AHA) published a Patient’s Bill of Rights
based on a foundation of respect for human beings as individuals and emphasizing
active patient participation in decisions about the care they will receive (Messner &
Lewis, 1996). Twelve rights are discussed in detail, yet the first states simply that
“the patient has a right to considerate and respectful care.” Accrediting agencies,
such as The Joint Commission and CMS, affirm that patient’s rights and personal
dignity should be respected and that care should be based on individual needs
(Centers for Medicare and Medicaid Services, 2015).
Advance Directives
Under federal law, an advance directive is defined as a “written instruction, such

as a living will or durable power of attorney for health care, recognized under state
law (whether statutory or as recognized by the courts of the state), relating to the
provision of health care when the individual who has issued the directive is
incapacitated” (Patient Self-Determination Act, 1990, §489.100). In accordance with
this definition, advance directives usually include do not resuscitate (DNR) orders
and specify a representative who can make decisions on the patient’s behalf should
the patient become incapacitated. If state law allows, an ASC may decline to initiate
elements of its patients’ advance directives as long as the ASC includes a clear
and precise statement of limitation in its advance directive policies and agrees to
follow other elements of the advance directives that can be appropriately honored
in the ASC. For example, if an ASC does not want to comply with a patient’s DNR
order, the facility’s statement of limitation may indicate that its’ policy is to provide
resuscitation. This information should be presented in lay terms and must be
communicated to every patient in writing and verbally prior to admission (see
Figure 2-3).
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Physician Ownership
Since 2008, CMS has required that an ASC that has physician owners or
investors must provide written notice to the patient or the patient’s representative or
surrogate prior to the start of the surgical procedure stating that the ASC has
physician-owners or physicians with a financial interest in the ASC. The intent of
this disclosure requirement is to assist the patient in making an informed decision
about his or her care by making the patient, or the patient’s representative or
surrogate, aware of when physicians refer their patients to the ASC for procedures
or that physicians who perform procedures in an ASC also have an ownership or
financial interest in the ASC (Centers for Medicare and Medicaid Services, 2015).
An example of this notification is below.
PHYSICIAN OWNERSHIP
Your physician may have a financial ownership in the surgery center.
This investment gives your physician a voice in the clinical management

of the center. Please ask your physician or you may call us at XXX-XXX-
XXXX for a full list of owners.
Please note that your physician provides care at various sites and you
have the right to choose a different location for your procedure.
PATIENT EDUCATION
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very interaction between the perioperative nurse and the patient and his or her
family or caregiver is a teaching opportunity. Patient teaching is especially
important in ambulatory surgery because of the self-care responsibilities assumed
E
when the patient agrees to have a procedure done on an outpatient basis.
Family members and caregivers must be included in the educational
process to prepare them to assume responsibility for care normally
provided by healthcare professionals in hospital settings. Assisting the
patients in developing a good understanding of their specific procedures and their
role in the recovery often increases their trust in the process. Benefits of ensuring
patient understanding include improving the patient’s ability to comply with the
healthcare plan and greater patient satisfaction (Reiter, 2014).
For learning to occur, the timing and setting must be conducive to learning and
the learner (patient) must be receptive. A patient overwhelmed with anxiety,
worries, groggy from anesthesia, or experiencing pain is not receptive to learning.
When these concerns have been addressed, learning and retention are more likely
to take place. Patient education must be individually tailored to the patient’s
surgical procedure, the surgeon’s specific instructions, and the patient’s perception
of expected recovery. A nurse who can assess patient education needs accurately
and adapt educational efforts to the individual patient is invaluable in the
ambulatory surgery setting. The nurse should be careful never to make
assumptions about patients based on their culture, sex, age, or other
characteristics. Individual assessment of each patient and his or her circumstances
is very important. The United States is a diverse country, and healthcare providers
should be aware that a patient’s culture may influence his or her health, and that
individuals from similar cultural backgrounds may vary substantially from one
another. Preadmission and preoperative assessment will assist the nurse in
determining the best educational plan for individual patients. The material must be
presented at the learner’s level of understanding. Knowing the patient’s prior
medical history and type of employment, along with assessing educational level
and family support, may provide insights into the patient’s ability to understand
abstract or complex concepts. Evaluation of the patient’s comprehension may be
possible by posing questions to the patient and requesting return demonstration.
However, if the patient is unable to fully understand the information because of
language barriers, his or her well-being may be jeopardized rather than benefited.
Language and learning assistance result in a patient who is more likely to
participate in his or her recovery and have a better surgical experience.
Communication with the patient should include provision of education and training
appropriate to the individual’s needs, abilities, learning preferences, and readiness
to learn. The ambulatory surgery nurse should be aware of the various and most
common languages spoken in the geographic area and confirm the availability of
written educational material in those languages and access to medical interpreters
or telephonic language services. Per CMS guidelines, it is the responsibility of the
facility to provide a medical interpreter, and it is not appropriate to ask a patient to
bring a family member or friend to interpret.
Methods of teaching common to ambulatory settings include one-on-one
conversation; demonstration, practice, and return demonstration; visual aids such
as videotapes that can be viewed in the facility or taken home; and written material
for the patient’s review and reference.
Common preoperative learning needs for the ambulatory patient include
what will be done in preparation for the procedure;

what they must do the evening before and the day of the procedure;
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what type of postoperative support must be available in the home; and
what they may experience at the facility, including sights, sounds, and
sensations.
Typically, the perioperative nurse provides most patient and caregiver teaching
and support, but providing in-depth information on the surgical procedure or
speculation on the results or complications is not the role of the nurse. The
physician should explain why the surgery is necessary; how it will be performed;
the potential benefits, risks, alternative treatments; and any diagnostic
preprocedure testing required.
The primary opportunities for perioperative nurses to provide the bulk of the
information that a patient needs is during the preadmission interview, during relay
of preoperative instructions, and upon admission. The nurse doing the
preadmission assessment should discuss postoperative restrictions so the patient
can plan ahead for work and home responsibilities. It should be made clear that,
depending on the nature of the surgery, there may be an extended recovery period.
The amount, quality, and probable duration of postoperative discomfort to be
reasonably expected must be presented carefully and diplomatically to inform and
not alarm the patient. Since ambulatory surgery is elective, the patient should be
given the opportunity to express scheduling preferences. Ideally, the physician,
ambulatory facility, and patient can work together to schedule the procedure for the
most optimal day and time for the patient. Preconceived expectations based on
hearsay related to surgical procedures and recovery should be carefully dispelled
or clarified.
Preoperative Instructions
Before surgery, the patient should be contacted to review the preoperative

instructions. This task may coincide with the preadmission interview, especially for
low-risk patients, or at a separate time. Having the patient or caregiver verbally
repeat, describe, or demonstrate the provided instructions provides an opportunity
to assess understanding. Patients with language barriers or those unable to read
may try to avoid this step, which should alert the nurse that compliance may be
questionable. The nurse should assess the patient for how he or she learns best.
Some patients will learn better by listening to instructions and others may prefer
visual aids. The nurse should always seek out family support or support from the
patient’s significant other(s). Community outreach programs may be available to the
patient, and the nurse can assess the need for these programs and connect the
patient to them as appropriate. Patients need preadmission instructions regarding
medications they take for existing medical conditions. Unless ordered otherwise,
most cardiovascular, asthma, antihypertensive, and anticonvulsant therapy is
generally continued until the time of surgery. Medication for Parkinson’s disease is
usually continued until surgery and resumed as soon as the patient is able to
tolerate oral ingestion postoperatively. All medication instructions should be on the
orders of the physician.
The type of anesthesia the patient will receive may be an important factor in
whether or not hypertensive medication is discontinued before surgery. Asthmatic
patients should be told to bring their bronchodilator inhaler with them the day of
surgery because the medication may be necessary to treat breathing difficulty
related to anxiety or to lessen the possibility of coughing or bronchospasm during
induction of general anesthesia.
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Anticoagulants are usually stopped several days before surgery to allow the
prothrombin time to return to normal. Antidepressant medication use should be
discussed with the patient’s anesthesiologist prior to patient admission to determine
the correct course for each patient. Patients with insulin-controlled diabetes will
need an individualized preoperative and postoperative regimen. Patients should
also be advised that any oral medication required the morning of surgery should be
taken with one sip of water. Explaining why something must be done or will be done
is usually better than presenting lists of do’s and don’ts. For example, explaining
that the concept of nothing-by-mouth (NPO) is a safety feature to prevent serious
complications may enhance compliance. Explaining that, in addition to no food or
liquid intake, NPO includes not chewing gum or sucking on lozenges because
either one of these may stimulate the production of gastric acid.
Patient understanding facilitates patient compliance. The nurse should make
sure the patient clearly understands
when to begin the NPO countdown – specifically by the hour, rather than a
general “6 hours before”;
when to arrive at the ambulatory surgical center – again, the specific hour (It
is usually best not to discuss the scheduled surgery start time as this can
easily be confused with the patient’s arrival time.);
what to leave at home – jewelry, valuables, and cosmetic prostheses if

appropriate (To promote safety and reduce stress, glasses and hearing aids
may be worn and removed before receiving medication or undergoing
surgery. This action should be documented, and the items should be placed
in safekeeping. Contact lenses must be removed.);
what to wear – loose-fitting clothes, low-heeled shoes;

what to bring – insurance card and any necessary copayment; and
any required durable medical equipment such as crutches or a walker.
When communicating with the patient, the nurse should always explain and
never assume.
Pain Management Education
Just as obtaining an oxygen saturation level preoperatively aids in evaluating

the patient during the postsurgery recovery phase, obtaining a preoperative pain
profile aids in postoperative evaluation and treatment of pain. Information elicited
from the patient or caregiver should include:
significant previous or ongoing instances of pain and its effect on the patient;
previously used methods for pain control that the patient has found either
helpful or unhelpful;
the patient’s attitude toward the use of opioid, sedative, or other medications,
including any history of substance abuse;
the patient’s typical coping response to stress or pain, including the possible
presence of disorders such as depression, anxiety, or psychosis;
family expectations and beliefs regarding pain, stress, and postoperative

course;
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ways in which the patient describes and shows pain; and
patient knowledge of, and preferences for, pain management methods and
instruction.
Providing patients with valid information about what they are likely to
experience, including the expected level of discomfort, decreases pain experienced
and analgesic use. Similarly, information related to physiologic healing, such as
coughing, deep breathing, physical therapy, and ambulation, also reduce the need
for pain medication. During the preoperative assessment, the patient should be
given practical advice about pain management at home. It is important for the
patient and caregiver to understand that it is more effective to prevent pain than to
treat it once it has been established.
SUMMARY
P
readmission assessment is a time for learning and instruction, for both the
nurse and the patient. The nurse should learn as much about the patient’s
history and current condition as possible and instruct the patient on how
best to prepare for surgery, experience the ambulatory procedure, and cope
postoperatively. To successfully accomplish these objectives, the nurse should not
overlook the need to support the patient psychologically.
Again, ambulatory surgery patients should be assessed as thoroughly as a
hospitalized patient would be, relative to the surgical procedure and patient’s
physical and mental condition, but with a strong focus on same-day discharge
planning. The patient’s family or significant other(s) should be included whenever
appropriate.
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EXAM QUESTIONS
CHAPTER 2
Questions 9–18
9. Which of the following criteria would qualify as a covered ambulatory surgery

center procedure according to the Centers for Medicare and Medicaid Services?
a. It directly involves major blood vessels.
b. It requires major or prolonged invasion of body cavities.
c. It commonly requires systemic thrombolytic therapy.
d. The patient would not typically be expected to require active medical
monitoring and care at midnight following the procedure.
10. According to the American Society of Anesthesiologists (ASA) a physical

status classification of ASA III is
a. a patient with mild systemic disease.
b. a patient with severe systemic disease.
c. a normal healthy patient.
d. a patient with severe systemic disease that is a constant threat to life.
11. Which factors are associated with an increased likelihood of unplanned

hospital admission following ambulatory surgery?
a. ASA classes II-IV, increased body mass index, and Mallampati 2
classification
b. Diabetes, hypotension, and patients under age 18 years of age
c. Stable chronic conditions such as well-controlled diabetes
d. Patient use of beta blockers and insulin
12. Which of the following is not a consideration when assessing for obstructive
sleep apnea?
a. Loud snoring
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b. Hypertension
c. Neck circumference
d. Anticoagulant therapy
13. During the preadmission assessment, the patient informs the nurse he has a
history of red man syndrome related to the administration of vancomycin. The
nurse knows this reaction is an example of
a. an allergic drug reaction.
b. an immune-mediated allergic reaction.
c. a nonimmune hypersensitivity reaction.
d. a desired reaction to an antibiotic.
14. Preadmission tests should be ordered based on all of the following factors
except
a. the patient’s health status.
b. the patient’s anxiety level.
c. the patient’s drug regimen.
d. the patient’s proposed procedure.
15. The Centers for Medicare and Medicaid Services mandates that a history and
physical exam must be completed
a. no more than 30 days prior to the procedure and must be reviewed and
updated on the day of the procedure by a physician or qualified practitioner.
b. no more than 45 days prior to the procedure and must be reviewed and
updated on the day of the procedure by the ambulatory surgery nursing staff.
c. on the day of the procedure by the physician’s office staff or by the
physician performing the procedure.
d. no more than 30 days prior to the procedure and must be reviewed and
updated after the procedure is completed.
16. Per the Centers for Medicare and Medicaid Services, prior to admission into
an ambulatory surgery center, patients must be informed about all of the
following except
a. patient rights and responsibilities.
b. advance directive policies.
c. history and physical exam requirements.
d. physician ownership.
17. During the preadmission interview, the nurse learns the patient does not speak
English and his preferred language is Spanish. What should the nurse do next?
a. Arrange for a medical interpreter
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b. Suggest the surgery be canceled

c. Ask the patient to bring a friend on the day of the procedure who can
translate
d. Enlist an ambulatory surgery nurse who speaks Spanish to translate
18. The preadmission nurse should provide the patient with education related to
a. why the surgery is necessary.
b. how the surgery will be performed.
c. the potential benefits and risks related to the surgery.
d. what type of postoperative support must be available in the home.
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CHAPTER 3
PREOPERATIVE ADMISSION AND

ASSESSMENT
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to identify preoperative
patient assessment requirements performed by physicians, anesthesia
providers, and nurses.
CHAPTER OBJECTIVES
A
1. Describe the informed consent process and the nurse’s role as a patient
advocate.
2. Discuss actions the preoperative nurse may take to ensure accommodation
of cultural needs and a therapeutic environment of care.
3. Discuss the use of a patient safety checklist and describe the benefits.
4. Explain the patient admission process and the actions associated with the
nursing assessment of the preoperative patient.
5. Describe the preanesthesia assessment and identify the reason for this
assessment.
6. Explain the physician’s role in the preoperative assessment of the patient.

7. Explain common medications administered to the preoperative patient.
INTRODUCTION
horough and comprehensive preoperative assessment of the prospective
T
ambulatory surgical patient is essential for perioperative management and
positive outcomes. Similarly, the importance of teaching patients before
surgery about what may be expected after surgery should not be
overlooked. Ambulatory surgery patients should be assessed by the physician
performing the surgical procedure, by the anesthesiologist, and by the nurse. This
assessment information should be used to ensure the best possible outcome for
the individual patient.
ADVOCACY
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mbulatory surgery patients assume considerable responsibility for self-care.

The patient and responsible adult who will attend the patient postoperatively
A
must be capable of understanding and providing the level of care necessary
for the best possible outcome. According to the Centers for Medicare and Medicaid
Services (CMS) regulations (Centers for Medicare and Medicaid Services, 2015),
unless a physician documents an exemption, the facility may not discharge any
patient who is not accompanied by a responsible adult. Facilities are advised to
develop policies that address what criteria a physician should consider when
deciding whether a patient does not need to be discharged in the company of a
responsible adult. Exemptions must be clear and specific to individual patients and
are not blanket exemptions to a whole class of patients (Centers for Medicare and
Medicaid Services, 2015). As the patient’s advocate, the nurse should assist in
arranging for preoperative assistance and postoperative care by community
healthcare professionals if dependable friends or relatives are not available.
Environmental factors should also be explored preoperatively. Distance from the
facility to the home and available emergency treatment near the patient’s home
must be considered. If professional home health care is the patient’s best option,
the home healthcare facility may arrange for a preoperative on-site interview in the
patient’s home allowing the nurse to evaluate and identify areas of postoperative
concern. In all cases, the nurse should try to identify potential postoperative living
adjustments that may be necessary and stress to the patient and caregiver the
need to make arrangements accordingly before the day of surgery.
Although other healthcare professionals advocate for their patients, the
advocate role is designated as a central role of nursing practice. Nurses define
advocacy as intervening on behalf of a patient within a system resulting in nurses’
actions of speaking, fighting, and standing up for patients (Hanks, 2010). Patient
advocacy is the nurse being the patient’s voice by acting as a guide or liaison,
protecting the patients, preserving their dignity, using expert knowledge to advocate
effectively for them by challenging traditional healthcare power structures, and
empowering the patients. Ambulatory surgery nurses must understand that they are
charged with advocating for their patients, sometimes before the patient even
arrives for surgery. The preadmission nurse and the preoperative nurse are well
positioned to assess the patient to ensure the ambulatory setting is appropriate for
the patient while considering other factors, including transportation issues, family
support, home environment, and work-related conflicts. The holistic approach is the
hallmark of nursing practice and especially important given the independence the
patient will face almost immediately after surgery.
INFORMED CONSENT
nformed consent for surgery refers to voluntary consent given by a mentally
I
competent prospective patient, or by a person legally responsible for the
patient, for treatment after the patient (or responsible party) is informed of the
purpose, methods, benefits, alternatives, and potential risks associated with the
treatment. Awareness of risk is necessary for any person to make an informed
choice.
The informed consent process begins in the physician’s office with discussion
between the physician and the patient or guardian. In its “Statements on
Principles,” the American College of Surgeons states that “Patients should
understand the indications for the operation, the risk involved, and the result that is
hoped to attain.” As part of their public information service, the College has
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suggested that every patient should ask his or her surgeon the following 10
questions before giving informed consent:
1. What are the indications that have led your doctor to the opinion that an
operation is necessary?
2. What, if any, alternative treatments are available for your condition?
3. What will be the likely result if you don’t have the operation?
4. What are the basic procedures involved in the operation?
5. What are the risks?
6. How is the operation expected to improve your health or quality of life?
7. Is hospitalization necessary and, if so, how long can you expect to be

hospitalized?
8. What can you expect during your recovery period?

9. When can you expect to resume normal activities?
10. Are there likely to be residual effects from the operation?
(American College of Surgeons, 2015)

A major issue is the patient’s capacity to understand the explanations; if the
patient speaks a foreign language or is deaf, a qualified interpreter will be needed.
Alternatives to the proposed treatment plan should also be presented. For a minor,
consent is usually granted by the parent or legal guardian. Increasingly, older
children are included in the decision-making process.
The ambulatory facility must have a legally approved consent form to document
permission for staff to provide patient care, which includes general treatment. The
essential components of informed consent documentation are a clear description of
the planned procedure and its risks and benefits; possible alternative treatment
therapies, including the option of no treatment, and their risks and benefits;
documentation that shows that the patient had the chance to ask questions; an
authorization with signature of the patient or guardian; and the signature of the
physician (Cainzos & González-Vinagre, 2014).
Informed consent for the procedure and anesthesia is required. More recently, a
separate written (or electronic) document has been used by some facilities to
document definitive procedural consent and definitive anesthesia consent. CMS
requires the anesthesia care provider to discuss with the patient or guardian the
risks and benefits, including the likelihood of each, related to anesthesia. The
anesthesiologist should document the occurrence of this discussion, as well as the
patient’s agreement and understanding, in each patient’s medical record. This will
accurately reflect that anesthesia consent is a separate process from the
procedural consent. Assessment for anesthesia consent is the unique domain of
the anesthesiologist. Nurses sometimes become involved in the informed consent
process if they notice a patient or guardian’s need for more information. These
circumstances require nurses to act as patient advocates. Nurses, who usually
have strong and favorable interaction with patients, family, and doctors, can ensure
that their patients’ rights to make an informed decision are respected. This role is in
keeping with the American Nurses Association’s Code of Ethics for Nurses. After all
details are explained to the patient by the surgeon and the anesthesiologist and
informed consent for the surgery is obtained, the perioperative nurse may obtain
the patient’s signature on the consent form(s). Nurses must not confuse any
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obligation to obtain informed consent with witnessing the patient’s signature on an

informed consent form. Even if the nurse is present during the informed consent
discussion and process, witnessing a patient’s signature on the informed consent
form is simply an attestation that the patient (or guardian) has signed his or her
name to that particular form at the date and time noted. The requirement to obtain
informed consent is not placed on the nurse. If, as part of the nurse’s assessment,
the nurse has concern that the patient may not understand the procedure he or she
has consented to undergo or that the patient may lack capacity to consent to such
treatment, it is the nurse’s duty to alert the physician (Wilhite, 2010).
If the ambulatory surgery facility has the capability to perform blood
transfusions, a signed and witnessed document stating the patient’s wishes
regarding transfusion should be obtained and made a permanent part of the
medical record. Ambulatory surgery facilities usually implement a consent-to-treat
document that is separate from the procedural and anesthesia consent and is
completed at the time of admission. This consent document, which is specific to the
facility, generally covers the documentation of preadmission patient notification of
rights, physician ownership, advance directive policy, presence of vendor
representatives, possibility of photography and video recording, medical and clinical
student involvement, and pathologist and anesthesiologist billing notification,
among other general policy topics.
ENVIRONMENT OF CARE
T
he preoperative nurse is responsible for ensuring a therapeutic environment
for the ambulatory surgical patient. The nurse should make safety checks at
every patient bay before admitting any patients to the area. Specifically, the
nurse should make sure oxygen and nasal cannulas are ready, warm blankets are
stocked, and anticipated medications are available. Each day, prior to the
admission of patients, the clinical staff should check the defibrillator or automated
external defibrillator for acceptable functions. The temperature of the medication
refrigerator should be viewed to ensure proper temperature was maintained
overnight. All medical gases should be inspected for current supply levels and
proper function. The humidity, temperature, and airflow should be confirmed in the
operating rooms, procedure rooms, sterile processing room, and soiled utility room.
The nurse should inspect the preoperative unit for available supplies and patient
wellness issues. The unit temperature should be adjusted for the comfort of the
patient; clean patient gowns and socks should be available. Ideally, the nurse
should have the ability to adjust lighting in the unit to the patient’s preference after
the IV is started. The nurse should note any equipment that is not functioning and
familiarize herself or himself with available replacement equipment. The patient
area should be kept clean and organized throughout the day. The clinical staff
should work together to create a comfortable and calm environment for the patient
while focusing on proactive solutions to safety concerns.
Cultural Competence
Expert nurses are culturally competent and take time to assess patients for
cultural needs. It is important to never assume patient’s needs based on culture
alone, thus avoiding stereotypes. The patient should be the source for information
about cultural needs, and the nurse may complete a cultural assessment upon
admission to identify language and learning preferences. This individualized
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assessment will assist the nurse in implementing actions that will meet the needs of
the patient (see Table 3-1).
Safety Checklist
In 2007, the World Health Organization (WHO) launched the Second Global
Patient Safety Challenge: Safe Surgery Saves Lives. This project’s goal was to
improve the safety of patients undergoing surgical procedures around the world.
Anesthesiologists, nurses, surgeons, safety experts, and patients developed the
WHO Surgical Safety Checklist. All of the items included on the Checklist are
supported by evidence that, if used reliably, can reduce complications from surgery
(World Health Organization, n.d.b). The Checklist helps ensure that important
safety steps are reliably followed for each procedure or surgical case. Many of the
items included in the list are already standard in some institutions, but the WHO
found that in most facilities there are opportunities for improvement in consistency.
See Figure 3-1 for the WHO safety checklist. The WHO’s example checklist is not
intended to be comprehensive, and modifications for use are encouraged.
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Note. From World Health Organization. (n.d.b) Surgical safety checklist and implementation manual. Retrieved from
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
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PATIENT ADMISSIONS
T
he preoperative nurse should greet the patient and family or responsible
adult in the waiting area. It is important for the nurse to provide a general
orientation to surroundings and to the process that will occur during the
patient’s stay. Before guiding the patient to the preoperative area, the nurse should
carefully identify the patient using two identifiers, such as the patient’s name and
date of birth. The nurse should be careful to ask the patient to independently
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provide his or her identifiers while never suggesting them. For example, the nurse
will ask, “What is your name and date of birth?” and not, “Is your name Joseph
Smith, born September 10, 1973?”
Upon arrival in the preoperative area, the nurse should assure the procedure
consent form is signed by the patient or guardian. The nurse will verbally verify with
the patient or guardian, and by comparing the medical record, that the procedure
and procedure site are correct. The nurse will ask the patient to verbalize what the
intended procedure is to be, rather than saying the procedure and having the
patient merely concur. The nurse should ensure the physician’s order for the
procedure matches the physician’s history and physical examination documentation
and matches the patient’s verbal verification. Finally, the nurse should verify the
operating room schedule lists the correct procedure for the patient. Any
discrepancy must be immediately and thoroughly investigated and resolved. If there
is no discrepancy or other issues, the patient may sign the procedure consent form.
The name and contact information of the responsible adult that will accompany
the patient postoperatively should be documented. The nurse should assure that
transportation and home support are appropriate and communicate any potential or
actual problems to the physician prior to the patient having any sedation. The nurse
should confirm the placement of an allergy bracelet on patients who have allergies.
After the patient changes into a patient gown, belongings should be labeled with
the patient’s name and placed in a safe place, preferably accompanying the
patient.
Nursing Assessment of the Preoperative Patient
The nurse should assess and document the following:
vital signs (e.g., temperature, blood pressure, pulse, respirations, and

oximetry reading);
breath sounds;
physical assessment appropriate to the procedure;
pain and comfort assessment;
allergies and type of reaction;
medications the patient is taking and those taken on the day of the
procedure;
NPO status (see Table 3-2);

skin condition at procedure site;
compliance with at-home preparation or instructions prescribed by the

physician;
prosthetic devices and personal belongings;
preprocedure blood glucose level on diabetic patients if ordered by

physician;
any special concerns or needs of the patient; and
deep vein thrombosis (DVT) risk assessment (see Figure 3-2).
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The preoperative nurse should repeat assessments as necessary and notify the
physician of abnormalities, noncompliance with preparation, or other problems. All
ambulatory surgery patients should be considered to have a heightened risk of
falling because of one or more of the following issues: anxiety and/or fear, general
weakness, nutritional and fluid status, unfamiliar environment, gastrointestinal
status from prior preparation, sedation, presence of an intravenous line while
ambulating, no shoes while ambulating, improper or inadequate positioning or use
of safety devices, and postoperative pain or splinting. Nursing assessment is
holistic and takes into consideration all of the patient’s potential risks, initiating
mitigation where a risk is identified as part of the overall procedural plan of care.
The nurse should identify, document, and communicate any special care needs
of the individual patient, taking into consideration the patient’s age; cultural and
family background; spiritual beliefs; sensory, intellectual, or motor limitations;
chronic pain or other conditions, and an identified or expressed level of anxiety or
specific fears and concerns.
PATIENT EDUCATION
D
uring the preoperative phase, the nurse should provide teaching to the
patient and family or significant others that includes general information on
the procedure and what to expect before, during, and after the procedure,
and after discharge. Teaching in the postoperative phase is unlikely to be effective
because of the lingering sedation effects on the patient. Provide adequate time and
open communication preoperatively to encourage questions and comments. It is
important to provide honest answers to questions and coordinate physician
consultation with the patient preoperatively as necessary. Patients and caregivers
often fear that they will not be able to provide adequate care after discharge. Even
worse, they are concerned that they may do the wrong thing and cause harm. The
more extensive the surgery is, the greater is their apprehension.
Patients usually equate recovery with the absence of pain and the ability to
return to normal daily living, but deficits in self-care activities may persist
postoperatively for as long as a week. Teaching practical applications of
postoperative care, in addition to the customary medical instructions, should be part
of patient education. Concerns that should be addressed include
bathing and washing hair,
dietary advice,
prevention of constipation secondary to analgesic medications,

allowed activities,
activities to avoid (lifting, driving, etc.),
therapeutic rest versus taking it easy, and
wound care.
For example, grocery shopping, caring for children, and doing laundry all fall
into the category of lifting. Patients also need to be aware that both pain and
medication might contribute to slower reaction times.
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Standard printed postoperative instructions could be improved with images and

personalized notations made by the nurse. Recently, web-based patient instruction
sites have been developed and are being offered to patients as a way to make the
learning experience more interactive. Ambulatory surgery facilities can direct
patients to these websites preoperatively and the patient can review facility-
approved instructions prior to admission and continue to review them as often as
needed upon arrival home after the procedure. Ideally, the patient arrives for
surgery well prepared and armed with any questions that need clarification.
In addition to medications or prescriptions, specific instructions given by the
surgeon and a 24-hour telephone number should be provided. Patients being
discharged from an ambulatory surgery facility are best prepared if the
perioperative nursing staff has addressed the practical postoperative self-care
topics that the patients and caregiver want to know, as well as the specific
postprocedure instructions they need to know.
Pain Management
The patient should be provided with education about pain management,

including the 0 to 10 scale or pediatric age appropriate tools, such as the Wong-
Baker FACES® Pain Rating Scale (see Figure 3-3), that will be used to describe
pain or discomfort in the postanesthesia care unit (PACU). Although patients should
be instructed to take the prescribed pain medication on a continuous basis for 1 to
2 days as tolerated, suggesting nonpharmacologic methods of pain management
may decrease the total amount of analgesic required and ease the transition from
medication. Cognitive-behavioral strategies include relaxation, distraction, imagery,
meditation, and prayer. Patients with cognitive deficits tend to benefit from the
distraction provided by music and may also be capable of rhythmic breathing
relaxation exercises with coaching from the caregiver. Physical interventions
include applications of heat or cold, massage, movement, and rest, or
immobilization. Applications of heat or cold, if ordered by the physician, alter the
pain threshold, reduce muscle spasm, and decrease local swelling. Simple rest is
an important part of pain management that should not be overlooked, especially in
the first 48 hours postoperatively.
Care of the Surgical Incision
Care of the surgical incision area is a major concern. Some patients fear that
the incision may open, especially after sutures or staples are removed.
Consequently, the nurse should explain the healing process simply and clearly in
lay terms. Ambulatory patients frequently are discharged with a wound dressing in
place and are concerned about causing infection when changing or removing the
dressing. To allay this fear, the patient (appropriate to age and mental status) and
caregiver should be instructed how to do this, preferably with the patient and
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caregiver giving a return demonstration. They should also be alerted that increased
pain, redness at the site, and fever are other symptoms of possible infection.
HISTORY AND PHYSICAL
A
ccording to the Centers for Medicare and Medicaid Services, a complete
history and a report of a physical examination appropriate to the procedure
being performed must be in the patient’s medical record prior to the
procedure being initiated. The medical history and physical examination must be
completed and documented by a physician or other qualified licensed practitioner in
accordance with state law and generally accepted standards of practice within 30
days prior to the procedure day. All history and physicals must be updated and
reauthenticated on the day of the procedure. If the history and physical is greater
than 30 days, it is expired and a current history and physical must be written and
placed in the medical record prior to the procedure. If the patient is readmitted
within 30 days for the same or related diagnosis, an interval history and physical
examination reflecting any subsequent changes may be used.
The history and physical should include the following generally required
elements:
chief complaint;
history of present illness;

medical and surgical history;
current medications;
allergies;
social and family history, if applicable;
review of body systems appropriate to the procedure;

physical examination that must include heart and lungs, and focused review
pertinent to the procedure; and
impression or diagnosis, and procedure(s) or plan of care.
The preoperative nurse and the circulating nurse should make sure an
appropriate history and physical is in the medical record before the patient is
transferred to the operating or procedure room. The nurse should review the history
and physical and note any variables related to the patient’s health that may be
significant during the care episode.
PREANESTHETIC ASSESSMENT
U
pon admission to the ambulatory surgery center, each patient must have a
presurgical assessment. A physician is required to examine the patient
immediately before surgery to evaluate the risk of the anesthesia and the
risk of the procedure for the individual patient. This component must be conducted
by a physician immediately prior to surgery and is not part of the history and
physical completed by the physician performing the procedure. This assessment is
most often performed by the anesthesiologist. The patient must be assessed for
any changes in his or her condition that might be significant for the planned
procedure or surgery. Patients may have had a change in health status after an
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initial history and physical done in the physician’s office but may not recognize the
significance. Any changes in health and medications can have an impact on the
patient’s ability to tolerate the surgery or anesthesia, and the postadmission,
presurgical assessment is designed to identify these changes and take appropriate
action up to and including postponing or canceling the surgery (Centers for
Medicare and Medicaid Services, 2015). In addition, the presurgical assessment
must identify and document any allergies the patient may have to drugs and
biologicals or indicate that the patient has no known allergies to drugs and
biologicals.
The preoperative assessment by the anesthesia provider is meant to build on,
not duplicate, the nursing assessment for the procedure. A skilled perioperative
nurse may identify areas of concern and provide valuable information to facilitate
safe anesthetic management, especially if the patient is not seen by the anesthesia
provider prior to the day of surgery. When there is a positive or suggested history of
previous anesthetic complications or allergic reactions, a review of previous records
is warranted if they can be obtained. It is also important that the anesthetic history
of blood relatives be evaluated because genetic predisposition is associated with
potential anesthetic complications, such as malignant hyperthermia (MH),
porphyria, and low plasma cholinesterase (pseudocholinesterase) levels that
prolong response to succinylcholine.
The medical record should be carefully reviewed for the patient’s medical
history, physical examination findings, results of diagnostic procedures and tests,
and pertinent personal information. All information should be evaluated relative to
how it may impact the patient’s response to and need for anesthesia. The patient is
then interviewed and examined, addressing specific areas of concern and
importance.
A major area of concern is airway maintenance during the procedure or in the
event of an emergency. Previous head or neck surgery, radiation therapy, chronic
neck pain, hoarseness, or sleep apnea are important considerations. The general
state of dentition should be examined and documented, including loose teeth,
missing teeth, protruding incisors, chipped or cracked teeth, partial and full
dentures, crowns, and other cosmetic dental prostheses. Mobility of the jaw and
neck, including extension capability of the neck, should be examined also. When
performed properly, the Mallampati classification (MMT) is reported to be a simple
and reliable method for preanesthetic airway assessment. MMT considers the
anatomy of the oral cavity and is particularly focused on the visibility of the base of
the uvula, faucial pillars (the arches in front of and behind the tonsils), and soft
palate. A high MMT score is associated with difficult intubation and a higher
incidence of sleep apnea (Manabe, Iwamoto, Miyawaki, Seo, & Sugiyama, 2014;
see Figure 3-4).
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Joint mobility may also be evaluated, and complaints of pain or limitation of

motion should be noted on the medical record to establish a reference for
comparison if postoperative complaints develop. This information is also helpful for
protective intraoperative positioning. If regional anesthesia is anticipated, the site of
injection should be examined for anomalies or skin infection. Potential venous
access difficulties also should be noted. The choice of anesthetic agents and
technique is influenced by the type of surgery, the patient’s physical status, the
patient’s preference, and the surgeon’s preference. As with the surgical procedure,
the options, techniques, benefits, and risks should be discussed with the patient or
legal guardian, and a plan should be developed for anesthetic management. When
all questions have been clearly answered and the patient agrees to the plan, legal
consent is obtained.
MEDICATION MANAGEMENT
T
he nurse will need to physically prepare the patient for the procedure
through preparation of skin, IV access, and ordered medications.
Documentation of the effects of all medication as appropriate is necessary.
The anesthesia provider and the physician performing the procedure may order
medications to be administered preoperatively. Emphasis for medication given for
ambulatory surgery is on achieving home readiness as safely and efficiently as
possible.
Primary objectives of the administration of medication preoperatively are relief
of anxiety, some degree of sedation, prevention of infection, and patient comfort.
Ideally, any medication prescribed for outpatients should have rapid onset of action
and should not prolong recovery nor unduly impair psychomotor skills.
Unfortunately, most sedatives, hypnotics, and analgesics currently available impair
psychomotor performance. Coordination and fine motor skills may be impaired for
up to 12 hours. However, preoperative anxiety, stress, and postoperative pain also
interfere with postoperative psychomotor function. Table 3-3 summarizes the
different classifications of preoperative medications.
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Note. From the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the
Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA). (2013). Clinical practice guidelines
for antimicrobial prophylaxis in surgery. Retrieved from http://www.ahaphysicianforum.org/resources/appropriate-
use/antimicrobial/content%20files%20pdf/SHEA-Clinical-Guidelines.pdf
Benzodiazepines
Benzodiazepines, such as Midazolam (Versed), are potent amnesics and

anxiolytics. Midazolam exhibits a short half-life, but its rapid disappearance from
the bloodstream does not guarantee fast recovery. Instead, recovery may be similar
to diazepam (Valium), which has been shown to affect coordination and reaction
skills for up to 5 hours. This lack of correlation between half-life and clinical
recovery has also been found when IV midazolam and diazepam are compared in
sedative techniques.
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When used as premedications, moderate, oral doses of midazolam do not

adversely affect the quality and duration of recovery after brief general anesthetic
exposures, whereas small doses may fail to produce sufficient relief from anxiety.
Small and moderate doses of oral midazolam may result in significantly impaired
performance for at least 2 hours after surgery. Dizziness is also a potential side
effect of benzodiazepines, regardless of the dosage.
Benzodiazepines are available in liquid form for children, but midazolam has an
unpleasant taste, so it is best given with a small amount of a sweet liquid other than
fruit juice, which may affect the medication’s metabolism.
Opioid Analgesics
The use of opioid analgesics as premedications in an ambulatory surgery

setting is controversial. Although it seems advisable to avoid the use of long-acting
narcotics, the use of fentanyl (Sublimaze) or sufentanil (Sufenta) may decrease the
sedative-hypnotic medication requirements intraoperatively. Postoperative nausea
and vomiting frequently associated with opioids may prolong recovery.
Because of the lower doses of anesthetic required intraoperatively, patients who
receive short-acting narcotics and do not experience undesirable side effects may
have a more rapid recovery than do patients who receive benzodiazepines.
Outpatients undergoing procedures associated with significant postoperative pain
may benefit from the use of longer acting narcotics, which may provide effective
analgesia after discharge.
For particularly anxious patients who might benefit from preoperative
pharmacologic support, the sparing and judicious use of benzodiazepines or short-
acting opioid analgesics may be advisable. This approach may be especially
applicable for patients undergoing regional anesthesia (i.e., regional block) when,
despite skin infiltration of the injection site with a local anesthetic, there may be
discomfort during the placement of the block.
Innovative methods of administration are available for patients unable or
unwilling to take oral premedication but requiring medication before an IV is started.
Fentanyl has been shown to be effectively absorbed transmucosally in lollipop form
(oral transmucosal fentanyl citrate) and provides a pleasant, nonthreatening
method of delivering preanesthetic medication, especially to children. Onset of
action occurs within 5 to 15 minutes, with maximum reduction in apprehension and
peak analgesic effect seen 20 to 30 minutes after the start of administration.
Antiemetics and Aspiration Prophylaxis
Certain physiologic conditions predispose the patient to regurgitation of gastric

contents, possibly resulting in pulmonary aspiration. Examples of such conditions
include morbid obesity, hiatal hernia with reflux, pregnancy, and diabetes. Extreme
anxiety, fear, and use of opioids are additional risk factors. These patients may
benefit from the preoperative administration of antiemetics. Combining agents with
different modes of action may increase efficacy.
Metoclopramide (Reglan) is a gastrokinetic medication with central and
peripheral actions. It increases motility of the upper gastrointestinal tract and
accelerates gastric emptying. Metoclopramide may be administered orally, via IV, or
intramuscularly (IM), either prophylactically as a preoperative medication or as a
postoperative treatment for nausea. It has no sedative effect, but dystonia or other
extrapyramidal effects are possible, especially with the concurrent use of
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phenothiazines or butyrophenones (e.g., droperidol) that also have antinausea

effects.
Ondansetron (Zofran) is a selective serotonin 5-HT3 receptor antagonist that
acts centrally in the brain and peripherally at vagal nerve endings. Unlike
metoclopramide, it does not affect gastrointestinal motility but appears to play an
important role in initiation of the vomiting reflex. Ondansetron has no sedative effect
and may be given either orally or by IV; pain may be experienced with IV injection.
Ondansetron may be administered preoperatively or during the surgery to prevent
postoperative vomiting.
Dolasetron (Anzemet), a 5-HT3 receptor blocking antiemetic agent, may cause
prolongation of cardiac conduction intervals. It should be used cautiously or
avoided in patients on antiarrhythmic medications, high dose anthracycline therapy,
or diuretics that may cause electrolyte imbalance such as hypokalemia.
The histamine-2 (H2)-receptor antagonists cimetidine (Tagamet), ranitidine
(Zantac), and famotidine (Pepcid) inhibit gastric acid secretion. They may be given
orally or by IV, preferably at bedtime the evening before surgery and repeated at
least 2 hours before surgery. H2-receptor antagonists only affect the pH of gastric
acids secreted after their administration.
Application of a transdermal scopolamine patch 2 hours before surgery may be
effective for nausea, but the anticholinergic side effects associated with
scopolamine, such as dry mouth, blurred vision, disorientation, and urinary
retention, may be a contraindication.
Antibiotics
Antibiotics given via IV may be ordered prophylactically, and the optimal time for
administration of preoperative doses is within 60 minutes before surgical incision.
Some agents, such as fluoroquinolones and vancomycin, require administration
over 1 to 2 hours; therefore, the administration of these agents should begin within
120 minutes before surgical incision. Because ambulatory surgery patients are
rarely in the preoperative phase for more than 60 minutes, ambulatory surgery
facilities are opting for alternatives to these agents because of the prolonged
infusion time.
Guidelines from the American Society of Health-System Pharmacists (ASHP),
the Infectious Diseases Society of America (IDSA), the Surgical Infection Society
(SIS), and the Society for Healthcare Epidemiology of America (SHEA) for selection
of antimicrobial agents for specific surgical procedures and alternative agents are
provided in Table 3-3.
THE PATIENT HANDOFF
A
consistent process must be used for a verbal handoff of patient information
during the transfer of care to another provider, such as when the
preoperative nurse hands off the patient to the intraoperative circulating
nurse. MAPS (definition below) is a common acronym used for this process. This is
a two-way process; there is opportunity to ask and answer questions among the
caregivers. This is an essential component of safe patient care that must be
completed for every patient. These four items describe the information needed in a
safe handoff.
MAPS Definition
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M = Medications (includes drugs received, such as sedation, analgesics, or

anesthesia agents)
A = Allergies (includes information on all patient allergies – medication and
other allergies)
P = Procedure/Pertinent Information (includes pertinent health history,
procedure done, findings, dressing, etc.)
S = Special Needs (includes family waiting in lobby, crutches in car,
communication concerns, disabilities, etc.)
SUMMARY
T
he preoperative patient may be experiencing anxiety and stress before
surgery. The preoperative nurse works to create a comforting and safe
environment for the patient and acts as the patient’s advocate when needed.
The nurse, physician, and anesthesiologist should work as a team to gather all
needed patient assessment information. These assessments are used to identify
any existing concerns related to the scheduled procedure and to proactively
mitigate those concerns to ensure the best possible outcome for the patient. The
nurse should understand how to use assessment information to keep the patient as
safe as possible.
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EXAM QUESTIONS
CHAPTER 3
Questions 19–26
19. The preoperative nurse interviews Mr. Smith after he is admitted for surgery at
the ambulatory surgery center. Mr. Smith tells the nurse he has questions for the
surgeon that he would like answered before surgery. At around the same time,
the circulating nurse and the anesthesiologist arrive at Mr. Smith’s bedside and
indicate they are ready to transport Mr. Smith to the operating room. The
preoperative nurse knows the surgery schedule is full and any delay could
cause disruption. What should the preoperative nurse do?
a. Ask the anesthesiologist to answer Mr. Smith’s questions
b. Give a report to the circulating nurse and let him or her know Mr. Smith
has questions for the surgeon
c. Contact the surgeon and explain that Mr. Smith has questions that need to
be addressed prior to sedation
d. Tell Mr. Smith there is no time for his questions
20. Which of the following is not part of the informed consent?

a. Available alternative treatments
b. Risks associated with the proposed treatment
c. Benefits associated with the proposed treatment
d. The gauge of the IV the nurse will use
21. The nurse does all of the following to integrate cultural competence into
patient care except
a. anticipating the patient’s needs based on stereotypes.
b. offering translated, written materials.
c. providing a medical translator.
d. completing a cultural assessment of the patient.
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22. Safety checklists contribute to patient safety in surgery by

a. ensuring important safety steps are reliably followed for each procedure or
surgical case.
b. helping the physician remember each step involved in the surgical case.
c. helping the nurse document all steps taken to ensure safety.
d. ensuring all staff is properly trained.
23. What is one method used by the preoperative nurse to ensure correct patient
identification?
a. The nurse checks the medical record for the patient’s name and then calls
out the name in the waiting room to see who responds.
b. The nurse asks the patient to state his or her name and date of birth, then
compares the patient’s response to registration documentation in the
medical record and the patient’s facility-provided identification armband.
c. The nurse identifies the patient based on the procedure scheduled and
the location of the stretcher the patient will occupy, such as, “The carpal
tunnel repair in bed 2.”
d. The nurse identifies the patient based on the order of the schedule and
the treating physician, such as, “Dr. Carson’s third patient.”
24. The preoperative nurse completes a deep vein thrombosis (DVT) assessment
on a 62-year-old, morbidly obese, female patient scheduled for an open
reduction internal fixation of the right radius. The operating room schedule
shows the case will take 2 hours. The patient’s medication list indicates she
takes hormone replacement therapy.Based on this information the nurse knows
a. the patient is at risk for a deep vein thrombosis.
b. the patient is not at risk for a deep vein thrombosis.
c. the patient’s planned surgery is not associated with deep vein thrombosis.
d. the patient is at risk for obstructive sleep apnea.
25. Immediately before surgery, a physician evaluates the risk of the anesthesia
and the risk of the procedure for the individual patient. This assessment is
called
a. the history and physical exam.
b. the medication reconciliation.
c. the preanesthetic assessment.
d. the preadmission interview.
26. Based on the American Society of Health-System Pharmacists’ therapeutic

guidelines, a healthy patient who is scheduled for a knee arthroscopy should be
given which antibiotic?
a. Cefazolin
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b. None
c. Clindamycin
d. Vancomycin
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CHAPTER 4
ANESTHETIC MANAGEMENT:
PROCEDURAL SEDATION
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain the concept
of procedural sedation.
CHAPTER OBJECTIVES
A
1. Discriminate between minimal, moderate, and deep sedation and general

anesthesia.
2. Identify the pharmacologic agents used to produce moderate sedation.
INTRODUCTION
M
oderate, or procedural, sedation, sometimes referred to as monitored
anesthesia care (MAC), is a term used to describe a state of minimally
depressed consciousness wherein the patient independently maintains
airway control and responds appropriately to physical stimulation and verbal
commands. It is a pharmacologically induced depression of consciousness, with or
without analgesia, which facilitates patient comfort and acceptance during
appropriate surgical procedures.
Most patients are concerned about pain and awareness during surgery under
local anesthesia, yet they would prefer not to undergo general anesthesia. With the
judicious use of sedation and analgesia, the patient objectives of relief of anxiety,
prevention of pain, and enhanced cooperation can be achieved with minimal risk.
Induced sedation is a continuum identified by four levels: minimal (anxiolysis),
moderate (procedural), deep, and general anesthesia (see Table 4-1). During
minimal sedation, the patient responds normally. During moderate or procedural
sedation/analgesia, the patient responds purposefully to verbal or tactile
stimulation, and the airway and cardiovascular system are maintained. In deep
sedation/analgesia, the patient responds purposefully only following repeated or
painful stimulation, may lose protective reflexes, and may not be able to maintain
the airway. At the level of general anesthesia, consciousness and the ability to
move are lost, the patient is unable to respond even to painful stimulation, and he
or she may not be able to maintain the airway (American Society of
Anesthesiologists, 2014a).
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<TABLE 4-1 WILL BE VIEWABLE AFTER PURCHASE>
The medications, doses, and techniques used for procedural sedation are not
intended to produce unconsciousness; the goal is to use as little medication as
possible to ensure the patient is as comfortable as possible and to do so as safely
as possible. Adequate sedation may be identified by a calm demeanor, slurred
speech, slowed heart rate, or reduced blood pressure. A sedated patient whose
only response is reflex withdrawal from painful stimuli is sedated beyond the level
of procedural sedation (American Society of Anesthesiologists, 2014a).
Deep sedation may be accompanied by a partial or complete loss of protective
reflexes, the inability to manage oropharyngeal secretions, or an inability to
continuously maintain a patent airway, leading to possible aspiration and hypoxia.
Other complications of deep sedation include hypotension, hypoventilation,
respiratory depression, and apnea.
Used in conjunction with local or regional anesthesia, procedural sedation,
when chosen thoughtfully for appropriate surgical procedures and patients, may
obviate the need for general anesthesia and its associated physiologic effects.
Patients with significant anxiety or previous unpleasant general anesthetic
experiences are candidates for this technique for ambulatory surgery. In children
and uncooperative adults, the use of procedural sedation may facilitate diagnostic
procedures that require the patient not to move. To achieve optimal patient safety
and comfort, effective communication with both the patient and surgeon is required,
along with the careful titration of sedative and analgesic drugs and the vigilant
monitoring of the cardiovascular, respiratory, and neurologic systems.
PROCEDURAL SEDATION MEDICATIONS
T
he desirable pharmacologic characteristics of procedural sedation include
the rapid onset of action, short duration of action, lack of cumulative effects,
minimal side effects, and rapid metabolization. Because sedation and
analgesia may be required to achieve a relaxed, pain-free state of detachment, a
combination of medications is often necessary. Potential adverse effects of these
medications on airway patency, respiratory function, and hemodynamic balance
should be fully understood by the practitioner administering the medications.
Adverse events during procedural sedation may be prevented through appropriate
preanesthesia assessment of the patient, intraprocedural monitoring of physiologic
function, and early intervention when adverse effects are recognized (Tobias &
Leder, 2011).
Benzodiazepines
Benzodiazepines produce dose-related sedation, anxiolytic effects, and

amnesia. Benzodiazepines have no analgesic properties. They may be used in
conjunction with analgesic medications, but the use of opioids prolongs recovery
times. Patient response to this pharmacologic category is widely variable, and drug
dosage must be carefully titrated, as well as reduced for elderly patients. When
benzodiazepines are used to produce profound sedation, amnesia may occur for
events during the early postoperative recovery period. For this reason, patient
education should be provided before the procedure or given to the patient’s
significant other. It is customary for the surgeon to seek out the patient’s significant
other and share the patient’s outcomes because the surgeon knows the patient
most likely will not remember any discussions from the immediate postoperative
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period. Benzodiazepines can lead to adverse effects on the respiratory system and
hemodynamic function. These effects are dose dependent and are amplified by
comorbid diseases and the synergistic effect of coadministration with other
sedatives or analgesic agents such as the opioids.
Diazepam (Valium)
Diazepam has been widely used for procedural sedation and is particularly
useful with regional anesthesia because it exerts the strongest anticonvulsant effect
of all the benzodiazepines by increasing the seizure threshold for local anesthetics.
When administered IV, the anesthesia care provider should titrate the IV dosage to
the desired sedative response, such as slurring of speech, with slow administration
immediately before the procedure (Hospira.com, 2015).
Diazepam should not be considered a drug of short duration. Following a period
of apparent recovery, patients can experience drowsiness for 6 to 8 hours.
Ambulatory surgery patients should be cautioned that they may feel tired for a day
or more after receiving IV diazepam. With large doses, impairment of coordination
and reactive skills may persist for 10 hours. A responsible adult should monitor the
patient for at least 24 hours after surgery. The nurse should advise the patient and
significant other that the patient should not drive, operate heavy machinery, cook,
or use any apparatus that requires coordination. (For a complete description of
discharge instructions, see Chapter 9.) Pain during IV injection and possible
postprocedure phlebitis are some drawbacks patients may experience. Using larger
veins and reducing the rate of injection may help alleviate pain and sequelae.
Midazolam (Versed)
Because midazolam is prepared in an aqueous solution, it causes minimal

venous irritation. It has a faster onset of action (1 to 2 minutes) and provides more
effective amnesia than diazepam. Because midazolam does not undergo
intrahepatic recirculation, drowsiness does not usually recur after the patient
recovers; however, large doses may cause prolonged drowsiness.
Midazolam’s rapid onset and redistribution have made it a popular choice for
procedures involving procedural sedation, but it should be given in small
increments, with sufficient time allowed for its effect to develop, until signs such as
slurred speech and drooping eyelids occur. Depending on the patient’s general
condition, drug history, and alcohol use, response is variable. Elderly patients may
require lower doses. Respiratory depression is the most significant adverse event
associated with midazolam (Hospira.com, 2010). Renal disease or failure may lead
to prolonged sedation with midazolam due to the accumulation of a conjugated
metabolite. See Table 4-2 for more information.
Opioids
Opioids are administered for their analgesic properties. In the context of

procedural sedation, they are used to supplement other agents, such as sedative-
hypnotics, to provide optimal conditions for patients to tolerate painful procedures.
Fentanyl, morphine, meperidine, and hydromorphone may also be administered to
patients during the recovery phase. Opioid selection is often based on the
medication’s onset and duration or its adverse effects (see Table 4-2).
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Fentanyl (Sublimaze)
Fentanyl is widely used in ambulatory settings. After IV administration, response

usually begins immediately and lasts 30 to 60 minutes. With a redistribution half-life
of 13.4 minutes, 98.6% of the injected dose is cleared from the plasma in 60
minutes (Hospira.com, 2014, June). This rapid clearance makes it useful for
outpatient sedation.
Although fentanyl is considered appropriate for ambulatory surgery, it can
produce marked respiratory depression. Care should be taken to avoid a dosage
sufficient to produce a sleeplike state in which there is a lack of spontaneous
verbalization. This sleeplike state has been identified as one of the recurring
problems found in unexpected cardiac arrests during spinal anesthesia. Cyanosis
frequently heralded the onset of cardiac arrest in patients exhibiting this degree of
sedation, which suggests that undetected respiratory insufficiency may have played
an important role.
Fentanyl is often given in combination with a benzodiazepine, which significantly
increases respiratory depression compared with either drug used alone.
Appropriate monitoring is essential for the patient’s safety. If fentanyl is injected too
rapidly, chest rigidity may occur (Hospira.com, 2014, June).
Morphine Sulfate
Morphine sulfate is indicated for the relief of severe pain. An absolute

contraindication to morphine use is the presence of a pre-existing allergy or acute
asthma. The most serious adverse effects of morphine administration are related to
the respiratory system and lead to hypoventilation and hypercapnia. Other, less
common adverse effects include central nervous system (CNS) depression,
psychosis, constipation, euphoria, and oliguria (Hicks, Hernandez, & Wanzer,
2012).
Meperidine (Demerol)
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Meperidine is a synthetic narcotic analgesic and is indicated for relief of

moderate to severe pain. Compared to morphine, this medication peaks faster but
also dissipates faster, resulting in a shorter duration. The most common adverse
effects of meperidine include respiratory depression, light-headedness, vertigo,
sedation, nausea, vomiting, euphoria, biliary tract spasm, and urinary retention
(Hicks, Hernandez, & Wanzer, 2012).
Hydromorphone (Dilaudid)
Hydromorphone is a pure opioid agonist used for analgesia. A contraindication

is gastrointestinal obstruction because this medication decreases peristalsis.
Therefore, the presence of biliary tract or pancreatic tract disorders may preclude
its use. Adverse effects of hydromorphone include respiratory depression,
hypotension, flushing, constipation, and urticaria. Hydromorphone is not often used
to treat the elderly patient population due to an increased risk for respiratory
depression. See Table 4-3 for more information.
Alfentanil (Alfenta)
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The opioids alfentanil, sufentanil, and remifentanil are typically administered by

an anesthesia provider in a monitored anesthesia care situation. Their potency and
potentially lethal side effects if improperly administered or monitored make these
drugs dangerous in less skilled hands.
Alfentanil is a short-acting fentanyl analog with one-quarter the potency and
one-third the duration of fentanyl. Nevertheless, large doses may result in
prolonged sedation and respiratory depression. Compared with fentanyl, alfentanil
produces more hypotension and more muscular rigidity if administered too rapidly,
although fentanyl, sufentanil, and alfentanil may cause rigidity severe enough to
prevent sufficient ventilation (Hospira.com, 2004).
Sufentanil (Sufenta)
Sufentanil is shorter acting than alfentanil and extremely potent. When used in
balanced general anesthesia, sufentanil is 10 times as potent as fentanyl
(Hospira.com, 2014, August). When administered by continuous IV infusion for
procedures of intermediate duration, recovery should occur almost 50% more
rapidly. However, compared with maintenance by intermittent boluses, IV infusion
may result in episodes of hypoxemia (Hospira.com, 2014, August).
Agonist-Antagonist Opioids
In an attempt to achieve analgesia with fewer side effects, agonist-antagonists

such as butorphanol (Stadol) and nalbuphine (Nubain) were developed.
Administered independently, this class of drugs produces opioid effects but
antagonizes the effects of full agonists if given with them. These agents may trigger
withdrawal symptoms in patients with a history of drug abuse.
Butorphanol has an analgesic potency five times that of morphine, whereas
nalbuphine is considered equipotent to morphine. Both drugs have sedative effects
as well. Their onsets of action occur within 2 minutes after IV administration, but
their durations, like those of morphine, are long. Some studies document the
recovery time of butorphanol as 1 to 2 hours and consider the postoperative
analgesia an asset. Realistically, their monitored recovery time should be 3 to 4
hours, and their use should be restricted to procedures in which considerable
postoperative pain is anticipated.
Sedative-Hypnotic Agents
These drugs, also referred to as rapid-acting IV induction agents, may be more

applicable to monitored anesthesia care (MAC). Although the term MAC is
sometimes used interchangeably with procedural sedation, as the name implies, an
anesthesia provider monitors the patient, ready to institute general anesthesia if
necessary.
Propofol (Diprivan)
Propofol is classified as a sedative-hypnotic without analgesic effect or amnesic

properties when given in doses that do not produce unconsciousness. It has gained
popularity because it results in rapid recovery with few side effects. Patients quickly
appear alert and clearheaded; some experience a significant sense of well-being.
Propofol is also believed to have some antiemetic effects, and the incidence of
postoperative nausea and vomiting is low.
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Propofol causes less postoperative sedation, drowsiness, and confusion than

midazolam, yet when given alone, it may cause dysphoria. When midazolam is
given preoperatively or at the start of the procedure with propofol, it does not delay
rapid recovery or cause additional side effects. This combined usage allows for the
rapid recovery associated with propofol as well as midazolam’s ability to provide
relief from anxiety and amnesia during the procedure.
It should be noted that propofol solution provides an excellent medium for
bacterial growth. Failure to use aseptic technique when handling propofol-injectable
emulsion has been associated with microbial contamination that led to patient
harm, including fever, infection and sepsis, and death. Propofol manufacturers state
that at the end of the procedure or at 12 hours, whichever is the soonest, both the
reservoir of propofol and the infusion line must be discarded and replaced as
appropriate.
Methohexital (Brevital)
Methohexital is an ultra-short-acting barbiturate also of the group known as IV

anesthetics. Widely used as an IV induction agent to produce unconsciousness
quickly, it may also be administered by continuous infusion, which results in a
reasonably short recovery period. Because it is strongly alkaline, methohexital
should be given cautiously to avoid extravasations. Methohexital is closely related
to thiopental (Pentothal), but despite its shorter recovery profile, methohexital is
more potent. Methohexital is also associated with hiccupping and muscle twitching
(Monarch Pharmaceuticals, 2007).
Ketamine (Ketalar)
Ketamine is unique because it can be administered by the intramuscular (IM) or

IV route, which makes it useful in situations in which IM administration before the
procedure may be an advantage. However, ketamine produces a dissociative state
with undesirable emergent side effects (especially in adults), such as disorientation,
hypersensitivity, vivid dreams, and tachycardia. When combined with a
benzodiazepine, these psychomimetic reactions and cardiostimulatory effects may
be attenuated.
Droperidol (Inapsine)
Droperidol, a butyrophenone derivative, has been used for many years as a

supplement to surgical and diagnostic procedures. Droperidol is not recommended
for any use other than treatment of perioperative nausea and vomiting in which
other treatments are known to be ineffective or inappropriate for the patient
(PDR.net, n.d.b). It provides sedation and a sense of detachment with minimal
amnesia. When combined with a narcotic, neuroleptanalgesia (i.e., dissociative
analgesia) results. Although it does not cause significant respiratory depression,
droperidol in large doses may cause hypotension, extrapyramidal effects, and
confusion. Droperidol carries a black box warning – the most serious warning for a
U.S. Food and Drug Administration (FDA) approved drug – because of its
association with fatal cardiac dysrhythmias.
Additionally, although clinical recovery from droperidol occurs after 25 minutes,
tiredness or drowsiness persists, and tests of coordination and attention remain
significantly abnormal after 10 hours. Droperidol is a potent antiemetic, and small
doses may be used prophylactically to reduce the incidence of postoperative
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vomiting in adults and children. Large doses, alone or in combination with fentanyl,
are generally considered inappropriate for ambulatory patients. The sedation far
outlasts the effect of the narcotic component. See Table 4-4 for more detail.
Antagonists
Naloxone (Narcan)
Naloxone reverses the central nervous system (CNS) and respiratory

depressant effects of narcotics in a dose-dependent manner by displacing opioid
binding at receptor sites in the brain and spinal column. It is usually administered IV
in small, repeated doses until the desired effect is achieved. CNS effects may be
seen in 1 to 2 minutes. Naloxone is an emergency drug and should be immediately
available wherever opioids are administered.
However, the reversal procedure should be done cautiously because abrupt
reversal may result in sudden pain perception, causing hypertension and
tachycardia. Caution should also be used with patients who have cardiac disease
or suspected or known narcotic dependence.
Flumazenil (Romazicon)
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Flumazenil works by displacing benzodiazepines at their receptor sites.

Therefore, it does not reverse the effects of drugs that bind elsewhere, such as
barbiturates, antidepressants, alcohol, or general anesthesia. Given IV, flumazenil’s
onset of action occurs in 1 to 2 minutes, with peak effect in 6 to 10 minutes.
The half-life of flumazenil is 40 to 80 minutes (Genentech, 2010). Except for
midazolam, most benzodiazepines have a longer half-life than flumazenil, so
patients should be monitored for resedation for up to 2 hours. Pain at the injection
site sometimes occurs, and flumazenil has been associated with thrombophlebitis.
Flumazenil is effective in reversing drug-induced sedation and respiratory
depression when only benzodiazepines have been administered. In patients who
have received both opioids and benzodiazepines, flumazenil is known to reverse
benzodiazepine-induced sedation; however, its effectiveness in reversing
respiratory depression under these circumstances is unclear. See Table 4-5 for
more information.
SUMMARY
T
he ambulatory surgery nurse is familiar with pharmacologic agents used to
induce and reverse procedural sedation. Ambulatory surgery patients need
education regarding expectations when receiving procedural sedation
because they may experience some level of awareness during the procedure. This
education will allow the patient to anticipate each step in the surgical care
encounter and be prepared for common effects and their duration. The use of
procedural sedation assists the patient and the ambulatory surgery team in
relieving anxiety, preventing pain, and enhancing cooperation with minimal risk.
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EXAM QUESTIONS
CHAPTER 4
Questions 27–28
27. Adequate sedation may be identified by all of the following except

a. slurred speech.
b. increased anxiety.
c. slowed heart rate.
d. reduced blood pressure.
28. Which of the following medications may be used to sedate a patient for a
procedure?
a. Sevoflurane (Sevorane)
b. Midazolam (Versed)
c. Lidocaine
d. Naloxone (Narcan)
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CHAPTER 5
GENERAL ANESTHESIA
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain the concept
of general anesthesia.
CHAPTER OBJECTIVES
A
1. Identify the techniques used to produce general anesthesia.

2. Describe nursing interventions related to the anesthetized patient.
3. Identify the pharmacologic agents used to produce general anesthesia.
4. Describe strategies for patent airway maintenance.
INTRODUCTION
T
he goal of the ambulatory surgery team is to provide the most pleasant and
safe experience possible for the patient. Under adequate general
anesthesia, the patient is unable to maintain control of the airway or respond
purposefully to external stimulation. The patient feels no pain and is not aware of
his or her surroundings. The general anesthetic plan typically involves the use of a
combination of fast-acting IV and inhalation agents.
The ambulatory surgery setting presents the clinical care team with challenges
and concerns beyond those for inpatient surgery because the patient is expected to
return home the same day of the procedure. In addition to being awake, breathing
spontaneously, being stable physiologically, and being able to respond to
instruction, the ambulatory patient recovering from anesthesia and surgery must, in
a short amount of time, be able to tolerate fluids without vomiting, void, understand
and remember instructions, and be able to take oral pain medication if needed. The
creation and use of new medications that induce and maintain general anesthesia
with fewer risks and side effects has contributed to safe ambulatory surgical care.
FACTORS INFLUENCING THE USE OF GENERAL

ANESTHESIA
C
ircumstances that may contribute to the choice of a general anesthetic
technique include the following:
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1. Patient age and mental status: Extremes of age or the inability to cooperate
may complicate the procedure.
2. Requirements of the surgery include the following:
a. Duration: The duration may exceed the duration of the regional block or
local infiltration that can be achieved using therapeutic doses of
appropriate anesthetics.
b. Position: The position may be too restrictive and uncomfortable for the
patient to tolerate.
c. Muscular relaxation: This may require the use of neuromuscular blocking
agents (NMBAs) that will affect the patient’s ability to breathe
spontaneously.
3. Patient preference: Patients sometimes refuse to undergo a surgical
procedure if they are not completely unconscious. This response is usually
caused by fear, including fear of paralysis from a regional block or a
previous unsatisfactory anesthetic experience.
4. The anesthesia provider also makes the decision about the appropriateness
of general anesthesia by evaluating potential contraindications, either
absolute or relative. The patient’s physical and diagnostic assessment may
uncover unstable metabolic, cardiac, or respiratory diseases that need to
be considered. Contraindications to general anesthesia include the
following:
a. Full stomach: This implies the danger of regurgitation of gastric contents
into the hypopharynx with subsequent aspiration into the lungs.
Regurgitation may be passive by reflux or active due to vomiting. In an
outpatient setting, a full stomach is usually caused by the patient’s failure
to follow preoperative fasting instructions (NPO status).
b. Physical status: Reimbursement issues mandate that more procedures
be performed on an outpatient basis, which can increase the likelihood of
patients with poorly controlled systemic disease (class P3 and P4 risks)
presenting for ambulatory surgery.
5. Abnormal preoperative test results that may affect the anesthesia provider’s
decision include
a. low hematocrit or hemoglobin, which will affect the oxygen-carrying
power of the red blood cells,
b. unstable heart rate indicated by electrocardiogram (ECG),
c. chest pathology, and
d. compromised hepatic or urinary status.
6. Upper respiratory infection (URI): Increased secretions may cause coughing
and laryngospasm, compromised ventilation, and the spreading of
infection.
PROGRESSION OF ANESTHESIA
T
raditionally, the progression of anesthesia is defined by four stages: stage I,
analgesia; stage II, delirium; stage III, surgical anesthesia; and stage IV,
medullary depression. Stage III is further divided into four planes. All of
these stages and planes may be achieved and observed if the sole anesthetic
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administered is an inhalation agent, as is used for young children. However, with

the use of ultra-short-acting intravenous (IV) barbiturates and sedative-hypnotics,
stage I and stage II pass so quickly that they are not readily observable. For this
reason, general anesthesia is more practically divided into induction, maintenance,
and recovery as shown in Figure 5-1.
General anesthesia may be induced with the use of an ultra-short-acting IV

agent, an inhalation anesthetic, or a combination of these until the level of surgical
anesthesia is achieved. During the maintenance phase, the depth of anesthesia is
adjusted as necessary based on surgical progress and patient response.
Although unconscious, a patient at a light level of anesthesia may respond
adversely to surgical stimulation (or other external stimulation). This response may
manifest as an increase in blood pressure, an increase in pulse, tearing of the
eyes, wrinkling of the forehead, or movement. Conversely, if the level of anesthesia
is excessively deep, hypotension and bradycardia may occur. Unaltered, an
extremely deep level of anesthesia may progress to cardiovascular and respiratory
collapse. Maintenance of anesthesia requires a therapeutic balance between these
levels to ensure patient safety and meet the needs of the patient and the surgery
team. (See Figure 5-2).
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As the surgery nears completion, anesthetic delivery is gradually decreased

because the goal is for the patient to maintain adequate, spontaneous respiration
by the end of the procedure and be responsive shortly thereafter. Depending on the
anesthetic agents and ancillary drugs administered, such as nondepolarizing
muscle relaxants, the use of specific reversal agents may be employed. See Table
4-5 for more information on reversal agents.
INHALATION ANESTHETIC AGENTS
W
ith the exception of nitrous oxide (N2O), inhalation anesthetic agents are
volatile liquids at room temperature. A calibrated vaporizer in the
anesthesia machine vaporizes the liquid, which is then supplied to the
patient via a carrier gas or gases. Oxygen (O2) is always one of the carrier gases,
but nitrous oxide may be added as a percentage of the total flow. This combination
is traditionally charted as N2O and O2.
The percentage of oxygen delivered to the patient must always exceed the
patient’s metabolic oxygen requirements and be in greater concentration than the
amount of oxygen found in room air. Most anesthesia machines have the capability
to mix room air with the oxygen flow for patients for whom 100% oxygen would be
detrimental, such as those with chronic obstructive pulmonary disease or
premature infants.
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Most operating rooms have oxygen and nitrous oxide piped in from a central
manifold outside the operating room suite. In some ambulatory surgical facilities,
such as in physician offices and special procedure areas, oxygen and nitrous oxide
must be supplied by portable tanks. By federal regulation, medical oxygen tanks
are always colored green, and nitrous oxide tanks are blue (U.S. Food and Drug
Administration, 1989).
Inhalation anesthetics may be used for induction and maintenance of
anesthesia. Induction exclusively by inhalation is mainly used for small children and
unique patient situations in which IV access is difficult to establish due to lack of
patient cooperation or is extremely painful due to limited venous access.
Advantages of the relatively new and less-soluble inhaled anesthetics,
sevoflurane and desflurane, have added a new dimension to patient care by
rivaling propofol in ambulatory surgery. They allow faster recovery and earlier
discharge home than the more traditional inhalational anesthetic agents (Kumar,
Stendall, Mistry, Gurusamy, & Walker, 2014). Uptake and distribution of the
anesthetic is influenced by inspired anesthetic concentration, alveolar ventilation,
the fresh gas flow rate from the anesthesia machine, blood and tissue solubility of
the anesthetic, cardiac output, and functional residual capacity (FRC) of the lungs.
Volatile anesthetic agents also produce varying degrees of skeletal muscle
relaxation and may trigger malignant hyperthermia (MH) in genetically susceptible
patients.
Potency of an inhalation anesthetic is related to its minimum alveolar
concentration (MAC) – the alveolar concentration of the gas at which 50% of
individuals will not move in response to a skin incision. The greater the tissue
solubility of an anesthetic, the lower its value for MAC; thus, the least soluble
volatile agent, desflurane, has a higher value for MAC than the most soluble,
halothane (Aranake, Mashour, & Avidan, 2013).
Anesthesia providers often refer to the MAC of an anesthetic when referring to
its potency. This should not be confused with the acronym sometimes used to
designate monitored anesthesia care, which is also MAC. There is no relationship
between the two terms.
Gaseous Agents
Nitrous Oxide
Nitrous oxide is the only inhalation anesthetic that is a gas at room temperature.
Because it has the lowest blood solubility, it quickly produces its effect and is
rapidly excreted in the exhaled breath, resulting in rapid awakening. The MAC of
nitrous oxide is 110%, which is unattainable; therefore, it cannot be used as a
complete anesthetic. To reach an adequate level of anesthesia, nitrous oxide must
be combined with a volatile anesthetic, an IV agent, or both. Nitrous oxide
increases the risk of postoperative nausea and vomiting but does not trigger
malignant hyperthermia.
Volatile Agents
Isoflurane (Forane)
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Isoflurane is widely used despite its pungent, irritating odor, which may be
overcome with the use of rapid-acting IV induction agents. Because it is primarily
excreted unchanged by the lungs, uptake and elimination are rapid, and there is
minimal chance of a cumulative effect from repeated exposure. The minimal
amount of agent metabolized by the body is also a benefit for patients with severe
systemic disease, but patients with severe hypovolemia may not tolerate its
vasodilating effects well.
Although isoflurane increases heart rate, arrhythmias are much less common
than with halothane. Isoflurane is less likely to sensitize the myocardium to the
effects of catecholamines than other volatile anesthetics, making it more compatible
with vasoconstrictor drugs used in conjunction with regional anesthetics. When
used in low concentrations with oxygen, as an adjunct to local anesthesia,
outpatients often meet discharge readiness criteria soon after the end of the
procedure.
Desflurane (Suprane)
Desflurane is the least soluble of the volatile agents; therefore, it provides the
most rapid onset of effect and the most rapid awakening. It is also the most
irritating, so coughing and laryngospasm may result, causing problems during
induction and emergence. Consequently, because of its pungent odor, desflurane is
sometimes avoided for induction.
According to the manufacturer, Baxter Healthcare Corporation (2015),
desflurane is an inhalation agent indicated for induction and/or maintenance of
anesthesia in adults and for maintenance of anesthesia in pediatric patients
following induction with agents other than desflurane, and intubation.
If the concentration of desflurane is increased too quickly, hypertension and
increased heart rate may occur before severe hypotension takes place. The
desflurane product label advises against using the agent alone for induction for
patients with coronary artery disease or if increases in heart rate or blood pressure
are undesirable. Desflurane also causes an increase in salivation, so the use of an
antisialagogue, such as atropine or glycopyrrolate, may be advisable.
Sevoflurane (Sevorane)
Sevoflurane is a volatile anesthetic, which was introduced in 1995 in the United

States, and has blood solubility slightly greater than desflurane but less than
isoflurane. This rapid effect and recovery profile, together with a pleasant odor that
does not cause airway irritation, make it appropriate for inhalation induction
(Phillips, 2013).
Patients tend to be clearheaded on awakening, and sevoflurane does not
sensitize the myocardium to the arrhythmic effects of epinephrine (Phillips, 2013).
Despite its high cost, the favorable pharmacologic properties of this inhalation
anesthetic make it an increasingly popular choice for use in ambulatory settings.
Seizures have been reported, primarily in children and young adults, with
sevoflurane. Desflurane, isoflurane, halothane, and nitrous oxide do not cause
seizures (Eger, Saidman, & Westhorpe, 2014).
Sevoflurane was not approved in the United States until 1995 because of
questions concerning its biodegradability. Although at the concentrations usually
achieved, it is not thought to be associated with organ toxicity (Phillips, 2013);
some clinicians prefer to avoid using sevoflurane with rebreathing techniques that
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put sevoflurane in contact with carbon dioxide absorption agents such as baralyme
or soda lime (Rothrock, 2015).
Halothane (Fluothane)
Halothane has a relatively sweet, pleasant odor; does not irritate the respiratory
tract; and dilates the bronchi. As with other volatile agents, halothane causes dose-
dependent hypotension; but unlike other volatile agents, it increases the sensitivity
of the heart to the dysrhythmic effects of epinephrine. This effect is especially
important in ambulatory surgery where local anesthetics are commonly injected into
the operative site to decrease general anesthesia requirements. Epinephrine
should not be included in the local anesthetic mixture or serious arrhythmias may
occur.
Halothane’s major drawback is the occurrence of hepatic necrosis following
repeated exposures, and it has a profound effect on body temperature, often
causing hypothermia.
Although rare, with a mechanism not completely understood, hepatic necrosis
appears to occur most often with repeated use and in obese adults and children
past puberty. Consequently, exposure is often minimized by changing to another
inhalation anesthetic for maintenance after the induction benefits of halothane have
been utilized (Morgan, Mikhail, & Murray, 2006). Halothane is infrequently used
because agents such as sevoflurane and isoflurane do not have hepatic toxicity
risks (Phillips, 2013). See Table 5-1 for more information.
INTRAVENOUS INDUCTION AGENTS
R
apid-acting IV hypnotic drugs are commonly used to induce anesthesia.
Some of the medications used during procedural sedation, such as
propofol and Brevital, are also used to induce general anesthesia.
Unconsciousness usually occurs within 15 to 30 seconds after IV injection, which is
the time it takes for blood to circulate from the site of injection (e.g., an arm) to the
brain (Phillips, 2013). Also referred to as IV anesthetic agents, these drugs produce
a pleasant transition for the patient but have no analgesic affect. Without
supplementation, IV hypnotic agents are only suitable for short surgical procedures
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with little associated pain because an unconscious patient may still react to painful
stimuli. Doses sufficient to prevent response to pain may produce severe
cardiovascular, respiratory, and central nervous system (CNS) depression.
Consequently, these drugs are usually supplemented with nitrous oxide and
oxygen, an opioid and nitrous oxide and oxygen, or a volatile inhalation agent and
oxygen, depending on the requirements of the surgery.
Before induction, a small test dose of the hypnotic is usually administered to
gauge patient response. This test dose is followed with a bolus dose sufficient to
produce unconsciousness and the loss of the eyelash reflex. Because of their short
duration of action, IV agent maintenance requires repeated incremental doses or
continuous IV infusion. Table 5-2 summarizes IV anesthesia agents and
supplemental drugs, including neuromuscular blocking agents.
Thiopental (Pentothal)
Thiopental is an ultra-short-acting barbiturate widely used as an IV induction

agent. Duration of action after a single induction dose is approximately 5 minutes
due to rapid redistribution from the brain to systemic tissue. It must then be
metabolized, primarily by the liver. Only 1% is excreted unchanged in the urine.
With repeated incremental doses, the duration of action becomes longer with each
dose because of the accumulation in peripheral tissues (Phillips, 2013).
Consequently, thiopental produces a residual sedative effect characterized by
grogginess and an inability to concentrate during recovery. This pharmacokinetic
profile makes thiopental unsuitable for continuous IV infusion, especially when
rapid recovery is the objective (Phillips, 2013).
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Large doses of thiopental may cause severe hypotension and depression of the
myocardium in patients with congestive heart failure or hypovolemia. Patients
taking beta-adrenergic antagonists or some antihypertensive medications may be
unable to tolerate even small doses without adverse effects. Because thiopental is
strongly alkaline, extravasation subcutaneously must be avoided; this is another
reason for the use of a small test dose.
With insufficient depth of unconsciousness, manipulation of the airway, including
any attempt to insert an oropharyngeal airway or aggressive positive-pressure
ventilation, may provoke coughing, laryngospasm, or bronchospasm. As of 2011,
thiopental is no longer manufactured in the United States (Rothrock, 2015).
As with all barbiturates, thiopental may precipitate severe crisis or death in
patients with acute intermittent porphyria or hereditary coproporphyria. It does not
trigger MH. In addition, thiopental may be used to treat convulsions due to CNS
toxic reactions, and it reduces intracranial pressure.
Methohexital (Brevital)
Methohexital is an ultra-short-acting barbiturate, pharmacologically similar to

thiopental. However, it is more potent and has a shorter duration of action.
Methohexital’s faster rate of hepatic clearance provides advantages for ambulatory
surgery. There is less drowsiness during recovery and less cumulative effect with
repeated doses (Rothrock, 2015). Methohexital may be administered by continuous
IV infusion for maintenance, which is followed by a relatively short recovery time.
Disadvantages of methohexital include coughing, hiccuping, and involuntary
movement. Some discomfort may occur during injection, and methohexital’s high
alkalinity may cause tissue damage if extravasation occurs.
Propofol (Diprivan)
Propofol was introduced clinically in 1977 and commercially in 1989 in the

United States (Eger, Saidman, & Westhorpe, 2014). It is the most widely used IV
sedative-hypnotic agent. Because of its rapid redistribution and elimination,
propofol produces a faster recovery after an induction dose than other IV agents
do, making it a popular choice for ambulatory settings. This rapid recovery is
characterized by clearheadedness and, in some patients, a sense of well-being.
Psychomotor impairment also appears to be reduced, and there is a low incidence
of nausea and vomiting; the drug may also have an antiemetic effect.
Although not a barbiturate, propofol’s hypnotic effect is (like that of thiopental)
thought to be through action on the gamma-aminobutyric acid A receptor; however,
propofol is suitable for continuous IV infusion. Patients are usually awake within 3
to 10 minutes after termination of an infusion regardless of duration or total dosage
(Eger, Saidman, & Westhorpe, 2014). Propofol provides an alternative to
barbiturates for patients with a history of allergic reaction to these drugs and those
patients with acute intermittent porphyria or hereditary coproporphyria.
Unlike thiopental, propofol does not increase airway irritability and may produce
bronchodilation. An induction dose causes a greater decline in blood pressure and
longer transient apnea than is seen with an equivalent dose of thiopental (Rothrock,
2015). Propofol is used with caution in geriatric and hypovolemic patients (Phillips,
2013).
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A disadvantage of propofol is pain on injection. This pain may be lessened by

using a larger vein, injecting lidocaine before the propofol, or adding lidocaine to
the propofol solution. Involuntary movements or convulsions, especially in children,
during induction have also been reported. When propofol is used as the sole
maintenance agent, postoperative dysphoria may occur. To prevent bacterial
growth, opened propofol and the infusion line should be discarded at the end of the
surgical case or at 12 hours.
Etomidate (Amidate)
Unlike other IV hypnotics, etomidate, an imidiazole derivative, has little

depressant effect on the cardiovascular system and may be used as an induction
agent for patients with hypovolemia and cardiac problems. It does not stimulate
histamine release and is suitable for patients with asthma. Etomidate’s onset and
duration of action are similar to thiopental, but because of its rapid elimination,
residual sedation and cumulative effect from repeated doses or continuous IV
infusion are brief. See Table 5-2 for more information.
AIRWAY MANAGEMENT
T
he goal of sedation is to have a comfortably sedated but minimally
depressed patient who is able to maintain a patent airway independently.
However, even at an optimal level of sedation, the patient who lapses into
sleeplike episodes may experience some degree of airway compromise. In the
supine position, as the pharyngeal muscles relax, the base of the tongue tends to
fall backward and may occlude the hypopharynx.
Signs of airway obstruction include
retraction of the sternum,

increased respiratory effort,
irregular chest movement,

noisy respirations, and
absence of breath sounds by auscultation.
Undetected or untreated, respiratory obstruction will lead to hypercarbia and

hypoxemia, which may prove fatal.
At optimal levels of sedation, gently turning the head to the side may relieve
minimal obstruction. If not, asking a question that requires a verbal response may
cause sufficient arousal for the patient to regain airway control. Questioning will be
necessary each time a sleeplike state occurs if there is even mild obstruction. A
patient sedated enough to snore may tolerate gentle upward pressure on the
mandible.
If the patient becomes deeply sedated, hyperextension of the head into the
classic sniffing position may pull the tongue forward and away from the posterior
pharyngeal wall. See Figure 5-3. The chin should be supported so that the mouth is
closed. Adults usually have more normal pharyngeal-laryngeal alignment if the
head is elevated on a firm support 3 to 4 inches high. Because of their relative
head-to-body proportion, children rarely need additional elevation.
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The most effective manual alignment and elevation of the tongue is the triple
airway maneuver, which is produced by lifting the mandible forward and upward
with the head tilted backward in the sniffing position (head-tilt, chin-lift, jaw-thrust
maneuver; see Figure 5-4). Fingertips are positioned at the angle of the lower jaw
and along the ridge but not into the soft tissue under the jaw. When the tongue and
soft tissues have been successfully lifted away from the posterior wall of the
pharynx and ventilation is unobstructed, a face mask for oxygen delivery can be
held with the thumb and forefinger while three fingers elevate the jaw, thus freeing
the other hand for positive pressure assistance. For the novice, two hands may be
necessary to control the mask and jaw, so an assistant should be available as
needed.
If these techniques fail to establish and maintain a patent airway and adequate
ventilation, the deeply sedated patient may tolerate the insertion of a nasal airway.
An unconscious patient will tolerate an oral airway if the gag reflex has been
obtunded. Retching and vomiting may occur if the reflex is still intact.
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Nasal Airway
A nasopharyngeal (nasal) airway is inserted through a nostril into the pharynx

behind the tongue, creating a passage to the lower airway for ventilation. A nasal
airway does not stimulate the gag reflex, but a traumatic insertion may cause
bleeding with accumulation of blood in the oropharynx, which in turn may result in
aspiration, laryngospasm, or bronchospasm. Consequently, the use of a nasal
airway is contraindicated for patients on anticoagulation therapy or those with
septal deformity or nasal polyps.
The nasal airway must be long enough to slip behind the tongue and create a
passage between the tongue and the pharyngeal wall. Approximate length may be
measured from the patient’s nasal entrance to the tip of the earlobe (Ignatavicius &
Workman, 2010). Patency of the nostril should be inspected before insertion is
attempted, and the circumference of the tube portion must be less than the size of
the naris. The airway must be malleable and well lubricated with water-soluble
lubricant before insertion is attempted. Stiff, hard airways should not be used.
Gentle insertion may be aided by slightly rotating the airway, but a nasal airway
should never be forced. If resistance is encountered in the nasal passage, insertion
should be abandoned in that nostril to avoid injury and bleeding. See Figure 5-5.
Oral Airway
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The oropharyngeal airway is curved to fit over the back of the tongue and hold it
away from the posterior pharynx. In addition to retching, which may result in
hypertension and tachycardia, attempted insertion of an oral airway may cause
bradycardia due to vagal stimulation, dental damage, oral lacerations, or
laryngospasm.
Using a tongue blade in one hand, the base of the tongue is lifted away from the
posterior pharynx as the airway is inserted between the teeth with the curve of the
airway conforming to the anatomy of the mouth. If the patient reacts to the tongue
blade, insertion of the airway should not be attempted. Appropriate airway size is
important; if it is too short, the tongue will not be effectively lifted, and if it is too
long, excessive reflex stimulation or trauma may occur. After proper insertion is
verified, the nurse should check to make sure the lips or tongue are not caught
between the airway and teeth.
An alternate technique for the insertion of an oral airway, often used in
emergency situations when a tongue blade is not available, involves inserting the
airway in the reverse position (concave portion facing upward toward the operator),
then rotating the airway into anatomic position when the tip reaches the back of the
tongue. With this method, care must be taken not to push the tongue backward into
the pharynx while the airway is being inserted.
In a deeply sedated, unconscious patient, if none of these maneuvers resolve
the respiratory obstruction, the insertion of a laryngeal mask airway (LMA) or
endotracheal tube by an anesthesia provider may be necessary. Low intracuff
pressures (less than 60 cm H2O) have been reported to reduce the incidence of
sore throat and provide better airway sealing pressures than at high cuff pressures
(Teleflex, Inc., 2013). An endotracheal tube with a properly inflated cuff seals the
trachea, which prevents aspiration and permits control of ventilation for sustained
durations. Neither of these two techniques should be attempted without advanced
training.
Laryngospasm
Stridor (crowing sounds) or total airway obstruction characterized by rocking

abdominal respirations may indicate laryngospasm. Laryngospasm, or spasm of
the laryngeal muscles, may be caused by reflex stimulation; airway manipulation; or
direct irritation from blood, mucus, or saliva. The vocal cords may be paralyzed in a
partially open position, which causes the crowing sounds, or completely closed,
preventing ventilation. Positive-pressure ventilation with 100% oxygen is
administered in an attempt to stop the spasm, but a small dose of a muscle
relaxant, usually the rapid-acting, depolarizing agent succinylcholine, may be
needed to relax the laryngeal muscles. Endotracheal intubation may also be
necessary.
The nurse monitor should be knowledgeable about and skilled in airway
management. An assistant should be readily available at all times during the course
of sedation, and an anesthesia provider or person skilled in endotracheal intubation
should be called as soon as basic interventions appear to be unsuccessful.
TOTAL INTRAVENOUS ANESTHESIA (TIVA)
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T
he availability of rapid-acting IV sedative-hypnotics and opioid analgesics
with fast onset and short duration have made it possible to induce and
maintain anesthesia solely by the IV route. To maintain levels of
unconsciousness appropriate to surgical stimulation, frequent, small doses must be
administered, gauged by signs of light anesthesia observed in the patient, to
overcome the redistribution and elimination characteristics of these drugs.
Continuous IV infusions are an alternative but also require adjustment depending
on the stimulation of the surgery.
If the IV drugs used have cumulative or additive effects, delayed awakening
may result. Because of its lack of cumulative effect, propofol is appropriate for
continuous infusion, but it lacks analgesic properties and produces little amnesia.
Propofol usually requires supplementation with a narcotic that has a rapid
elimination profile. Midazolam may be used to provide amnesia.
The advantages of TIVA include
reduced rates of postoperative nausea and vomiting,

smooth induction and emergence, and
a mechanism of anesthesia delivery that is independent of the ventilation of

the patient.
(Everett & Tattersall, 2010)

Unlike inhalation anesthetics, the drugs used for TIVA provide no muscular
relaxation. Depending on the requirements of the surgery, the administration of a
neuromuscular blocking agent (NMBA) may be necessary. When the patient is
paralyzed by an NMBA, movement in response to painful stimulation, an important
indicator of the patient’s level of consciousness, is obscured. Signs such as
tachycardia, tachypnea, elevated blood pressure, tearing, and wrinkling of the
forehead become the primary indicators of response to pain and the need for
additional medication.
A major disadvantage of TIVA is the increased possibility of patient awareness.
Balanced anesthesia implies the use of combinations of drugs to produce the
appropriate amount of analgesia, hypnosis, and muscular relaxation, but it also
includes the use of low concentrations of an inhalation anesthetic. The possibility of
patient awareness is reduced, but as with TIVA, the large amounts of IV narcotics
that may be used with this technique tend to prolong cognitive recovery and
increase the possibility of nausea and vomiting in ambulatory patients.
NEUROMUSCULAR BLOCKING AGENTS
T
he advent of neuromuscular blocking agents (NMBAs) in the 1940s allowed
the anesthesia care provider to reduce the depth of anesthesia, manage the
airway for prolonged surgery, abolish reflex muscle activity, and optimize
patient positioning (Farooq & Hunter, 2014). Muscle relaxants are also used to
facilitate the insertion of an endotracheal tube by relaxing the vocal cords, which
reduces the risk of injury.
Neuromuscular blockade occurs primarily at the neuromuscular junction (NMJ)
at the cholinergic-nicotinic receptors on the motor endplate. Muscle relaxants cause
paralysis of striated muscle, but they do not affect awareness, cognition, or pain
perception. It is essential that the patient be unconscious before receiving an
NMBA and that respiration be supported until paralysis has worn off or been
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pharmacologically reversed. The mode of action of NMBAs is either depolarizing or

nondepolarizing.
Depolarizing NMBAs
As of the publication of this course material, succinylcholine (Anectine, Quelicin)

is the only depolarizing muscle relaxant in widespread clinical use (Farooq &
Hunter, 2014). When molecules of succinylcholine occupy receptors on the motor
endplate, the muscle transiently contracts, causing fasciculations. However, as
depolarization persists, neuromuscular transmission is interrupted, and the muscle
becomes flaccid (Farooq & Hunter, 2014). Succinylcholine produces muscular
relaxation in less than 1 minute, and a single dose lasts approximately 3 to 5
minutes. This rapid onset and short duration of action make it well-suited for
ambulatory surgery, as well as relatively short procedures in general. For the same
reasons, succinylcholine is usually administered by continuous infusion. The initial
muscle fasciculation, although often not observable, may be responsible for
postoperative muscle pain. Generalized muscular aches seem to occur more
frequently in outpatients, especially young adults, after minor surgery. Neostigmine
is the most commonly used reversal agent, but it antagonizes neuromuscular block
slowly, or inadequately, especially during profound block or in the presence of deep
inhalation anesthesia (Farooq & Hunter, 2014). Anesthesia care providers should
consider coadministration of an antimuscarinic agent such as glycopyrrolate or
atropine to combat bradycardia, arrhythmias, bronchospasm, nausea, vomiting, gut
peristalsis, and salivation that can be caused by neostigmine administration.
There are several disadvantages to the use of succinylcholine, including
hyperkalemia, ocular hypertension, raised intracranial pressure, myalgia, malignant
hyperthermia, suxamethonium apnea, and anaphylaxis and its muscarinic effects
such as bradycardia (Farooq & Hunter, 2014).
Nondepolarizing NMBAs
Stimulatory motor nerve impulses cause acetylcholine to be released at the

NMJ. Nondepolarizing muscle relaxants prevent acetylcholine from binding to its
receptors to cause muscle contraction. They require 2 to 3 minutes to achieve full
effect, which may last 45 minutes or longer, depending on the particular relaxant.
However, nondepolarizing muscle relaxants may be pharmacologically reversed
with the use of a cholinesterase inhibitor such as neostigmine, pyridostigmine, or
edrophonium (Tensilon). Atropine or glycopyrrolate (Robinul) are usually
administered along with the reversal agent to offset undesirable parasympathetic
effects, most commonly bradycardia and increased respiratory secretions.
Short-acting, nondepolarizing agents, such as mivacurium (Mivacron), which
has a duration of 15 minutes, and intermediate-acting agents, such as vecuronium
(Norcuron), atracurium (Tracrium), rocuronium (Zemuron), and cisatracurium
(Nimbex), are suitable for ambulatory surgical procedures. These drugs do not
trigger MH but may cause hypotension due to histamine release. Cisatracurium,
however, does not cause histamine release.
The effect of nondepolarizing muscle relaxants may be potentiated by
commonly used medications such as certain antibiotics, lidocaine, quinidine, beta-
antagonists, and calcium channel blockers such as verapamil. Mivacurium, the
shortest-acting depolarizing NMBA, may be prolonged by inadequate levels of
plasma cholinesterase.
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Peripheral Nerve Stimulation
By delivering a strong electrical stimulus to a peripheral nerve and observing the

pattern and strength of muscle twitch that occurs, the amount of existing
neuromuscular blockade can be assessed. This technique may be used during or
at the completion of surgery and is frequently used to test the patient’s recovery of
muscle strength. If accessible, the ulnar nerve in the forearm is usually the nerve
tested.
Peripheral nerve stimulation can also be used to differentiate the type of
blockade present; normally, depolarizing and nondepolarizing muscle relaxants
produce different patterns of response. However, if a phase II block has occurred
subsequent to a depolarizing blockade, the response resembles that of a
nondepolarizing blockade and is indicative of the untoward occurrence. Physical
assessment of residual neuromuscular blockade in the recovering patient can be
done by asking the patient to use a tight handgrip for 5 seconds or assessing the
patient’s ability to hold the head off the bed for 5 seconds. However, these methods
can be unreliable and electrical stimulus is most accurate (Thomas & Morgan,
2011).
SUMMARY
T
he ambulatory surgery nurse educates patients who are undergoing general
anesthesia about the perioperative care experience they can expect. Patient
education should include the anticipated sequence of events before, during,
and immediately following the procedure. Knowing what to expect may ease the
patient’s anxiety and facilitate a smooth recovery. The nurse should explain what
the patient might see, feel, and hear during the continuum of care. Because
ambulatory surgery patients are cared for at home after their procedure, it is critical
that the ambulatory surgery nurses involved in the patient’s care prepare the
patient and the patient’s significant other(s) for what they can expect related to the
procedure the patient had and the medications that were administered. Although
most general anesthesia medications used during ambulatory surgery are short
acting, some residual side effects may be experienced by patients even after they
arrive home. The nurse can help the patient to stay safe by providing a clear
description of known anesthetic side effects, tips on how to manage them, and
instances that should be reported to the physician.
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EXAM QUESTIONS
CHAPTER 5
Questions 29–32
29. General anesthesia may be induced via all of the following except
a. the use of a benzodiazepine.
b. the use of an inhalation agent.
c. a combination of an ultra-short-acting IV agent and an inhalation agent.
d. the use of an ultra-short-acting IV agent.
30. What actions should be taken to ensure safety when using propofol?
a. To prevent bacterial growth, opened propofol and the infusion line should
be discarded at the end of the surgical case or at 12 hours.
b. To avoid waste, a single-dose vial of propofol should be distributed among
several patients until it is completely empty.
c. To avoid increased costs, a multidose vial of propofol should be accessed
repeatedly using the same syringe and needle.
d. Propofol should not be used in ambulatory surgery.
31. The anesthesia provider administers medication to sedate the patient. The
nurse notices the patient displays signs of increased respiratory effort. In order
to assist the patient and the anesthesia provider, what does the nurse do first?
a. Call a code blue over the intercom system.
b. Document the respiratory issue in the medical record.
c. Gently turn the patient’s head to the side.
d. Call for a new anesthesia provider to replace the current provider.
32. At the end of the surgical case, the anesthesia provider extubates the patient
without difficulty. Just before transport to the postanesthesia care unit (PACU),
the patient shows signs of total airway obstruction characterized by rocking
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abdominal respirations. What is the cause and treatment?

a. This is local anesthetic toxicity. Treat with an infusion bolus of 20% lipid
emulsion.
b. The patient’s tongue has fallen toward the posterior pharyngeal wall. Treat
by supporting the chin so the mouth is closed in the sniffing position.
c. This is laryngospasm and the vocal cords are completely closed. Treat
with a small dose of muscle relaxant, positive pressure ventilation with 100%
oxygen, and prepare for endotracheal intubation.
d. This is caused by residual sedation. Treat by rubbing the patient’s
sternum to cause pain and wake the patient up.
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CHAPTER 6
REGIONAL AND LOCAL ANESTHESIA
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain the concepts
of regional and local anesthesia.
CHAPTER OBJECTIVES
A
1. Identify the pharmacologic agents used to accomplish regional and local

anesthesia.
2. Recognize the necessity of vigilant patient monitoring during regional and
local anesthesia.
INTRODUCTION
B
ecause most patients are concerned about pain when undergoing a surgical
procedure, various nerve blocks and injectable anesthetics are used to
prevent pain. Regional and local anesthesia may be used synergistically
with general anesthesia or procedural sedation or may be used in place of other
anesthetic techniques. The ambulatory surgery nurse educates the patient about
the effects of these techniques.
REGIONAL ANESTHESIA
A
s the name implies, regional anesthesia techniques produce loss of
sensation in a particular area of the body. This effect is accomplished with
the injection of drugs, collectively referred to as local anesthetics, that can
temporarily interrupt or block the conduction of impulses along nerve fibers.
Consequently, these techniques are often referred to as conduction anesthesia or
simply as blocks.
When used as the sole anesthetic technique, regional anesthesia causes little
systemic, physiologic alteration. By using a local anesthetic with a duration effect
appropriate to the anticipated length of the surgical procedure, the ambulatory
surgical patient may be expected to quickly recover and be ready for discharge to
home soon after the procedure is completed. When no contraindications exist, the
use of short-acting, local anesthetics with epinephrine may be preferable for
ambulatory surgical procedures.
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Regional anesthesia is not a panacea for any class of physical status or any
type of surgery. Contraindications for regional anesthesia include
extremes of age and mental status or the inability of the patient to cooperate;
coagulopathy or anticoagulation therapy and the potential for bleeding
causing compression of the nerves or tissue damage;
infection at the site of injection, including the spread of infection via the
needle and decreased effectiveness of the local anesthetic agent in the
acidic tissues near an infection;
patient preference (the patient’s refusal of regional anesthesia because of
apprehension about what he or she will see and hear in the operating room
or a fear of paralysis);
pre-existing neurologic deficits (relative contraindications that must be

evaluated on a case-by-case basis); and
systemic disease (hepatic or renal impairment that may alter metabolism of

local anesthetics, increasing the risk of systemic toxicity; patients with
coronary artery disease may respond adversely to the effects of epinephrine
mixed with the anesthetic).
In an ambulatory surgical setting, a potential disadvantage of regional

anesthesia is the time required to perform the block and the delayed onset of
anesthetic effect. This disadvantage may be overcome by performing the block in a
designated area outside the operating room. Full resuscitation equipment should be
immediately available in the area where regional anesthesia is performed, including
medications used to treat local anesthetic toxicity.
Patients scheduled for regional anesthesia must be prepared preoperatively by
maintaining nothing-by-mouth (NPO) status in case of an adverse drug reaction or
the need for general anesthesia. However, this protocol is becoming less common
and depends largely on the type of procedure scheduled, facility policy, and
physician preference.
Mild anxiolytic premedication may improve the patient’s anesthetic experience
and increase safety. Nerve injury may be reduced because patients who are more
relaxed are less likely to move during injection of the local anesthetic. In addition,
large total doses of local anesthetic are less likely to cause central nervous system
(CNS) toxicity if a benzodiazepine is given preoperatively to raise the seizure
threshold.
For the very anxious ambulatory surgical patient, premedication may best be
accomplished with the use of small IV doses given just before the placement of the
block.
Monitoring during regional anesthesia focuses on detecting delayed local
anesthetic toxicity from excessive tissue absorption (typically 15 to 60 minutes after
injection), ensuring adequate ventilation and oxygenation, and managing the
consequences of surgical stress, such as tourniquet pain or blood loss. Patients
with adequate blocks may be sedated, and the use of supplemental oxygen is
appropriate. Maintaining IV access is advisable during all types of regional
anesthesia.
Spinal Anesthesia for Ambulatory Surgery
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Spinal anesthesia may be suitable for ambulatory surgical procedures involving

the lower half of the body; however, discharge may be delayed due to persistent
orthostatic hypotension, prolonged motor or sensory blockade, or urinary retention.
In an outpatient setting, it is important that the local anesthetic used for spinal
anesthesia has a duration effect appropriate to the anticipated duration of the
surgical procedure to ensure efficient recovery and discharge. Consequently, short-
acting agents are preferable whenever possible. Lidocaine for shorter procedures
and bupivacaine for longer procedures have been the most commonly used for
ambulatory surgical patients and are discussed under “Local Anesthetic Agents.”
A possible postoperative complication of spinal anesthesia, postdural puncture
headache (PDPH), appears to occur more frequently in outpatients. PDPH is
thought to result from leakage of cerebrospinal fluid (CSF) from the subarachnoid
space through the dura mater. PDPH usually takes 24 to 72 hours to develop and is
aggravated by sitting and standing. Treatment includes lying flat in bed, analgesics,
and liberal fluid intake. In protracted cases, an autologous blood patch is usually
effective. This intervention involves injecting 10 to 15 ml of the patient’s own blood
into the epidural space at the level of the original lumbar puncture to seal the dural
leak.
Peripheral Nerve Blocks
A peripheral nerve block may involve a single nerve or a plexus of nerves. To

avoid neuropathy, the local anesthetic is injected adjacent to the nerve or nerves to
be anesthetized, where it diffuses into the neural tissue. Anesthesia develops in the
area of distribution of the blocked nerve. Profound analgesia is possible, although
the amount of motor paralysis depends on the concentration achieved.
Proprioception may not be affected, and the patient may still be aware of a limb
being positioned or skin being prepared for surgery.
Brachial Plexus Block
Nerves in the brachial plexus supply virtually all of the sensory and motor
innervation of the arm. There are three possible injection approaches: interscalene,
supraclavicular, and axillary.
The interscalene approach is suitable for shoulder and upper arm surgery, but
there is a danger of inadvertent injection into the cervical subarachnoid or epidural
spaces, resulting in spinal or epidural anesthesia. Inadvertent injection of the local
anesthetic into the vertebral artery may result in systemic toxicity. Phrenic nerve
block and neuropathy of the C6 nerve root are also potential complications
associated with this technique.
Supraclavicular injection, as well as infraclavicular injection, produces
anesthesia of the elbow, wrist, and hand. These approaches are associated with a
risk of inadvertent puncture of the pleura, resulting in pneumothorax. If the patient
coughs as the needle is being advanced or complains of respiratory distress,
oxygen should be administered by mask immediately and appropriate treatment
instituted. These patients should be monitored for dyspnea or absent breath
sounds.
The axillary approach is suitable for surgery of the hand and forearm. There is
no risk of pneumothorax, but a large dose of local anesthetic is required, increasing
the risk of systemic toxicity. Additionally, the arm must be able to be raised to allow
access to the axilla. The axillary approach remains the block with the lowest
potential complication rate, though vascular puncture and possible inadvertent IV
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administration remain concerns, especially if the needle tip visualization is lost

(Raju & Coventry, 2014). For ambulatory surgery, a brachial plexus block provides
the benefit of postoperative analgesia. However, because of the resulting prolonged
lack of sensation and impaired mobility, there is a danger of accidental injury to the
arm after discharge of an ambulatory patient.
IV Perfusion Block
This regional technique, also known as a Bier block, is especially useful in

ambulatory settings for surgical procedures of short duration on the elbow, forearm,
wrist, hand, and foot. Advantages include rapid onset, rapid recovery and
discharge, and high reliability. The technique involves occluding the circulation of
the arm or foot using a pneumatic tourniquet above the operative site. There will be
between 35 to 45 minutes of anesthesia, and after 20 to 30 minutes, the patient will
likely begin to experience pain from the tourniquet (Stancil, 2014). The extremity is
elevated and, starting at the fingers or toes, tightly wrapped with an Esmarch
elastic bandage to exsanguinate it. The tourniquet is then inflated, and local
anesthetic is injected IV to distend the veins. The tourniquet prevents the exit of the
local anesthetic from the extremity as the anesthetic diffuses out of the veins to
block small nerves and nerve endings.
Once the anesthetic is injected, the tourniquet must remain inflated 15 to 20
minutes, regardless of a shorter duration of surgery, to reduce the risk of systemic
toxicity when the local anesthetic is released into the bloodstream. After surgery,
the tourniquet is slowly, or intermittently, deflated, and any remaining anesthetic is
gradually released into the systemic circulation. Sensation usually returns within 2
to 5 minutes.
Pain at the tourniquet site may become intense. This pain may be alleviated by
using a double tourniquet where the upper section is first inflated for the IV
injection. When discomfort develops around the tourniquet, the lower, or distal,
section is inflated in the area that has become anesthetized, and the upper section
is released. Failure of the tourniquet or inadvertent release before 15 minutes have
elapsed may result in seizures or cardiovascular collapse caused by the rapid
distribution of a large dose of local anesthetic into the bloodstream.
In some instances, the rapid return of sensation may be considered a
disadvantage for ambulatory patients because there is a lack of postoperative
analgesia. In addition, the exsanguination process may be too uncomfortable for
patients with a painful extremity.
LOCAL INFILTRATION AND TOPICAL APPLICATION
O
ne of the most commonly used local anesthesia techniques for ambulatory
surgical procedures, local infiltration, involves the injection of a local
anesthetic into the skin and subcutaneous tissue in the area of the
operative site thus blocking transmission at the nerve endings where pain impulses
would arise. Topical application produces analgesia and anesthesia over a limited
surface area and is most frequently used for mucous membranes, where it is
rapidly absorbed. Cocaine may be used topically for some nasal, upper respiratory,
or ophthalmic procedures, which makes careful monitoring of the patient for
hypertension, dysrhythmias, or seizures essential.
Local Anesthetic Agents
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Local anesthetics differ in potency, onset of action, duration of effect, and

potency (see Table 6-1). There are two main pharmacologic classes, or types, of
local anesthetics: amides and esters. Amides are detoxified by the liver, and esters
are metabolized by ester hydrolysis and plasma cholinesterase
(pseudocholinesterase). All local anesthetics, regardless of the type, are capable of
producing systemic, toxic reactions. Local anesthetic toxicity occurs most frequently
from accidental intravascular injection of a local anesthetic during performance of a
peripheral nerve block (Collins, Neubrander, Vorst, & Sheffield, 2015). Effects of
local anesthetic toxicity depend on the drug used and the amount administered.
Peak blood concentrations may be delayed for 15 to 60 minutes after injection, so
patients must be continuously monitored.
Symptoms of developing CNS toxicity include
light-headedness,
tinnitus,
metallic taste in the mouth,
vision disturbances,
numbness around the mouth,

vague sensations not easily defined by the patient,
agitation,
muscle twitches, and
uncontrollable shaking.
Treatment of local anesthetic toxicity includes airway management, circulatory

support, and minimizing other systemic effects such as neurologic symptoms.
Seizures may be terminated quickly using benzodiazepines. Lipid emulsion therapy
has demonstrated positive outcomes in the reversal of cardiotoxic side effects
caused by local anesthetics (Collins et al., 2015). The lipid emulsion accelerates
the removal of local anesthetics from cardiac tissue with a restoration in cardiac
function. Cardiovascular toxicity is characterized by
hypotension,
bradycardia, and
dysrhythmia.
If cardiovascular toxicity is undetected or untreated, circulatory collapse and

cardiac arrest may occur. Immediate treatment includes oxygen administration, IV
fluids for intravascular expansion, and pharmacologic cardiac support.
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See Table 6-2 for more information.
Patients receiving regional anesthesia without premedication may exhibit

symptoms that must be differentiated from those of toxicity. The anxious or
frightened patient may appear agitated and suffer from nausea and vomiting. A
vasovagal response may be accompanied by hypotension, bradycardia, and
faintness. Administering oxygen and increasing IV fluid flow rate, if not
contraindicated, are advisable while the evaluation is being made.
For peripheral nerve blocks and infiltration, larger volumes produce a better
blockade, so less concentrated solutions of a local anesthetic are used to prevent
an overdose and possible toxicity.
Vasoconstrictors
Vasoconstrictors added to local anesthetics slow tissue absorption, which

prolongs the duration of anesthesia and reduces toxicity. Epinephrine is most
frequently used in concentrations of 1:100,000 or less. Using lidocaine, peripheral
nerve blocks last for 60 to 90 minutes; adding epinephrine may extend these times
by 50%. With bupivacaine, blocks may last more than 3 hours; with epinephrine
added, blocks may last for more than 12 hours. Due to the potential for skin and
muscle necrosis and injection site inflammation, lidocaine with a high concentration
of a vasoconstrictor is not recommended for infiltration anesthesia (Vesal, Jahromi,
& Oryan, 2012).
Epinephrine added to local anesthetic solutions to delay absorption and prolong
the anesthetic effect may cause tachycardia, diaphoresis, pallor, anxiety, changes
in mental perception, and strange subjective feelings for the patient that may be
misinterpreted as an allergic reaction.
Allergic Reactions
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Hypersensitivity, or allergic reactions to local anesthetics, such as urticaria,

bronchospasms, and anaphylaxis, have been reported but are rare. They may be
more associated with the ester types of anesthetics because these drugs are
metabolized to para-aminobenzoic acid (PABA), which is known to cause allergic
reactions under other circumstances. However, bacteriostatic and preservative
additives may be responsible for some of the reported reactions.
Careful questioning of the patient as part of the preoperative assessment is
important. A patient who relates urticaria and difficulty breathing during a previous
anesthetic procedure probably had an allergic reaction, whereas a patient who
describes palpitations and a headache immediately after injection of the local
anesthetic probably had effects from the epinephrine in the local anesthetic
solution, which may have been injected intravascularly.
SUMMARY
R
egional and local anesthetic techniques allow the recovering ambulatory
surgery patient to be almost pain free for a specific amount of time. The
time is relative to the duration of effectiveness of the medication provided.
These techniques and medications contribute to the safety of ambulatory surgery
and allow more patients to recover in the comfort of their homes. The ambulatory
surgery nurse educates the patient and significant other or caregiver about
expectations related to regional and local anesthetics, including duration of effect,
oral pain medications as ordered by the physician, precautions related to temporary
loss of sensation, and signs and symptoms to report to the physician.
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EXAM QUESTIONS
CHAPTER 6
Questions 33–34
33. During administration of a local anesthetic, the patient complains of ringing in

the ears, a metallic taste, and numbness around the mouth. The nurse
recognizes these complaints as being consistent with
a. local anesthetic toxicity.
b. known side effects of local anesthetic administration.
c. cardiovascular toxicity.
d. known side effects of epinephrine.
34. The physician requests a mixture of lidocaine and epinephrine for injection.
The nurse know the addition of the epinephrine will
a. decrease the duration of the local anesthetic effects by 60 minutes.
b. increase the duration of the local anesthetic effects by 60 to 90 minutes.
c. increase the duration of the local anesthetic effects by 12 hours.
d. decrease the duration of the local anesthetic effects by 60 to 90 minutes.
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CHAPTER 7
INTRAOPERATIVE CARE
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to describe
intraoperative patient care related to patient safety and advocacy, including
widely accepted infection prevention techniques and safety protocols.
CHAPTER OBJECTIVES
A
1. Describe the circulating nurse’s role as a patient advocate.

2. Explain the reason for conducting a preoperative patient interview and
content covered during the interview.
3. List areas of concern in the surgery environment and describe how to ensure
patient safety regarding those concerns.
4. Discuss widely accepted practices implemented to prevent infection in the

ambulatory surgery patient.
INTRODUCTION
A
ccording to the Association of periOperative Registered Nurses (AORN),
the goal of perioperative nursing practice is to assist patients, their family
members, and/or significant others to achieve a level of wellness equal to or
improved after the invasive procedure (Association of periOperative Registered
Nurses, 2014). Although the perioperative registered nurse may delegate tasks in
accordance with applicable law, regulations, and standards, responsibility for those
tasks remains with the nurse. It is widely accepted, and in some states, it is
required, that every patient undergoing a surgical or invasive procedure will be
cared for, at minimum, by a registered nurse (RN) in the circulating role. This role
cannot be delegated. The registered nurse in the circulator role should have no
other competing duties other than caring for the patient. The Association of
periOperative Registered Nurses (2014) states, “At a minimum, one perioperative
RN circulator should be dedicated to each patient undergoing a surgical or other
invasive procedure and be present during that patient’s entire intraoperative
experience.”
PATIENT ADVOCACY IN THE OPERATING ROOM
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he nurse who takes on the role of circulator in the procedure or operating

room has a duty to protect the patient at all times. It is important for the
nurse to understand that the patient’s protective reflexes are compromised
T
due to anesthesia administration. The nurse works collaboratively with the
surgeons, anesthesia care providers, surgical technicians and other healthcare
team members to meet the patient’s needs. The circulating registered nurse is
accountable for patient outcomes resulting from the nursing care provided during
the surgical or procedural case. Nurses in the operating room are focused on
ensuring care is provided in the safest manner possible. The nurse serves as an
advocate when he or she, for example, limits unnecessary traffic in and out of the
operating room, delays the start of a procedure until the correct instruments are
available, participates in the Universal Protocol’s time-out process, and reminds the
anesthesia provider to administer the prophylactic antibiotic before the surgical
incision is made. Nurses in the operating room play a critical role in monitoring the
environment of care, ensuring safe care, and promoting best practices for infection
prevention.
PREOPERATIVE PATIENT INTERVIEW
T
he circulating nurse’s preoperative interview of the ambulatory surgery
patient allows the nurse to assess the patient for appropriateness of care
and facilitates patient safety and care continuity. As discussed in Chapter 3,
the circulating nurse should seek out the preoperative nurse and receive a full
report, including the MAPS definition.
MAPS Definition
M = Medications (includes drugs received, such as sedation, analgesics, or
anesthesia agents)
A = Allergies (includes information on all patient allergies – medication and
other allergies)
P = Procedure/Pertinent Information (includes pertinent health history,
procedure done, findings, dressing, etc.)
S = Special Needs (includes family waiting in lobby, crutches in car,
communication concerns, disabilities, etc.)
It is helpful for this hand-off report to occur in the presence of the patient so the
patient may contribute information and feel assured that his or her needs are being
communicated to each member of the care team.
The circulating nurse puts the patient at ease by greeting the patient warmly
and with confidence. The nurse explains his or her role in the operating room and
includes a clear description of what the patient can expect, such as, “It may feel
cold in the operating room, but I will have plenty of warm blankets for you.” The
nurse is responsible for assessing the patient’s general condition and notifying the
surgeon and anesthesiologist if any irregularity is noted. Prior to transporting the
patient into the procedure or operating room, the nurse reviews the preoperative
safety checklist and takes time to inspect the patient’s medical record for an
accurate and fully executed consent form. The procedure or procedures listed on
the consent form should be confirmed verbally with the patient or guardian as well
as compared to the physician’s history and physical and written order. It is
important for the nurse to ask, “What procedure are you having done today?” rather
than, “I see you are having a right carpal tunnel repair. Is that correct?” The nurse
should give the patient adequate time to articulate a description of the procedure,
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as he or she understands it, in order to determine whether all parties are in

agreement. Any questions, doubts, or discrepancies must be satisfactorily
addressed before the patient is transferred to the operating or procedure room. The
nurse has a duty to “stop the line” until any confusion, abnormalities, or queries are
cleared. (See Universal Protocol on next page.)
The nurse reviews any available lab and imaging results and understands how
these results may affect the patient’s outcomes. The history and physical
examination should include mention of the physician’s impression, or diagnosis,
and a plan, or procedure(s) agreed upon. This is valuable information for the
circulating nurse to review. This information allows the nurse to understand what is
ailing the patient and what the physician plans to do in the operating room to
alleviate that ailment. The nurse should review any orders submitted by the
anesthesia care provider and surgeon or procedural physician and ensure those
orders have been carried out. During the patient interview, the nurse should review
and verbally confirm allergies, nothing-by-mouth status, physical limitations and
positioning restrictions, and removal of contact lenses, dentures, and jewelry. The
nurse should ask the patient about the presence of any implants, such as an
automatic implantable cardioverter-defibrillator, joint replacement implants, or metal
plates and screws (often used to repair bone fractures). The circulating nurse
knows to avoid placement of certain medical equipment, such as electrosurgical
pads, relevant to implantable device location. Finally, the nurse makes sure the
patient has a facility-issued hat on to cover hair and is relatively comfortable. The
nurse should assure the patient that he or she will be present throughout the
procedure and safe care is the utmost priority.
UNIVERSAL PROTOCOL
I
n January of 2005, The Joint Commission, a quality accrediting agency,
launched its Universal Protocol for Preventing Wrong Site, Wrong Procedure,
and Wrong Person Surgery™. During the past decade, the Universal Protocol
has been widely adopted across ambulatory surgery centers, hospitals, and other
healthcare facilities nationwide. Its three fundamental components are
preprocedure verification, site marking, and a time-out. At the publication of this
course wrong site, procedure, or person events are still a problem:
Each year, 1,300 to 2,700 wrong-site surgeries occur.
On average, 40 to 60 wrong-site surgeries occur weekly.

Inadequate planning is the attributable cause of 85% of analyzed wrong-site
surgeries.
A defect in the time-out process is the attributable cause of 72% of analyzed
wrong-site surgeries.
(The Joint Commission, 2015)

Preprocedure verification starts in the physician’s office during the interaction
between the physician and the patient. The procedure is documented by the
physician and then scheduled at the surgical facility of choice. It is important to note
that the scheduling of the procedure is handled by clerical staff who may or may not
have training in communication and medical terminology documentation. The
ambulatory surgery nurse will verify the procedure scheduled by reviewing the
physician’s history and physical examination of the patient for a corresponding
impression and plan, or diagnosis and procedure(s). Then, each nurse, including
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the preoperative nurse and circulating nurse, will review the written order submitted
by the physician that details the procedures to be listed on the facility’s required
consent form. Finally, each nurse who cares for the patient preoperatively will ask
the patient or guardian to verbally confirm the procedure the patient is having. All of
these checks and balances must line up before the patient is transported to the
operating or procedure room.
According to The Joint Commission (2015), site marking is done to prevent
errors when there is more than one possible body location for a procedure.
Examples include different limbs, fingers and toes, lesions, level of the spine, and
organs. In cases where bilateral structures are extracted (such as tonsils or
ovaries), the site does not need to be marked. The mark is a communication tool
about the patient placed for members of the team to use as another check and
balance. The Joint Commission (2015) states the individual who knows the most
about the patient should mark the site and involve the patient in the process. In
most cases, that will be the person performing the procedure; however, the nurse
should familiarize himself or herself with the ambulatory surgery facility policies and
procedures in place around Universal Protocol and site marking. The Joint
Commission believes that delegation of site marking to another individual may be
acceptable in limited situations as long as the individual is familiar with the patient
and directly involved in the procedure. Examples include individuals who are
permitted through a postgraduate education program to participate in the
procedure, a licensed individual who performs duties requiring collaborative or
supervisory agreements with a licensed independent practitioner, such as
advanced practice registered nurses and physician assistants. It is important to
note the licensed independent practitioner remains fully accountable for all aspects
of the procedure even when site marking is delegated. The circulating nurse should
not allow the patient to be transported to the operating room until the site marking
process is correctly completed with a surgical skin marker.
Evidence indicates that procedures that place the patient at the most risk for a
wrong site, wrong side, wrong patient event includes those that involve general
anesthesia or procedural sedation (The Joint Commission, 2015). Active
involvement of each member of the surgical team and use of effective methods of
communication among all members are important for success. Consistent
implementation of a standardized communication protocol is most effective in
achieving safety, paying special attention to empowering all team members to
protect patient safety. The purpose of the time-out pause and verification is to
conduct a final assessment that the correct patient, site, and procedure are
identified (The Joint Commission, 2015). Some have found that it is important to
conduct the time-out before anesthesia administration so the patient can be
involved. An organization may conduct the time-out before anesthesia or may add
another time-out, in addition to a time-out prior to the surgery start, at that time.
During a time-out, activities are suspended to the safest extent possible so that
team members can focus on active and cognitive confirmation of the patient, site,
and procedure. Some states require the physician to initiate the time-out. The time-
out must include standardized, active communication among all present members
of the procedure team and allow for resolution of discrepancies before the
procedure is started. The ambulatory surgery nurse should review the surgery
facility’s policies governing time-outs. An example of the standardized time-out
process used in Minnesota is below in Table 7-1.
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SAFETY CHECKLIST IN SURGERY
B
efore the incision is made or the procedure begins, the surgical team should
ensure each team member is introduced as appropriate and his or her role
is understood. All team members in the room should stop nonessential
activities and verbalize two patient identifiers, such as the patient’s name and date
of birth; the surgical site, including the correct side if applicable; and the
procedure(s) to be performed. The team should confirm the prep is dry and confirm
the site marking is still visible, even after draping. The surgical checklist should also
include consideration of anticipated critical events, including confirmation of sterility,
equipment, implant, and imaging availability, along with fire risk and its mitigation.
The team should confirm all medications on the field are properly labeled and
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prophylactic antibiotics, if ordered, are administered before the procedure starts

and before an incision is made.
Prior to transporting the patient from the procedure or operating room to the
recovery unit, the nurse should verbally confirm with the team that (1) the
procedure(s) performed are recorded in the medical record; (2) the instrument,
sponge, and needle count are correct, if applicable; (3) the specimen, if one was
taken, is labeled correctly; and (4) whether there are any equipment or instrument
issues that need to be addressed. Finally, the surgeon, anesthesia provider, and
circulating nurse should discuss concerns and solutions related to the patient’s
anticipated recovery.
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ENVIRONMENT OF CARE DURING SURGERY
T
he circulating nurse is well positioned to monitor for safety hazards in the
surgery environment. Ambulatory surgery nurses should work as a team to
assess their area of practice and offer environment of care improvement
suggestions for discussion.
Potential hazards associated with fire safety should be identified and discussed
prior to each case. Many surgery teams hold this discussion just before
transporting the patient into the operating or procedure room. The fire risk
assessment should identify (1) fuels that are present, (2) ignition sources that are
present, (3) the potential for the presence of an oxygen-enriched environment, (4)
the specific type of fire extinguisher that is required based on the fuel and
involvement of electrical current, and (5) additional preventive measures that are
required as determined by the location of the fire and fuel sources (Association of
periOperative Registered Nurses, 2013). Ignition sources in surgery include active
electrosurgical electrodes, lasers, electrocautery devices, and fiber-optic light
cords. Fuel sources include alcohol-based skin antiseptic agents, collodion, drapes,
gowns, and endotracheal tubes. These items should be controlled to prevent
contact with ignition sources. Flammable skin antiseptic agents should be
prevented from pooling on or under drapes or soaking into linens or the patient’s
hair. Adequate time should be provided to allow flammable skin antiseptic agents to
dry completely and to allow any fumes to dissipate before surgical drapes are
applied or a potential ignition source is used (Association of periOperative
Registered Nurses, 2013). Flammable skin antiseptic agent manufacturers include
the appropriate drying time on the solution’s label. The operating room should
include a timer so the nurse can monitor the drying time accurately. Oxidizers such
as oxygen, accumulated anesthetic gases, and nitrous oxide should be used with
caution near any ignition or fuel sources. More environment of care concerns are
listed in Table 7-2.
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PATIENT POSITIONING
A
nesthetized and sedated patients are at risk for injury related to their
position on the operating room table. These patients are not able to
communicate discomfort or reposition themselves when needed. In addition
to ensuring proper positioning for the safety of the patient, the circulating nurse and
surgical team must consider the needs of the anesthesia provider in relation to
accessing the patient’s airway and the needs of the surgeon in relation to optimal
access to the surgery site. The nurse also must assess the patient’s circulatory,
respiratory, integumentary, musculoskeletal, and neurologic structures during
positioning and routinely throughout the case. Positioning the patient requires a
coordinated effort by the entire surgical team.
Surgical team members, including the circulating registered nurse, should
ensure that all patients are correctly positioned. The goals of positioning include
1. providing adequate exposure of the surgical site;

2. maintaining patient dignity by avoiding undue exposure;
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3. allowing for optimum ventilation by maintaining a patent airway and avoiding

constriction or pressure on the chest;
4. providing adequate access to IV lines and monitoring equipment keeping in
mind that the anesthesia professional may assess urinary output, blood loss,
and irrigation use and that visibility of measuring devices and drainage bags
should be incorporated into the positioning plan;
5. avoiding poor perfusion;

6. observing and protecting the patient’s fingers, toes, and genitals;
7. maintaining circulation; and
8. protecting muscles, nerves, and bony prominences from pressure injury.
(Spruce & Van Wicklin, 2014)

The choice of position should be made collaboratively with input from all
members of the surgical team. The perioperative nurse should make sure that the
patient’s eyes are protected by avoiding any pressure on the eyes. Direct pressure
on the eyes during surgery can cause central retinal artery occlusion, which can
result in temporary or permanent blindness. Use of the prone position, procedures
that last longer than 6.5 hours, and significant blood loss during the surgery are all
risk factors for eye injuries (Spruce & Van Wicklin, 2014). Cervical alignment should
be maintained in all positions by avoiding flexion, extension, and rotation. Male
genitalia should be free from pressure, and pendulous skin folds should be void of
pinching. Padding can be used to protect the knees when in prone position or to
support the knees when in supine position. Care should be taken to keep pressure
off the toes (when prone) or heels (when supine). Some patients, such as the very
old or nutritionally challenged, may be susceptible to skin tears and injury to bony
prominences. The circulating nurse should assess for this risk and pad areas as
needed while always using great care to be gentle.
MEDICATION ADMINISTRATION
T
he ambulatory surgery nurse should ensure that medications are given
accurately and in a standardized method, as prescribed by the physician.
Medications should be administered following the Five Rs of administration,
and the nurse administering the medication should be aware of its purpose, side
effects, and proper dosage. The Five Rs are:
1. the right patient,

2. the right drug,
3. the right dose,
4. the right route, and
5. the right time.
It is imperative that ambulatory surgery staff adheres to the Centers for Disease
Control and Prevention (CDC) guideline of one needle, one syringe, one time,
which is outlined in their One and Only Campaign. The One and Only Campaign is
a public health effort led by the CDC and the Safe Injection Practices Coalition to
raise awareness among patients and healthcare providers about safe injection
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practices (Centers for Disease Control and Prevention, 2012). The campaign aims
to eliminate infections resulting from unsafe injection practices (see Table 7-3).
Safe Injection Practices
The following guidelines supplied by the Centers for Disease Control and
Prevention apply to the use of needles, cannulas that replace needles, and, where
applicable, intravenous delivery systems:
1. Use aseptic technique to avoid contamination of sterile injection equipment.
2. Do not administer medications from a syringe to multiple patients even if the

needle or cannula on the syringe is changed. Needles, cannulas, and
syringes are sterile, single-use items; they should not be reused for another
patient or to access a medication or solution that might be used for a
subsequent patient.
3. Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and
connectors) for one patient only and dispose of appropriately after use.
Consider a syringe or needle/cannula contaminated once it has been used to
enter or connect to a patient’s intravenous infusion bag or administration set.
4. Use single-dose vials for parenteral medications whenever possible.

5. Do not administer medications from single-dose vials or ampules to multiple
patients or combine leftover contents for later use.
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6. If multidose vials must be used, both the needle or cannula and syringe used
to access the multidose vial must be sterile.
7. Do not keep multidose vials in the immediate patient treatment area, which
includes operating and procedure rooms, and store in accordance with the
manufacturer’s recommendations; discard if sterility is compromised or
questionable.
8. Do not use bags or bottles of intravenous solution as a common source of
supply for multiple patients.
Vials labeled by the manufacturer as single dose or single use should be used
for a single patient. These medications generally lack antimicrobial preservatives,
can become contaminated, and serve as a source of infection when they are used
inappropriately.
To ensure safe delivery of medications, labeling of medication containers – such
as syringes, medicine cups, basins, or other solutions on and off the sterile field –
must occur when any medication or solution is transferred from the original
packaging to another container unless the medication is immediately administered
(The Joint Commission, 2015). Most ambulatory surgery facility policies state that
the syringe or new container will be labeled immediately upon solution being
added. The label should include the drug name, strength, amount, and expiration
date or time as appropriate. Labels should be visually and verbally verified when
the person preparing the medication is not the person administering the medication,
which is often the case intraoperatively.
SURGICAL SITE INFECTION PREVENTION
T
he Centers for Disease Control and Prevention (2010) defines a surgical site
infection (SSI) as “an infection that occurs after surgery in the part of the
body where the surgery took place.” See Table 7-4 for Surgical Site Infection
Prevention.
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Eleven Steps to Surgical Site Infection Prevention
Surgical site infections can be prevented by following these relatively simple

recommendations:
Personnel should
1. clean their hands often with an alcohol-based product and perform

appropriate surgical hand scrubs;
2. perform surgical skin antisepsis using an appropriate technique and
antiseptic;
3. wear clean, facility-laundered scrub attire;

4. minimize operating room traffic;
5. follow environmental cleaning protocols;

6. engage with a patient who has experienced an SSI or the patient’s family
member to develop SSI prevention strategies;
7. follow a surgical safety checklist;
8. implement team training to promote a team-based approach to SSI

prevention;
9. minimize the use of immediate use steam sterilization;

10. clean instruments thoroughly before sterilizing or disinfecting; and
11. speak up whenever a break in sterile technique is witnessed, and correct the
break as soon as possible.
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(Spruce, 2014)
STERILIZATION AND ASEPTIC TECHNIQUE IN

SURGERY
P
roperly using, handling, disinfecting, and sterilizing surgical instruments is
required to reduce the risk of surgical site infections. Reusable surgical
instruments must be reprocessed according to manufacturer’s guidelines
and instructions for use. Reusable devices and instruments can be properly cared
for on-site in the ambulatory surgery sterile processing department. Items to be
sterilized on-site should be cleaned, decontaminated, inspected, packaged,
sterilized, and stored in a controlled environment and in accordance with the device
manufacturer’s validated and written instructions for use. The circulating
ambulatory surgery nurse is responsible for ensuring that reusable surgical items
have undergone appropriate disinfection and sterilization before they are used on
patients. This is accomplished when the nurse and surgical technician check
specific indicators to verify that cleaning, decontamination, and disinfection or
sterilization have occurred. The nurse and surgical technician should visually
inspect all sterile wraps and packaging for any holes or breaks that may
compromise sterility. All questionable items should be held back from the sterile
field and reprocessed.
Instruments labeled as single-use should not be reprocessed unless U.S. Food
and Drug Administration (FDA) guidelines for reprocessing of single-use
instruments or devices are followed. This usually cannot be accomplished on-site;
therefore, the instruments must be shipped to an FDA-approved, third-party
reprocessing facility where disinfection and sterilization can be done safely.
All ambulatory surgery team members must adhere to the basic principles of
aseptic practices throughout the preoperative, intraoperative, and postoperative
phases in order to minimize wound contamination. Each individual is responsible
for his or her own professional performance in providing the ambulatory surgery
patient with a standard of quality care. In order to possess a surgical conscience, a
practicing professional must include a commitment to honesty, integrity, and
assertiveness. All items utilized within a sterile field must be sterile. The use of
unsterile items may introduce harmful micro-organisms within the operative wound
site, resulting in a postoperative infection. The edges or borders of sterile items are
to be considered contaminated once the item has been opened. All sterile
packages dropped on the floor are to be considered contaminated and must be
reprocessed. During the force of the fall, room air may enter the package through
the weave of the material, pinholes, or seal breakage. Sterile items must be lifted
off storage racks, not pulled, to prevent tearing of the outer wrapper. Care must be
taken to avoid excessive pooling of liquids on the sterile field. Pouring sterile liquids
from a bottle must be accomplished in such a manner that the solution does not
drop or splash on the unsterile portion of the bottle. Any solution doing so must be
considered contaminated and therefore must be discarded.
The sterile surgical gown that is worn by the surgeon and all scrubbed
personnel is to be considered sterile in front from chest to table level and the
sleeves of the gown are sterile up to 2 inches above the elbow, with all other areas
considered unsterile, including the neckline, shoulders, areas under the arm, and
back. Draped operating room tables are considered sterile only at table level.
Sterile barriers will be considered contaminated when permeated by filtration or
airborne micro-organisms, strike through of a wet substance, or compromised by
perforations. Prior to dispensing a sterile item, the circulating nurse must check the
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integrity of the package, appearance of sterilizer indicating tape, and out-of-date

indicators as applicable.
DOCUMENTATION
D
ocumenting nursing activities in the operating room record provides a
description of the intraoperative nursing care administered, status of
patient outcomes on transfer, and information for continuity of patient care.
At a minimum, the following information should be documented:
1. time in the room, procedure start time or incision time, procedure completion
time, time out of the room;
2. team members present;
3. allergies;
4. confirmation of the time-out and when it was completed;
5. preoperative diagnosis, procedures completed, postoperative diagnosis;

6. specimens taken and handling orders;
7. wound classification;
8. areas prepped and solution used;
9. occurrence of instruments’ counts;

10. positioning details, including position chosen and assistive devices and
padding used;
11. use of electrocautery equipment, lasers, and surgical tourniquets and
corresponding settings and times used as applicable;
12. confirmation of instrument sterility;
13. information about any implants that were left in the body, including the
location in the body that they were implanted; the manufacturer’s name,
serial numbers, and expiration dates of the items; and medications
administered by the nurse or physician (excluding medications administered
by the anesthesia care provider);
14. wound dressing;
15. status of nursing diagnoses per facility policy; and

16. status of patient upon arrival to postanesthesia care unit (PACU) and to
whom the patient was handed off.
The circulating nurse’s operating room record is used to communicate the

patient’s care to other providers. This record serves as a useful tool to the PACU
nurse as he or she may use it to answer the patient’s questions or those of family
members or significant others. The physician performing the procedure will usually
write a short, immediate postoperative note and then dictate an operative note that
will be inserted into the medical record upon final approval from the physician. In
the meantime, most of the information needed by the ambulatory surgery team and
patient can be found on the circulating nurse’s operating room record.
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The anesthesia provider will also document relevant information during the
procedure. The anesthesia record will contain patient vital signs throughout the
procedure, medications given by the anesthesia provider, type of airway used, and
type of anesthesia administered.
SUMMARY
I
ntraoperative care of the ambulatory surgery patient is, perhaps, the most
routinely intensive area of ambulatory surgery nursing. Upon administration of
anesthesia, the patient is unable to communicate his or her needs; therefore,
the circulating nurse and the surgery team are responsible for anticipating those
needs and ensuring patient safety at all times. The circulating nurse is one member
of a multidisciplinary team who come together to provide the best outcome
possible. In that shared effort, the circulating nurse should work closely with the
anesthesia provider, the surgeon, the surgical technician, and other team members
to maintain a safe environment, prevent infection, administer medications safely,
and promote communication among providers.
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EXAM QUESTIONS
CHAPTER 7
Questions 35–42
35. Before transporting the patient to the operating room, the circulating nurse
seeks out the preoperative nurse for a hand-off report. It is appropriate for the
preoperative nurse to include all of the following information except
a. an allergy to aspirin that causes hives.
b. a history of hypertension.
c. the age of the patient’s significant other.
d. use of a medical interpreter.
36. The circulating nurse reviews the patient’s history and physical examination,
the physician’s orders, and the surgical consent. The nurse then asks the
patient what procedure she is having done today. The patient indicates she is
having a cataract removed from her left eye and an intraocular lens will be
inserted. All documentation in the medical record indicates the right eye is
scheduled for this procedure. What does the nurse do next?
a. Alert the physician of the discrepancy.
b. Ask the patient’s significant other if he knows what eye should be worked
on today and then proceed with whichever eye he confirms is correct.
c. Review the scheduling form sent to the surgery center from the
physician’s office and proceed with whichever eye was scheduled.
d. Let the patient know that the right eye procedure will be completed today.
37. During the preoperative interview, the circulating nurse reviews the patient’s
lab results and notes they are abnormal. What does the nurse do next?
a. Cancel the case.
b. Notify the anesthesiologist and surgeon to ensure they are aware.
c. Discuss the results with the patient.
d. Transport the patient to the operating room.
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38. All of the following content should be included in the circulating nurse’s
preoperative interview except
a. the presence of any implants.
b. the risks and benefits of the proposed procedure.
c. physical limitations and positioning restrictions.
d. removal of contact lenses, dentures, and jewelry.
39. What actions do circulating nurses take to avoid fire in the operating room?
a. Discuss potential fire hazards and prevention techniques prior to the case
and allow adequate dry time for flammable skin preps.
b. Participate in the time-out pause and use assistive patient transfer
devices.
c. Adjust alarm volumes so they are heard and routinely inspect for
compromise, including frayed cords and damaged plugs.
d. Identify the specific type of fire extinguisher that is required based on the
fuel and involvement of electrical current.
40. When positioning an anesthetized patient in preparation for surgery, the

surgical team is focused on all of the following except
a. providing adequate exposure of the surgical site.
b. maintaining patient dignity by avoiding undue exposure.
c. maintaining circulation.
d. the comfort of the nurse during surgical skin preparation.
41. All of the following are consistent with safe injection practices except
a. using single-dose vials instead of multi-dose vials when possible.
b. using a single sterile needle for an injection and immediately discarding it.
c. preparing medication in a designated, clean area.
d. reusing the same syringe on multiple patients.
42. How can the ambulatory surgery staff help prevent surgical site infection?
a. Wear clean, facility-laundered scrub attire.
b. Participate in fire drills every quarter.
c. Handle chemicals such as disinfectants safely.
d. Assess patients for latex allergies.
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CHAPTER 8
POSTPROCEDURE CARE
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to discuss common
interventions used during postprocedure care to promote patient comfort
and safety.
CHAPTER OBJECTIVES
A
1. Identify essential postoperative patient assessment parameters.

2. Identify common postoperative side effects and complications that may occur
during recovery from surgery and anesthesia.
3. Implement nursing care that will encourage uncomplicated patient recovery.
4. Explain interventions implemented in response to side effects and

complications.
INTRODUCTION
W
ith the use of short-acting opioids and anesthetics, ambulatory surgical
patients are typically alert and in stable condition upon transfer from the
operating room to the postanesthesia care unit (PACU). Some
ambulatory surgery facilities choose to separate the PACU into phase I and phase
II recovery stages or to use step-down recovery areas where the patient sits in a
reclining chair and, in some cases, may be attended to by his or her family or
caregiver in preparation for discharge. Advocates believe this arrangement
enhances patient and caregiver learning for the extended recovery period and
decreases the time to home readiness.
Postoperative care in outpatient settings emphasizes control of nausea and
vomiting and adequate pain management to achieve home readiness as quickly as
possible (Maurice, 2015). However, ambulatory surgical patients are at risk for
postoperative complications as are inpatients undergoing similar procedures;
consequently, ambulatory patients require the same level of skilled postoperative
care and monitoring. During the postoperative period, potentially life-threatening
respiratory and circulatory complications can occur. Patients should be monitored
during recovery after all types of sedation or anesthesia, including local infiltration.
ENVIRONMENT OF CARE
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he postprocedure nurse should assess the recovery unit for safety while
anticipating patient needs. Supplies such as oxygen tubing, suction tubing
T and canisters, Ambu bags in various sizes, and oral and nasal airways
should be at the bedside and in working condition. Warm blankets should be
stocked in the blanket warmer and ready for patients as needed. The nurse
should ensure there is a separate, designated area reserved for medication
preparation. Postprocedure nurses may find they administer analgesics frequently
and should be provided space, without interruption, to prepare medications safely.
Postprocedure nurses often set up mobile workstations so they can attend to the
immediate needs of their recovering patients and hear and see patient monitors at
all times.
Each patient emerges from anesthesia differently, so it is wise to have soft
pillows available to help position patients and prevent any injuries related to
stretcher railings. It is tempting to turn down the lights in the recovery area to allow
for patient comfort, but it is imperative that the healthcare providers be able to
visually assess patients as they recover from surgery. No food or drink should be
permitted in this area due to infection concerns.
THE POSTANESTHESIA CARE UNIT
T
he goal of nursing care in the postanesthesia care unit (PACU) is to identify
any potential anesthesia or surgical problems and intervene when
appropriate (Brenner & Kautz, 2015). The PACU registered nurse (RN)
performs an initial airway, breathing, and circulation assessment, along with
identification of the patient’s electrocardiogram (ECG) rhythm, level of
consciousness, vital signs, pain, surgical site incisions, IV access, and medication
given and ordered for use in the PACU (Brenner & Kautz, 2015). Supplemental
oxygen requirements in recovery are determined by the patient’s respirations,
oxygen saturation level, preoperative baseline, and medical history. The PACU RN
monitors for deviations in the patient’s vital signs and ECG from the preoperative
baseline status. The goal is to restore normothermia and monitor for complications
such as shivering, bleeding, altered medication metabolism, pain, infection, and
late signs of rare malignant hyperthermia (Brenner & Kautz, 2015). The PACU RN
also assesses the patient’s surgical site to monitor for signs of drainage,
hematoma, or active bleeding through the surgical dressing. The nurse should not
remove the surgical dressing without an order from the surgeon.
An awake, alert patient with no airway difficulties, stable cardiovascular and
respiratory functions, and appropriate oxygen saturation may be considered to
have acceptable clinical criteria to bypass phase I in the PACU and be sent directly
to the phase II setting (Pandit, 1999). However, pre-existing conditions, such as
sleep apnea or comorbidities of some elderly patients, may eliminate fast-tracking
as an option. Decisions about the necessary level of care for these patients should
be made on a case-by-case basis after reviewing the patient’s complete health
profile and assessing for potential complications requiring intervention.
POSTPROCEDURE ASSESSMENT
A
dmission to the PACU involves the transfer of immediate responsibility for
the patient’s safety and welfare from the intraoperative anesthesia or
sedation provider to the PACU nurse. The patient’s name, type of surgery,
and pertinent medical history should be described by the anesthesia provider. The
nurse should be given a brief summary of the anesthetic technique, course of the
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operation, total amount and type of fluid administration, complications and the
treatment provided, patient’s condition prior to transfer, and suggestions for
personalized postoperative management, if indicated (see Table 8-1). The
circulating nurse should provide information about any surgical events, positioning
concerns, skin assessment, and reaction to anesthesia, along with the hand-off
report that includes MAPS (see Chapter 7; Crosson, 2015). Any unexpected
change from the patient’s preoperative assessment or concerns of the RN circulator
should be passed on to the PACU RN for further evaluation and management.
Before accepting responsibility for the patient, the nurse should assess airway
patency and then determine and record respiratory rate and character; pulse rate,
rhythm, and amplitude; and systemic blood pressure. Level of consciousness and
skin color should also be assessed and recorded. Assessment of these conditions
every 5 minutes for the first 15 minutes and every 15 minutes thereafter is the
generally accepted protocol during an uncomplicated recovery. Recording the
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patient’s temperature may be appropriate on arrival and prior to discharge. Families

or significant others of the patient are increasingly being admitted to the PACU.
Primary concerns for nurses in these circumstances are personal confidentiality for
all patients in the PACU, pain and comfort management, and potential
emergencies. The nurse should stay with the patient’s family members to allay
fears and address concerns (Herd & Rieben, 2014).
Nausea and Vomiting
Nausea, vomiting, extended drowsiness, and pain are the most common
management problems in the ambulatory PACU (Maurice, 2015). The strain of
retching and vomiting may also create a risk of postoperative bleeding or
hematoma formation.
About one third of ambulatory surgical patients experience postoperative
nausea and vomiting (PONV; Maurice, 2015). Risk factors for developing PONV
include a history of PONV or motion sickness, female gender, use of perioperative
opioids, a nonsmoking status, and the type and duration of surgery (Maurice,
2015). Pretreating at-risk patients with fluid boluses of 20 ml/kg of isotonic IV fluids
in the preoperative area can decrease the incidence of PONV. For high-risk
patients, the anesthesia provider may choose a combination of local anesthetics,
anxiolytics, adequate hydration, total IV anesthesia with propofol, and the use of
nonpharmacologic techniques to prevent PONV (Maurice, 2015).
The postoperative ambulatory surgical nurse should provide the patient with
alternative self-care strategies for dealing with PONV that might develop
postdischarge; these techniques include deep breathing, a cool washcloth to the
forehead, aromatherapy, and repositioning (Maurice, 2015).
Pain is often an overlooked cause of nausea and vomiting; and sudden
movements or position changes should be avoided, as should sounds and visual
stimuli (Maurice, 2015). Patients may deny nausea but may be reluctant to move or
open their eyes (Maurice, 2015).
Pain Management
As patients arrive in the PACU more alert and clearheaded, they are also more
aware of pain. Relieving postoperative pain with minimal side effects from the
analgesics administered is a primary concern in the PACU. Beyond patient comfort,
relief of pain reduces sympathetic nervous system response to the pain, thus
helping to control hypertension, tachycardia, and agitation. A patient’s interpretation
of pain sometimes correlates poorly with sympathetic response. The patient may
exhibit severe hypertension, tachycardia, and possibly dysrhythmias with minimal
complaint of discomfort. Conversely, others may complain of severe pain without
clinical signs. This divergence may be related to psychologic, cultural, or
cardiovascular variations among individuals. Pain management needs to be
tailored for different age groups and various cultural groups (Hayes & Gordon,
2015).
The current trend is to attempt to qualify perceived pain by using subjective,
patient-based scoring systems. These include the visual analog scale (VAS) that
ranges from no pain to the worst pain (Figure 8-1); a numeric rating scale where 0
represents the least pain and 10 the worst (Figure 8-2); a numeric descriptor scale
with 1 representing mild pain, 2 distressing pain, 3 severe pain, 4 horrible pain, and
5 excruciating pain; and an observational behavior faces scale (e.g., smiling faces
or frowning faces; see Chapter 3, Figure 3-3). Only the observational behavior
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faces scale is appropriate for use with a patient who is unable to communicate or
cooperate in the assessment process, as may be the case with children or geriatric
patients (Wong-Baker FACES® Foundation, n.d.).
The increased focus of some accrediting agencies regarding measuring and

reporting pain has led to an overreliance on opioids to relieve pain and an alarming
increase in cases of oversedation, as well as significant respiratory depression
(Hayes & Gordon, 2015). The lack of predictable results from opioid administration
due to many unique patient factors led the American Society for Pain Management
Nursing (ASPMN) and the American Pain Society (APS) to develop a consensus
statement on the use of pro re nata (PRN) opioid range orders for acute pain,
stating that care providers should not prescribe or administer an opioid dose based
solely on pain intensity ratings (Hayes & Gordon, 2015). In addition to considering
the patient’s pain intensity rating, medication administration decisions should be
based on other factors such as a thorough pain assessment, knowledge of the
medication to be administered, assessment of an individual patient’s risk for
adverse effects, and the anticipated onset, peak effect, and duration of the opioid to
be administered (Hayes & Gordon, 2015). Although a VAS score of 2 or 3 may
signify a comfort level that the patient finds satisfactory at rest, the same score may
prove intolerable during coughing, deep breathing, or moving. Comparison of VAS
scores both at rest and when ambulating may be more indicative of the adequacy
of analgesia as well as home readiness. Current management is directed toward
pre-emptive or early treatment, such as the use of regional blocks and local
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anesthesia that decreases the total required amount of analgesia, which avoids
contributing to nausea and vomiting or sedation that may prolong the PACU stay.
Medication Management
Long-acting opioids, such as morphine or meperidine, are considered poor

choices for ambulatory patients by some healthcare providers. Conversely,
alfentanil and remifentanil are too short acting to provide analgesia of adequate
duration, and sufentanil’s potency raises safety concerns. Fentanyl, administered
by the intravenous (IV) route in small, incremental doses, may be the best choice of
opioid analgesic in the ambulatory PACU (Maurice, 2015). The IV administration is
more flexible and predictable than intramuscular injection. A summary is provided
in Table 8-2.
If IV fentanyl does not provide adequate pain relief, hydromorphone (Dilaudid)

given IV or intramuscularly (IM) has been shown to provide good analgesia with a
minimum of nausea and vomiting (Maurice, 2015). However, hydromorphone is
more potent than morphine, has a more narrow range of safety (toxic to therapeutic
ratio), and may be associated with a greater risk of respiratory depression
(Maurice, 2015). Opioid agonists-antagonists, such as nalbuphine (Nubain) or
butorphanol (Stadol), tend to produce less respiratory depression but may have a
so-called ceiling effect in which increasing doses beyond a certain level may not
increase the effect.
In a consensus statement of the American Society of Pain Management Nurses
and the American Pain Society authored by Drew, Gordon, Renner, Morgan,
Swensen, and Manworren (2013), the following was agreed upon:
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Effective pain management requires careful individual titration of

analgesics that is based on a valid and reliable assessment of pain and
pain relief. A registered nurse, who is competent in pain assessment and
analgesic administration, can safely interpret and implement properly
written “as-needed” or “PRN” range orders for analgesic medications. The
American Society of Pain Management Nurses (ASPMN) and the
American Pain Society (APS) support safe medication practices and the
appropriate use of PRN range orders for opioid analgesics in the
management of pain.
To be effective and safe, range orders should be carefully prescribed and
delineated. Since 2004, The Joint Commission, per standard MM.04.01.01 EP1
(2016), requires all organizations to have a policy on the required elements for all
medication orders. Just as importantly, range orders must be skillfully and carefully
interpreted by the perianesthesia nurse.
Nonsteroidal anti-inflammatory drugs (NSAIDs) do not have the undesirable
side effects associated with opioids (e.g., sedation, respiratory depression, nausea
and vomiting, urinary retention), and they may be continued after discharge. They
may act synergistically with opioids without causing respiratory depression
(Maurice, 2015). Postoperatively administered NSAIDS provide significant pain
relief and decreased intensity of pain (Penprase, Brunetto, Dahmani, Forthoffer, &
Kapoor, 2015). More effective oral medications have replaced NSAIDs during the
past 10 years, including cyclooxigenase-2 (COX-2) inhibitors and gabapentin.
Research indicates that the use of COX-2 inhibitors for pre-emptive analgesia
reduces postoperative pain and decreases the overall use of opioids
postoperatively while avoiding the undesirable gastrointestinal bleeding effects
sometimes noted with the use of NSAIDS (Penprase et al., 2015). Numerous
studies have suggested that gabapentin used as a pre-emptive analgesic has a
beneficial effect on both pain scores and postoperative opioid consumption
(Penprase et al., 2015).
Ketorolac (Toradol), a parenteral NSAID, may be given IV or IM. Its potency is
believed to be similar to that of morphine, but for severe pain, supplementation with
small doses of an opioid may be necessary. Some surgeons may be concerned
that ketorolac may cause bleeding at the surgical site because of inhibitory action
on platelets. However, studies show postoperative bleeding is not significantly
increased with Toradol use (Gobble & Hoang, 2012). Acetaminophen is the most
commonly used oral analgesic worldwide because it is effective for mild pain and
has few adverse effects when the recommended daily dose is not exceeded. The
maximum adult oral dose is 4 g (4,000 mg) over 24 hours (Ziolkowski et al., 2015).
Acetaminophen has a significant opioid-sparing effect, and it can be administered
rectally to children. Unlike NSAIDs, it does not irritate gastric mucosa, affect platelet
function, or cause renal dysfunction. Intravenous acetaminophen was approved for
use on November 2, 2010, by the U.S. Food and Drug Administration (FDA).
Overall results and recommendations from the literature support the use of IV
acetaminophen as a safe alternative to opioids for pain control in postoperative
patients (Ziolkowski et al., 2015). Providing postoperative pain relief for obese and
morbidly obese patients without causing excess sedation and concomitant
respiratory depression may be challenging; however, it is necessary to avoid upper
airway obstruction caused by excess pharyngeal tissue. Similarly, respiratory
depression resulting from pain management medications must be avoided in
patients with obstructive sleep apnea (OSA). If the use of an opioid becomes
necessary, opioid antagonists should be immediately available.
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Pain is a potent stimulus that may support respiration, alertness, and blood
pressure. Consequently, when pain is relieved, hypoventilation, somnolence, or
hypotension may develop. Hypovolemic patients may exhibit precipitous
hypotension when sympathetic support due to the stimulation of pain ceases,
resulting in venous and arterial vasodilation. Additionally, the depressant effects of
analgesics may cause hypoventilation that may result in hypoxemia and respiratory
acidosis. Patients who are confused and agitated due to hypoxemia, acidosis, or
cerebral ischemia may be difficult to differentiate from those with true pain, but it is
essential that no further analgesic is administered until these causes have been
eliminated.
Local anesthetic infiltration of the incision, or anesthetic splashed into the
wound near the end of the procedure, provide effective postoperative analgesia.
Nerve blocks are also effective but carry the risk of injury due to lack of sensation
and motor control, especially if an extremity is involved. Intra-articular boluses of
local anesthetic, with or without morphine, reduce the need for supplementary
analgesia after orthopedic surgery.
Currently, multimodal analgesia is the most effective plan used to relieve
postsurgical pain (Manworren, 2015). The use of analgesics in at least two
medication classes along with nonpharmacologic therapies allow clinicians to target
different pain control mechanisms. Perioperative nurses should anticipate treating
patients’ postoperative pain with combinations of local anesthetics, acetaminophen,
NSAIDs, opioids, alpha-adrenergic agonists, and biobehavioral interventions
(Manworren, 2015). In ambulatory surgery, poor pain management may delay
discharge and may cause patient dissatisfaction with the entire surgical experience.
The Joint Commission, per standard RI.01.01.01 EP 8 (2016), and other
accrediting agencies, requires ambulatory surgery facilities to respect the patient’s
right to pain management.
Other Common Postoperative Complications
Respiratory assessment is the most critical patient assessment to perform upon

arrival in the PACU after general anesthesia or sedation. Some patients will require
airway management and close monitoring to prevent postoperative complications.
Ineffective airway management can quickly lead to hypoxemia and will ultimately
compromise patient care.
Airway Obstruction
Obstruction of the airway is most frequently associated with patients who are
semiconscious, especially those in supine or sitting positions. The patient’s tongue
falls back against the posterior pharyngeal wall, usually due to central nervous
system depression resulting from drugs such as opioids (Scott, 2012). Partial
airway obstruction is accompanied by noisy breathing, such as inspiratory stridor or
expiratory wheeze. Complete obstruction is characterized by a “see-saw” chest
movement and silence. Head tilt and chin lift, as well as jaw thrust and the lateral
“recovery” position, can be utilized to prevent many physiologic obstructions (Scott,
2012).
Hypoventilation
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Residual sedative, narcotic, or anesthetic effect, residual neuromuscular

paralysis, and airway obstruction are the most frequent causes of postoperative
hypoventilation. Benzodiazepine effects may respond to reversal with flumazenil,
and narcotic effects may be reversed with naloxone. However, ambulatory surgical
patients should be monitored long enough to ensure that cardiorespiratory
depression does not recur (Apfelbaum et al., 2013). Although patients with OSA are
at increased risk for hypoventilation, oxygen therapy may cause airway
complications by increasing partial pressure of carbon dioxide and reducing
hypoxia, thereby reducing the patient’s respiratory drive (Scott, 2012). Oxygen may
thicken secretions within the respiratory tract and cause detrimental effects on
patients suffering from chronic obstructive pulmonary disease (Scott, 2012).
Oxygen is a drug requiring a physician’s order. Although the availability and use of
shorter-acting, nondepolarizing neuromuscular blocking agents (NMBAs) has
reduced the incidence of residual paralysis, it still occurs and may be fatal if not
recognized and treated. Testing with a peripheral nerve stimulator shows
neuromuscular transmission by means of acceleromyography and is the most
reliable way to diagnose residual neuromuscular block (Videira & Vieira, 2011).
Clinician tactile or visual assessment for residual block is associated with
systematic diagnostic error that prompts anesthesia providers to extubate patients
who are experiencing residual paralysis (Videira & Vieira, 2011).
When the core body temperature or acid-base balance is not normal, the
metabolism of neuromuscular agents may be affected. Patients who appear to be
breathing well when admitted to the PACU may later develop signs of inadequate
respiration. If conscious, the patient may complain of respiratory distress or have
difficulty speaking, but unconscious patients may drift into hypoventilation (Wilson,
Collins, & Rowan, 2012).
Oxygen and manual or mechanical respiratory support must be given
immediately when residual paralysis is present. Nondepolarizing NMBAs may be
reversed with an appropriate reversal agent, but a phase II block following the
depolarizing muscle relaxant succinylcholine is pharmacologically more complex to
treat. In either case, ventilation must be assisted until adequate spontaneous
respiration resumes. If the patient is unconscious, intubation may be necessary.
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Hypoxemia
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Causes of hypoxemia include hypoventilation, airway obstruction, ventilation-

perfusion abnormalities, aspiration, or pulmonary edema. Cyanosis is a late sign of
hypoxemia and may not be seen in patients with low hemoglobin or hematocrit
levels. To avoid irreversible cellular damage or a fatal outcome, oxygen
supplementation and ventilatory support must be provided while the cause of the
hypoxemia is established and treated.
Hypotension
The most common cause of hypotension in the PACU is hypovolemia (Seifert &
Wadlund, 2015). Blood loss and inadequate fluid replacement resulting in
hypovolemia reduce the venous return to the heart. Hypotension may be defined as
a systolic blood pressure less than 90 mm Hg and a diastolic blood pressure less
than 60 mm Hg or a blood pressure 30% less than the patient’s preoperative
baseline blood pressure (Seifert & Wadlund, 2015). Hypotension due to developing
hemorrhagic shock is usually accompanied by tachycardia; cold, moist, pale, or
cyanotic skin; and increased restlessness or agitation, often described as air
hunger. Initial treatment includes administering oxygen and, unless contraindicated,
increasing IV fluid flow rate and elevating the legs.
Sympathetic blockade due to residual spinal or epidural anesthesia, opioid
effect, or allergic reactions are also possible causes of hypotension. Patients on
steroids may develop an Addisonian crisis. Oxygen supplementation should be
provided while the cause is identified and treated. Dizziness associated with sitting
up (orthostatic hypotension) or dangling legs suggests incomplete recovery of
sympathetic function (Seifert & Wadlund, 2015).
Hypertension
Postoperative hypertension is frequently seen in patients with hypertensive

disease and systemic atherosclerosis. More common causes are pain, bladder
distention, hypercapnia, hypoxemia, or fluid overload. Tachycardia and
arteriosclerosis may promote an exaggerated response to stimuli that may result in
vasoconstriction (Lien & Bisognano, 2012).
Uncontrolled hypertension may lead to an increased risk of bleeding at the
surgical site, cerebrovascular events such as hemorrhagic stroke, cerebral
ischemia, and encephalopathy and myocardial ischemia, and myocardial infarctions
(Lien & Bisognano, 2012). The underlying cause of hypertension must be identified
and treated.
Tachycardia
Although some types of surgery are more likely to produce tachycardia during
recovery, more common causes include pain, hypovolemia, hypoxia, hypercapnia,
anemia, and fever. In addition to the operative site, pain may be caused by an
overdistended bladder or even a strain resulting from positioning during the
procedure (Tarrac, 2006). Treatment of tachycardia should be aggressive to assure
adequate coronary output and peripheral perfusion. Depending on the cause,
treatment may consist of volume expansion for hypovolemia, analgesics for pain, or
medication to produce beta blockade.
Shivering
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Shivering is uncomfortable for the patient and may increase wound pain and
intraocular and intracranial pressures. Shivering may be due to hypothermia that
develops intraoperatively and is also associated with emergence from volatile
anesthetics. Sepsis, allergy, and transfusion reaction may also be serious causes.
Intense shivering increases oxygen consumption and physiologic stress that may
be detrimental to patients with cardiovascular or pulmonary impairment. Oxygen
administration is appropriate. Inadequate pain control is another possible cause. If
the shivering does not respond to external warmth, such as warm blankets, small
doses of IV meperidine are usually effective.
Agitation and Delirium
Agitation is usually due to inadequately controlled pain, but fear and discomfort
from bladder or gastric distention are also possible precipitating factors. Ketamine,
large doses of phenothiazines (particularly in geriatric patients), and
anticholinergics (e.g., atropine, scopolamine; especially in children) may produce
agitation and delirium. Patients recovering from ketamine benefit from a quiet
atmosphere with subdued lighting; IV diazepam may also be beneficial. IV
physostigmine is often effective for delirium associated with phenothiazines and
anticholinergics.
Patients with emergence delirium have been found to have a longer duration of
preoperative fasting time (Xará, Silva, Mendonça, & Abelha, 2013). Delirium can
reflect pathophysiologic comorbidities, underlying problems like hypoxemia, and/or
pharmacologic interactions or intoxication. Emergence delirium usually lasts for
about 30 minutes and may present with agitation, irritability, hypervigilance, and
hyperactivity (Xará et al., 2013). It is linked to general anesthesia and usually is not
associated with permanent aftereffects.
Somnolence
Prolonged somnolence is most frequently due to residual anesthetic, sedative,

or analgesic drug effect. However, hypoventilation is commonly the cause of
delayed emergence from inhalation anesthetics, so airway patency and other
possible causes of hypoventilation should be investigated and relieved before
pharmacologic intervention. Prolonged somnolence may also be due to serious
intraoperative events (e.g., cerebrovascular accident or systemic disease, such as
a patient with diabetes who becomes hypoglycemic).
Dehydration
Unrecognized, untreated dehydration due to nothing-by-mouth status may be

responsible for some common postoperative adverse effects. Preoperative fluid
administration with the goal of correcting dehydration and decreasing postoperative
complications is recommended (Moghadamyeghaneh, Phelan, Carmichael, Mills,
Pigazzi, Nguyen, & Stamos, 2014). Preoperative as-needed status can lead to
dehydration, which has been shown to increase postoperative nausea and
vomiting. Intravenous fluids administered preoperatively and throughout the
surgical case can be helpful, but clinicians must be familiar with the patient’s
cardiac status to avoid fluid overload.
Postintubation Laryngitis
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Postintubation laryngitis may occur after a short-term intubation or after a long

procedure because of irritation from the endotracheal tube. Primarily involving the
subglottic area, postintubation laryngitis may cause laryngeal edema and airway
obstruction. The most obvious symptom is stridor, but the recovering patient should
be monitored for sudden changes in oxygen saturation (preferably by pulse
oximetry), decreased breath sounds, and changes in mental status. Initially,
treatment consists of supplemental oxygen and cool humidity, but the use of an
aerosolized vasoconstrictor or steroids may become necessary.
RECOVERY FROM REGIONAL ANESTHESIA
R
egional anesthesia is not synonymous with lack of possible postoperative
complications. For example, the following conditions may develop after
regional anesthesia administration:
1. Hypotension, accentuated by position changes, is a common problem

following spinal and epidural anesthesia due to residual sympathetic
blockade. Early head-up positions and ambulation are associated with an
increased occurrence of postdural puncture headache after spinal
anesthesia.
2. An unusual delay in recovery of motor function or sensation following nerve
block, spinal, or epidural anesthesia may be a serious complication requiring
treatment. Although regional anesthetics are effective, the patient is at risk
for injury due to lack of sensation or poor coordination.
3. Many patients receive sedation in addition to regional anesthesia and need
to be observed in a controlled recovery area until they are alert, stable, and
suitable for discharge.
Although toxicity related to a local anesthetic may be delayed as much as 1

hour, depending on absorption, it more commonly occurs soon after injection.
Consequently, patients who have had their procedures done with local infiltration
and no sedation frequently bypass the phase I (PACU) recovery stage and are
prepared for discharge in the phase II, or step-down, area.
SUMMARY
T
he types and number of ambulatory procedures continue to increase. To
maintain and improve favorable statistics, it is necessary that postoperative
ambulatory surgical care delivery systems and practitioners embrace
evidence based principles, standards, and processes.
Patients primarily want to be pain-free, nausea-free, and included in decisions
about their care, with the ultimate shared goal being a return to optimum health.
Interventions implemented by the postoperative nurse are focused on providing
comfort measures and safe care for the patient while continuously monitoring for
any deviations from the expected course. PACU nurses are knowledgeable about
pharmacologic treatments, as well as nonmedication related comfort measures
used to treat pain and postoperative nausea and vomiting. The nurse in the PACU
works closely with the anesthesia provider and surgeon to ensure the patient
receives the best possible outcome.
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EXAM QUESTIONS
CHAPTER 8
Questions 43–50
43. Upon arrival in the postanesthesia care unit (PACU), the PACU nurse monitors
for
a. deviations in the patient’s vital signs and electrocardiogram (ECG) from
the patient’s preoperative baseline status.
b. deviations in the patient’s vital signs and ECG from the results obtained in
the operating room.
c. deviations in the patient’s vital signs and ECG from the results of most
patients of the same age.
d. deviations in the patient’s vital signs and ECG from the results of most
patients having the same procedure.
44. Before accepting responsibility for a patient arriving from the operating room,
the postanesthesia care unit nurse should assess all of the following except
a. airway patency.
b. respiratory rate and character.
c. the presence of a responsible adult to care for the patient at discharge.
d. pulse rate, rhythm, and amplitude.
45. Which of the following are risk factors for developing postoperative nausea
and vomiting?
a. Motion sickness and male gender
b. Female gender and use of perioperative opioids
c. Duration of surgery and history of hypertension
d. Current smoker and female gender
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46. All of the following are assessed when considering the administration of
medication to relieve pain except
a. the patient’s pain intensity rating.
b. knowledge of the medication to be administered.
c. individualized patient assessment for risk of adverse effects.
d. the patient’s ability to tolerate oral intake.
47. A recovering patient in the postanesthesia care unit complains of difficulty

breathing and difficulty speaking. The nurse recognizes these complaints as
possible signs of
a. airway obstruction.
b. hypoventilation.
c. hypotension.
d. delirium.
48. What is the most common cause of hypotension while in the postanesthesia
care unit?
a. Hypovolemia
b. Fluid overload
c. Pain
d. Bladder distension
49. The postanesthesia care unit nurse receives a patient who is at risk for
hypotension. What can the nurse do to decrease the occurrence of
hypotension?
a. Advise the patient to lay flat and obtain a physician order for IV fluids.
b. Encourage early ambulation and sit the patient up in the stretcher.
c. Provide oxygen via nasal cannula and encourage deep breathing.
d. Turn the lights down and turn off the monitor alarms.
50. What is the initial treatment for postintubation laryngitis?

a. IV fluids and cold packs
b. Gargling with saltwater
c. Antibiotics
d. Supplemental oxygen and cool humidity
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CHAPTER 9
PATIENT DISCHARGE
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to identify the various
aspects of nursing care needed for the safe transition of the patient from the
immediate postoperative recovery phase to discharge from the facility.
CHAPTER OBJECTIVES
A
1. List the criteria that is met prior to transitioning from phase I to phase II of
recovery.
2. Explain discharge scoring systems, including their purposes and limitations.
3. Describe phase II recovery nursing assessment and monitoring.

4. Discuss criteria that must be met prior to discharge from the ambulatory
surgery facility.
5. Explain appropriate discharge education content, including techniques to
ensure an optimal recovery.
6. List available therapies in the community that may assist with the recovery of
ambulatory surgery patients.
INTRODUCTION
A
ll patients must be monitored by a nurse in the postanesthesia care unit
until they have regained control of their airways, have stable cardiovascular
and respiratory systems, and are awake and able to communicate per
baseline status. Once all qualifications are met, the patient enters a less intense
postoperative monitoring phase, known as phase II, and begins preparation to be
discharged from the facility.
Some patients are candidates for bypassing phase I of the recovery process
(see Chapter 8) and immediately enter phase II. This is commonly referred to as
fast-tracking and may result in significant cost benefits and enhanced patient
satisfaction. Patients recovering from ambulatory surgery are usually more satisfied
with their postoperative experience if their discharge process is streamlined and
customized to their needs. Phase II of the recovery process may occur in the same
area as phase I or may be separated into an area equipped with amenities such as
recliners, televisions, music, and light nourishment.
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Upon meeting criteria for phase II recovery, the patient will be assessed by a
nurse and discharge planning will focus on the patient’s physical and emotional
status, including pain management, type of procedure, anesthesia or sedation,
family support, and learning needs.
PROGRESSION FROM PHASE I RECOVERY TO

PHASE II RECOVERY
P
atients in phase I of recovery are usually able to transition to phase II of
recovery when the following criteria are confirmed via nursing assessment:
Patient is free of airway obstruction.

Patient has cough and swallowing reflex with absence of nausea and
vomiting.
Patient has stable vital signs.
Patient is easily aroused.

Patient is able to move extremities unless contraindicated.
Patient is oriented to person, place, and time comparable to preoperative
mental status.
The surgical dressing is intact. No significant bleeding is present.
Patient has obtained a minimum score of 8 in the modified Aldrete Scoring
System (see Figure 9-1) or obtained the minimum score appropriate from
another approved scoring system or the anesthesiologist has approved
transition to phase II.
Patient has minimal pain or has received appropriate medication to control
postoperative pain.
The Aldrete Scoring System is used by nurses to objectively assess a patient

recovering from surgery (Figure 9-1). This tool has five categories: respiration,
color, consciousness, circulation, and activity. Each category has a scoring range
from 0 to 2. Most ambulatory surgery facilities consider a score of 8 or above
appropriate for transitioning the patient into phase II of the recovery process.
<FIGURE 9-1 WILL BE VIEWABLE AFTER PURCHASE>
The postoperative care nurse knows every patient recovers differently. The
patient’s current health status, age, time under anesthesia, procedure type, and
medications administered all affect recovery time. A patient who had a cataract
removed may be ready for phase II monitoring immediately, whereas a patient who
had an open reduction and internal fixation with plates and screws may recover
under phase I monitoring for a few hours or more. Along those lines, a healthy
patient, classified as American Society of Anesthesiologists (ASA) class I, may
recover much faster than a patient classified as ASA class III, even if all other
factors, including procedure type, are the same.
PHASE II ASSESSMENT AND MONITORING
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n many situations, the nurse who cared for the patient during phase I of
I
recovery also cares for the patient during phase II of recovery. If the patient is
transferred to the care of another nurse, all vital patient information is reported
to the accepting nurse, including medications, allergies, the procedure(s)
completed and pertinent information, and any special needs. (See Chapters 3 and
7 for more information on patient handoff and MAPS.) The patient is assessed by
the accepting nurse at handoff and periodically for mental alertness and level of
orientation. The patient is expected to continue to advance along the continuum
from more to less sedated during the phase II recovery period.
Vital signs are checked upon entry to the phase II recovery period and usually
every hour, or as indicated by patient status, and upon discharge. Many patients
may be discharged well before reaching 1 hour in phase II of recovery. The nurse
assesses for pain and introduces comfort measures such as positioning, cold
therapy, guided imagery, deep breathing, and pharmaceutical treatment as
appropriate to optimize the patient’s comfort level. The surgical site or dressing is
assessed throughout the phase II recovery period. Soiled dressings may be
reinforced or changed according to the physician’s orders.
DISCHARGE CRITERIA
C
linicians and researchers agree that discharge from an ambulatory surgery
setting should not be time-based, as it may prolong the recovery process
unnecessarily (Ambardekar & Joshi, 2015). The American Society of
Anesthesiologists’ practice guidelines for postanesthetic care recommend a
mandatory stay should not be required and discharge criteria should be designed to
minimize postdischarge risk of central nervous system and cardiorespiratory
depression (Apfelbaum et al., 2013).
Discharge after an ambulatory surgery or procedure should be done in a safe
manner with the emphasis on patient readiness. Numeric discharge scoring
systems may assist nurses to assess whether a patient is fit for discharge from the
facility. Numeric scoring systems have been developed that provide objective
assessment of the patient’s progress and readiness for discharge and serve as
medicolegal documentation of the patient’s status. The postanaesthesia discharge
scoring system (PADSS) is the most commonly used tool to determine home
readiness after anesthesia administration (Ambardekar & Joshi, 2015). PADSS
(Figure 9-2) requires that patients have stable vital signs, can ambulate at a
preoperative level, have minimal postoperative nausea and vomiting, and have
minimal pain and bleeding before they are declared ready for discharge. In the
most updated version, shown in Figure 9-2, oral intake and voiding before
discharge is not required. Most ambulatory surgery policies require a PADSS score
of 9 or above before discharge can occur.
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Ambardeker & Joshi (2015) state the PADSS tool is the gold standard for
determining home readiness after ambulatory surgery in adults; however, the
Aldrete Scoring System and the postanesthesia discharge scoring system have not
been validated. The American Society of PeriAnesthesia Nurses (ASPAN) does not
endorse any specific postanesthesia scoring tool or system (American Society of
PeriAnesthesia Nurses, 2012).
ASPAN recommends that discharge criteria policies be developed in conjunction
with the ambulatory surgery anesthesia care providers to meet the needs of the
patient population (American Society of PeriAnesthesia Nurses, 2012). Often,
written discharge criteria stipulate that a minimum postanesthesia score be
achieved prior to patient discharge. A discharge scoring system is not meant to be
used exclusively as the discharge criterion for a postanesthesia patient (American
Society of PeriAnesthesia Nurses, 2012). Clinical assessments must also be
considered. Since each patient’s condition varies and must be assessed
individually, time frames for discharge are not appropriate. Critical thinking and
nursing judgment are essential factors in determining readiness for discharge. For
example, the nurse knows that patients with certain conditions such as diabetes
must be able to take and retain fluids before discharge.
Mobility without dizziness is important for patients who will be discharged from
the ambulatory surgery facility. Despite progression to phase II recovery where the
caregiver or a family member may be in attendance, the patient should be assisted
by the nursing staff when first attempting to stand up or ambulate. For those who
have had spinal or epidural anesthesia, evaluation should be done in three stages:
sitting up only, dangling legs, and standing with assistance.
The postoperative analgesia associated with peripheral nerve blocks often
reduces the need for pain medication; however, with the absence of sensation or
motor control comes the danger of inadvertent injury. The patient must be
instructed to protect the limb and monitor circulation, sensation, and swelling. After
a brachial plexus block it may be advisable to place the affected arm in a sling for
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protection. Digits should be evaluated for adequate circulation, and sensation and
circulation should be satisfactory in an extremity on which a tourniquet was used
during surgery.
Discharge readiness does not equate with street safety. Safe discharge from the
ambulatory facility not only requires the return to baseline and satisfactory vital
signs and systemic functions to near preoperative levels, but it also requires the
patient to be free from significant cognitive or psychomotor impairment. The
residual effect of sedatives and anesthetics may last 24 hours or more, during
which time the patient should not engage in activities that require quick reflexes or
sound judgment. For the same reason, patients should be cautioned against
drinking alcoholic beverages, taking sedatives or antihistamines, and driving or
operating machinery for 24 hours. The American Society of Anesthesiologists
recommends patients at risk for obstructive sleep apnea maintain a nonsupine
position if given opioids (American Society of Anesthesiologists, 2014b).
Many regulatory agencies and, consequently, facility policies mandate the
ambulatory surgery facility assure the patient is discharged with a responsible
adult. These arrangements are finalized preoperatively and communicated to the
nursing team.
All discharge requirements established by the ambulatory surgical facility should
be met, and the patient should have no symptoms that would threaten a safe
recovery. If there is any question of fitness for discharge, the nurse should seek a
direct evaluation and discharge clearance from the physician. The Centers for
Medicare and Medicaid Services (CMS) require an evaluation of the patient’s
recovery from anesthesia to determine whether the patient is recovering
appropriately, which must be completed and documented by a physician or
anesthetist before the patient is discharged from the center (Centers for Medicare
and Medicaid Services, 2015, April 15).
DOCUMENTATION
D
ata are obtained and documented by the nurse via physical assessment,
review of records, and consultation. While evaluating the completed
procedure and the patient’s health status, the postanesthesia care unit
(PACU) nurse may document the following assessments as appropriate prior to
discharge:
lung sounds and use of any airway or oxygen delivery devices;

cardiac rhythm;
mobility tolerance;
abdominal assessment, if applicable;
capillary refill and pulses, motor, sensation assessment as appropriate to the
procedure;
assessment of operative site and dressing, and any surgical drains;

discharge scoring system results;
vital sign measurements, including pain level and resulting interventions;

medication administration;
IV and oral fluid intake, voiding as applicable;
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any abnormal assessments, changes in patient condition, and physician

reports and orders; and
time of discharge from the facility and person who will accompany the
patient.
DISCHARGE EDUCATION
A
lthough discharge planning and initial postoperative education should begin
preoperatively, it is carried through the continuum of care and reinforced
prior to discharge. It is imperative the patient have a responsible party by
his or her side that is able to understand the discharge instructions provided and
ask pertinent questions. The PACU nurse knows the patient may be drowsy and
experience some amnesia related to the medications administered. For this reason,
the patient’s significant other or caregiver must be capable of providing care to the
patient at home by following through on the discharge instructions. While these
instructions should be reviewed with the patient preoperatively, some specific
instructions that could not be anticipated prior to arrival in the PACU, such as
wound care and mobility restrictions, will be addressed just prior to discharge. The
PACU nurse seeks return demonstration from the patient or patient’s significant
other when teaching about any care activity that requires motor skill, such as
emptying drains, changing dressings, using crutches, or wearing an immobilizer. It
is important for the nurse to help the patient and caregiver understand the typical
course of recovery as it correlates to the procedure so that if unexpected variations
occur, he or she will recognize them and call the appropriate healthcare provider.
The nurse carefully explains that patients may experience some minor and
expected fluctuations in their daily progress during recovery. The nurse provides
education to the patient that is specific enough to prepare the patient for what is
expected, but broad enough that the patient is not alarmed by minor variations.
Patients and caregivers may feel anxious about the responsibility of
postoperative care. Patients and caregivers often fear that they will not be able to
provide adequate care after discharge and are concerned that they may do the
wrong thing or cause harm. The nurse who provides instructions eases anxiety by
allowing time for questions and clarifications. The expert nurse often anticipates
questions based on previous experiences and shares information freely with the
patient and the patient’s caregiver.
Care of the incision is a major concern of most patients. Some fear the incision
may open, especially after sutures or staples are removed. Consequently, the nurse
should explain the healing process simply and clearly in lay terms. Ambulatory
patients frequently are discharged with a wound dressing in place and are
concerned about causing infection when changing or removing the dressing. To
allay this fear, the patient (appropriate to age and mental status) and caregiver
should be instructed how to do this per the physician’s orders, and preferably with
the patient or caregiver giving a return demonstration. The importance and benefits
of proper hand hygiene must be thoroughly explained. If allowed by the surgeon,
viewing the incision with the nurse will facilitate the patient’s ability to identify
changes such as redness or swelling that should be reported. The nurse also alerts
the patient and caregiver to other signs and symptoms of infection such as pain
and fever.
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Patients usually equate recovery with the absence of pain and the ability to
return to normal daily living, but deficits in self-care activities may persist
postoperatively for a few days or longer depending on the procedure type and the
patient’s current health status. Teaching practical applications of postoperative
care, in addition to the customary medical instructions, should be part of
postoperative patient education. For example, grocery shopping, caring for
children, and doing laundry all fall into the category of lifting, which is often
restricted. Patients also need to be aware that both pain and medication might
contribute to slower reaction times. Patients must be instructed about when they
may resume bathing and what modality is appropriate. Primary closure incisions
are protected by sterile dressings for 24 to 48 hours (Centers for Disease Control
and Prevention, 2011). Depending on the incision site, the surgeon may advise the
patient to shower, rather than bathe, upon removal of the dressing as an extra
measure to avoid contact with micro-organisms.
A basic example of general discharge instructions is found in Figure 9-3.
Ambulatory surgery facilities often include procedure- and physician-specific
education that contains diagrams and pictures (see Figure 9-4). Oftentimes the
surgeon will provide specific instructions to the patient and may have other, written
instructions for the nurse to review with the patient and caregiver.
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Although patients can be instructed to take the prescribed pain medication on a

continuous basis for 1 to 2 days if appropriate, suggesting nonpharmacologic
methods of pain management may decrease the total amount of analgesic required
and ease the transition from medication. Cognitive behavioral strategies include
relaxation, distraction, imagery, meditation, and prayer. Patients with cognitive
deficits tend to benefit from the distraction provided by music and may be capable
of rhythmic breathing relaxation exercises with coaching from the caregiver.
Physical interventions include applications of heat or cold, massage, movement,
and rest or immobilization. Applications of heat or cold, if ordered by the physician,
alter the pain threshold, reduce muscle spasm, and decrease local swelling. Simple
rest is an important part of pain management that should not be overlooked, but the
nurse takes care to define what is meant by “rest” while considering the procedure
completed. Some patients may define “rest” as staying in bed with no activity for 48
hours, whereas others may do too much activity yet consider it in line with “rest”
when compared with their normal, active lifestyles. The nurse must be specific
about what common activities are allowable and what is restricted while
emphasizing deep breathing exercises and any other exercises the surgeon
promotes.
Many patients take multiple medications and the complexity of managing those
medications make medication reconciliation an important safety goal per The Joint
Commission (2015). The ambulatory surgery nurse performs medication
reconciliation by comparing the medications a patient is actually using to the new
medications that are ordered for the patient at discharge and resolves any
discrepancies. There have been challenges with this goal because it can be difficult
to obtain a complete list of accurate medications used from patients. Clinicians are
hopeful that as health care evolves with the adoption of more sophisticated
systems (such as centralized databases for prescribing and collecting medication
information), the effectiveness of these processes will grow (The Joint Commission,
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2015). The ambulatory surgery facility is responsible for making a good faith effort
to collect complete medication information, including any new medications that are
started after discharge. This list is shared with the patient, who can then provide the
complete list to his or her pharmacist and other healthcare providers.
Depending on the facility, prior to discharge the nurse may prepare any medical
supplies that may be needed by the patient for the next 24 hours such as dressings
and tape for wounds, measuring cups for drain monitoring, cotton balls, and so on.
Some ambulatory surgery facilities go above and beyond by presenting the patient
with a small care package that may include, for example, crackers, soup packets,
mints, and a greeting card wishing them a speedy recovery. Ideally, the patient
already has all prescriptions filled and waiting at home, but in some instances, the
physician may not give the patient any prescriptions until after the procedure. If
practical, the patient’s caregiver may pick up the prescriptions while the patient
recovers so the patient and caregiver can go straight home upon discharge. The
nurse or other staff member accompanies the patient and caregiver out of the
facility, making sure they have the supplies they need, written discharge education,
health provider contact information, and prescriptions. Another way to comfort the
patient is to end the visit by informing him or her that he or she will be contacted the
next day (as is standard) to check on his or her progress.
COMMUNITY OUTREACH
S
ome surgeons, particularly orthopedic surgeons, will educate postoperative
patients about gentle exercises and stretches they can do to enhance full
range of motion. Following some ambulatory surgery procedures, the
patient will be referred for outpatient physical therapy. The primary purpose of
physical therapy is to return the patients to a level of function that enables them to
resume activities that are important to them (Warne, 2015). Physical therapy
following joint surgery has been shown to improve outcomes and mobility (Warne,
2015). Strength, range of motion, and balance are three key components of
functional rehabilitation. Exercises to restore optimal strength, motion, and balance
can include passive, active assisted, active, and hold-relax stretching.
Occupational therapy after surgery may be prescribed with the goal of helping
the patients function in all of their environments (e.g., home, work, school,
community) and address the physical, psychologic, and cognitive aspects of their
well-being through engagement in occupation (American Occupational Therapy
Association, Inc., n.d.). Hand therapy is a specialty area of occupational therapy
and includes rehabilitation after fractures of the hand or arm, lacerations and
amputations, burns, and surgical repairs of tendons and nerves.
Some patients may benefit from visits from a home health nurse after discharge
from the ambulatory surgery facility. In more complex cases, effective transition to
home with supervision of a home healthcare nurse has been identified as among
the factors leading to reducing hospital admissions within 30 days of discharge
(Labson, 2014). Home health nursing may be considered for patients with
comorbidities, complex surgical procedures, overwhelmed family caregivers, or
inadequate assistance from significant others. The physician may identify this need
and order a homecare evaluation, or the nurse may discover the need for further
evaluation during assessment and share these findings with the physician.
POSTDISCHARGE FOLLOW-UP
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atients should receive a postdischarge follow-up telephone call the next day to
P
verify a safe and uneventful recovery, identify complications, evaluate
potential problems, and address any concerns or grievances related to the
procedure. Follow-up calls are regarded as a standard of practice.
The registered nurse who contacts the patient must be able to communicate
appropriately and make valid assessments through telephone contact. A
standardized checklist of questions developed by the ambulatory surgery facility,
such as those listed in Table 9-1, assists the nurse in uncovering the patient’s
status via telephone interview. The nurse should have thoroughly reviewed the
patient’s chart and be able to provide explanations for minor symptoms, give
general reassurance, and give appropriate advice on contacting the physician or
getting emergency assistance if necessary. The nurse who discharged the patient
from the facility is the ideal person to evaluate the patient’s status the following day.
In addition to standard questions, facilities may create procedure-specific questions
to include inquiries about active bleeding, ambulation and mobility, fluid intake, or
diet.
If a problem is identified during a postoperative follow-up call, the nurse asks

targeted questions to gain more information and uses critical thinking skills to assist
the patient with resolution of the problem. The postoperative call is a tool to
reinforce discharge teaching, and the nurse documents all teaching and
interventions in the patient’s medical record. In some cases, the nurse may instruct
the patient to contact the surgeon’s office to discuss problems or questions.
Accordingly, the nurse will notify the surgeon directly of any concern or change in
the patient’s status. Ambulatory surgery facilities often track patient emergency
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department visits and admissions to the hospital within 24 hours of discharge from
the facility to allow for monitoring of any possible complications (see Chapters 10
and 13).
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SUMMARY
A
s the patient progresses to phase II of the recovery process, the nurse
begins to focus on preparation for discharge to home while monitoring the
patient for appropriate markers that signify satisfactory recovery. The nurse
educates the patient and caregiver by explaining care at home, anticipating
questions, providing demonstration and observing patient return demonstration of
skills taught, and reinforcing preoperative education. The nurse communicates in a
simple and clear way what the patient and caregiver can expect and what to do if
the unexpected happens. Exercises prescribed by the physician, pain management
techniques, and medication are discussed. If the patient requires other
interventions, such as physical therapy, occupational therapy, or home health
nursing visits, the ambulatory surgery nurse facilitates as needed. Just as the
ambulatory surgery nurse begins care of the patient even before admission, care of
the patient after discharge continues with the follow-up phone call.
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EXAM QUESTIONS
CHAPTER 9
Questions 51–57
51. Which of the following criteria does not have to be met before transitioning
from phase I recovery to phase II recovery?
a. Patient is free of airway obstruction.
b. Patient has stable vital signs.
c. Patient has an Aldrete score of 10.
d. Patient has no significant bleeding.
52. Which of the following assessments is assigned a score of 2 in the Aldrete

Scoring System?
a. Patient has warm and dry skin with preprocedural coloring.
b. Patient can be aroused on calling.
c. Patient is able to move two extremities.
d. Patient has dyspnea or shallow breathing.
53. The phase I nurse gives a report on her patient to the phase II nurse. In the
report, the nurse includes the procedure completed as right knee arthroscopy;
the pain medication given as morphine, 2 mg IV, 30 minutes ago; and the
location of the patient’s caregiver as at the bedside. What critical information did
the nurse forget to report?
a. The type of suture used and its expiration date
b. The patient’s arrival time to the facility
c. The patient’s snack preference
d. The patient’s allergy information
54. Which of the following is not required for the patient to be discharged from the
ambulatory surgery facility?
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a. Minimal postoperative nausea and vomiting

b. Sixty minutes in phase II recovery
c. Minimal bleeding
d. Ability to ambulate at a preoperative level unless restricted due to the
procedure
55. Which of the following assessments is assigned a score of 1 in the Modified

Postanesthetic Discharge Scoring System for Determining Home Readiness?
a. Blood pressure and pulse 20% to 40% of preoperative value
b. Steady gait, no dizziness, or meets preoperative level
c. Acceptable pain level
d. Minimal surgical bleeding: does not require dressing change
56. What is an appropriate way for the nurse to ensure the patient’s caregiver
understands instruction regarding care of a surgical drain?
a. Provide written instructions and have the caregiver sign and date the
form.
b. Read the instructions to the caregiver and ask for verbal confirmation of
understanding.
c. Observe return demonstration of the caregiver emptying the drain and
recording the amount of drainage.
d. Let the caregiver know you will e-mail the instructions.
57. Mrs. Taylor, a full-time teacher who enjoys painting and golf, had ambulatory
surgery on her hand and asks the nurse why the surgeon has prescribed
occupational therapy. The most appropriate response from the nurse is
a. “Occupational therapy is prescribed to assist you with regaining the most
function possible in your hand so you can continue to be fully productive at
work and enjoy your hobbies.”
b. “I’m not sure. You should ask the physician.”
c. “Occupational therapy is prescribed because you will be unable to care for
yourself during recovery. A therapist will be with you to make your meals and
give you medication.”
d. “Occupational therapy is prescribed to help you regain strength, range of
motion, and balance. Due to your hand surgery, you will feel weak, stiff, and
dizzy for several months.”
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CHAPTER 10
COMPLICATIONS AND EMERGENCIES
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to recognize serious
complications and emergencies that may occur during ambulatory surgery
and anesthesia.
CHAPTER OBJECTIVES
A
1. Identify serious complications that may occur intraoperatively and recognize

the need for constant preparedness.
2. Effectively treat complications.
3. Discuss implications of delayed recognition of developing complications.
4. Select appropriate interventions to enhance favorable treatment outcomes.

5. Understand what malignant hyperthermia is, recognize the signs to watch for,
and determine how to effectively treat it.
6. Recognize and learn how to effectively treat common allergic reactions.
INTRODUCTION
A
s the familiar axiom states, there is no such thing as a minor surgical
procedure or minimal anesthesia. Technical developments or patient
variables, not always identifiable or controllable preoperatively, may lead to
complications or emergencies. Being aware of their possible occurrence and being
prepared to quickly and efficiently treat untoward intraoperative events allows the
perioperative nurse to play a pivotal role in the successful resolution and positive
outcome of these events. Key nursing strategies include being knowledgeable
about possible complications or emergencies, making sure the operative area is
equipped with appropriate medications and well-maintained emergency equipment,
knowing how to use emergency equipment, recognizing early signs of
complications or emergencies, and alerting the appropriate members of the
operating room team. The ambulatory surgery team must communicate clearly and
assist each other to facilitate optimal patient care.
Certain surgical procedures are recognized as having the inherent possibility of
developing complications, regardless of the operative setting in which they are
performed. Several of these procedures, currently and frequently performed in
ambulatory surgical facilities, are reviewed in this chapter. As outpatient surgery
evolves and expands, so too may the hazards involved.
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Interventions initiated by the perioperative nurse should be consistent with the

facility’s guidelines, the state’s nurse practice act, the nurse’s level of skill and
training, and the actions of a prudent nurse.
SURGICAL COMPLICATIONS
Technical Complications
Complications may occur as a result of inadvertent technical errors. Examples

include pneumothorax caused by puncture of the pleura during upper abdominal
surgery or laceration of an organ or blood vessel during laparoscopy. Also, when
pathology is found to be more advanced than anticipated, a more extensive
procedure and postoperative hospital admission may be necessary.
Laparoscopic Surgery
To create a space for visualization, instrumentation, and manipulation within the

abdominal cavity, a pneumoperitoneum must be established by instilling gas into
the cavity, which lifts the abdominal wall away from the viscera. Carbon dioxide or
nitrous oxide may be used, but because nitrous oxide supports combustion, carbon
dioxide is usually used. Trocars are inserted through the skin at strategic points in
the abdomen and are used to insert and remove instruments, remove fluid, and
extract tissue or organs (Morton, 2012). Inadvertent errors may occur with these
necessary steps as well as during the procedure.
Carbon dioxide is rapidly absorbed across the peritoneal membrane into the
general circulation, resulting in hypercarbia and respiratory acidosis, which requires
careful monitoring and treatment (Morton, 2012) because both conditions may
produce myocardial depression. Theoretically, because of the high solubility of
carbon dioxide, there would be rapid absorption of an embolus, should one occur.
However, if a sufficient quantity is rapidly taken into the circulatory system, an air
lock in the right side of the heart may occur (Morton, 2012). Injuries to vessels of
the abdominal wall are most common with procedures using lateral trocar
placement and larger trocars (Morton, 2012). The creation of a pneumoperitoneum
necessarily results in increased intra-abdominal pressure, but overpressurization
may have serious consequences. Intrathoracic space may be reduced, leading to
inadequate ventilatory exchange and inadequate cardiac output. Pulmonary edema
may develop in patients with compromised cardiac effectiveness. Regurgitation and
aspiration of gastric contents may be caused by increased pressure on the
diaphragm. Excessive pressure may also cause carbon dioxide to diffuse into the
bloodstream, resulting in hypercarbia and dysrhythmias.
Although postoperative pain in the shoulder and neck due to irritation of the
phrenic nerve is common following laparoscopic abdominal surgery, excessive
pressure may damage the nerve as well as cause severe discomfort for the patient.
Because the phrenic nerve supplies the diaphragm, respiratory adequacy may also
be affected. The use of an insufflator that automatically vents excessive carbon
dioxide is the best precaution, but applying pressure to the abdomen to evacuate
residual gas before the last trocar is removed at the end of the procedure or
implementing intraperitoneal normal saline infusion is also advisable (Tsai et al.,
2011).
Gas Embolism
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With increased intra-abdominal pressure, if a blood vessel is injured, the

pressure may allow carbon dioxide to enter the circulation. Inadvertent placement
of the carbon dioxide insufflator into a blood vessel or organ is another possible
cause of gas embolism.
Symptoms of gas embolism include tachycardia, hypotension, cyanosis,
dysrhythmia, and a characteristic mill wheel murmur. Evidence of right heart block
or strain may be seen on an electrocardiogram if the embolus is large (Seifert,
Yang, & Munoz, 2015). Shock and cardiac arrest may develop. End-tidal carbon
dioxide (ETCO2) may increase before declining because of excretion of carbon
dioxide that has been absorbed into the blood (Seifert et al., 2015). Sudden
development of hypercapnia during intra-abdominal carbon dioxide insufflation
means an embolism has developed (Seifert et al., 2015). Routine analysis of
ETCO2 during laparoscopic surgery may detect even small emboli.
Treatment of gas embolism includes
administering 100% oxygen;

increasing ventilation to increase carbon dioxide excretion;
placing the patient in the left lateral decubitus position after the source of air
is controlled to allow the gas to rise away from the pulmonary circulation and
following with placing the patient in the supine position;
inserting a multiple-orifice central venous catheter to aspirate gas;

supporting blood pressure with vasopressors and IV fluids; and
eliminating the source of gas, if possible.
(Seifert et al., 2015)

If severe hypotension develops, inotropic support (i.e., influencing the force of
muscular contractions) may help maintain the patient’s cardiac function. For
example, chest compressions at 100 per minute may be used to fragment large
bubbles (Seifert et al., 2015).
Carbon Dioxide Escape
Carbon dioxide may escape from the abdomen to the pleural spaces,
pericardium, mediastinum, or subcutaneous tissues. Clinical signs may range from
shock and respiratory failure (due to pneumothorax) to swelling of the face and
neck with crepitation, due to gas in the tissues. Head and neck swelling is usually
treated conservatively with elevation of the head postoperatively.
Peak inspiration pressures and chest movements should be closely monitored
during laparoscopic surgery. A sharp increase in peak inspiratory pressure may
indicate tension pneumothorax. Treatment of pneumothorax consists of 100%
oxygen with positive end-expiratory pressure (PEEP; Seifert et al., 2015).
Unrecognized injury to a large blood vessel or the bowel may become life
threatening postoperatively. Symptoms of internal bleeding are more readily
observable, whereas those of bowel involvement, if not identified during surgery,
may not be properly identified until after discharge home (Krieger, Wojcicki, Berry,
Reuther, & McArthur, 2015). Signs and symptoms include acute abdominal pain,
tender abdomen upon palpation, and tympani upon percussion (Krieger et al.,
2015). Therefore, any unusual or persistent postoperative complaint of abdominal
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discomfort, no matter how vague, should be thoroughly assessed, documented,

and reported to the surgeon.
Laparoscopic cholecystectomy is the second most frequently performed general
surgical procedure and is typically performed in the ambulatory surgery setting with
very low risk of complication. However, the ambulatory surgery nurse is aware of
possible complications and interventions (Brenner & Kautz, 2015). The rate of
unplanned hospital admission following ambulatory general surgery is 0.57%
(Martín-Ferrero, Faour-Martın, Simon-Perez, Pérez-Herrero, & de Pedro-Moro,
2014).
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Ophthalmic Surgery
Ophthalmic procedures have been the most frequently performed ambulatory

surgeries. Adult ophthalmic surgery is most frequently performed using a nerve
block with procedural sedation. The following complications apply to extraocular
procedures (e.g., strabismus correction, lacrimal duct probing, lid surgery,
enucleation) and intraocular procedures (e.g., cataract extraction, vitreoretinal
surgery, glaucoma-related procedures):
Oculocardiac reflex: Oculocardiac reflex is caused by pressure on the

eyeball or traction on the eye muscles. It causes sudden, severe bradycardia
and possibly asystole. Treatment involves immediately releasing the
pressure or traction, administering IV atropine, or, if the patient is under
general anesthesia, deepening the level of anesthesia. Continuous
monitoring of the heart rate during ophthalmic procedures is essential.
Establishing and maintaining IV access is advisable.
Periorbital block complications: The risks associated with infiltration
anesthetic block for cataract extraction are periocular ecchymosis, globe
perforation, ptosis, optic nerve damage, retinal vein occlusion, and
respiratory arrest (Bhat, Mahrukh, Raja, Qureshi, & Ashraf, 2015). Topical
anesthetic agents are becoming a much more common anesthetic choice for
ophthalmic procedures by many physicians. Bhat et al. (2015) found topical
anesthesia is as effective as peribulbar block techniques and can be
recommended as a safe and effective alternative to peribulbar blocks for
manual small-incision cataract surgery with posterior chamber intraocular
lens implantation.
Hypoventilation: A sedated patient with his or her face covered by drapes
may experience hypoxemia. Pulse oximetry and careful, continuous
observation of chest excursion is necessary.
Coughing or movement: Coughing or movement can result in globe injury or
vitreous extrusion.
Unplanned anterior vitrectomy: An unanticipated event can decrease the

likelihood of improved postoperative visual acuity and generally results in
poor long-term outcomes after cataract surgery.
(ASC Quality Collaboration, 2015)
Otolaryngology and Oral Surgery
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Complications following surgery involving the nose, throat, and mouth are
associated high blood pressure (1.6%), nausea (1.6%), and bleeding (1.2%;
Mahboubi & Verma, 2013). Total perioperative complications were reported in 9.7%
of cases, with 3.3% requiring hospital admission (Mahboubi & Verma, 2013).
If the procedure has been done under general anesthesia with endotracheal
intubation, the endotracheal tube is usually left in place with the cuff inflated until
the patient’s gag and swallowing reflexes have returned.
After dental surgery, patients often have packing in place that may obstruct the
airway, especially if the patient is somnolent. Procedures done under local or
topical anesthesia may result in systemic local anesthetic toxicity. Topical local
anesthesia is rapidly absorbed from mucous membranes. In addition, dental injury
is possible due to surgical instrumentation or airway manipulation.
Ear surgery is associated with a high incidence of postoperative nausea,
vomiting, dizziness, and vertigo. If an incision was made, bleeding and infection are
possibilities.
An environmental complication to be avoided is injury from an unstable
microscope used during surgery. The microscope should be equipped with an
emergency stop to prevent patient injury. Eighty-two cases of soft tissue burns
resulting from the use of an operative microscope have been reported to the U.S.
Food and Drug Administration (FDA) since 2004 (Latuska, Carlson, Neff, Driscoll,
Wanna, & Haynes, 2014). Thirty percent of these events occurred during
otolaryngology cases with other specialties, including neurosurgery, orthopedic
surgery, plastic surgery, and urology (Latuska et al., 2014). An increasing amount of
light intensity is required to illuminate the deeper operative field associated with
otolaryngology, and this light generates more heat, which is coupled with thin
auricular skin, leading to increased risk for burn. It is imperative that the operative
microscope user is familiar with the model used and its safety features. As a
general rule of thumb, the circulating nurse knows that if the surgeon complains his
or her hands are getting hot while operating the microscope, then the light intensity
is too high for the focal length (Latuska et al., 2014).
Cosmetic and Reconstructive Surgery
Despite the fact that many cosmetic procedures are considered office
procedures, serious complications are possible.
Lipoplasty is associated with major fluid compartment shifts, resulting in
hypotension, electrolyte imbalance, and edema. Large amounts of local anesthetics
injected throughout the procedure may cause systemic toxicity. The occurrence rate
of deep vein thrombosis in patients undergoing liposuction is 0.59% (Matarasso &
Levine, 2013). Risk assessment and prophylaxis treatment are worthwhile
considerations (see Chapter 3).
Breast reduction or augmentation may involve significant blood loss and the
possibility of pneumothorax from inadvertent injury to the pleura.
Rhinoplasty patients may experience postoperative bleeding and airway
compromise. Postoperative bleeding and swelling may distort an incision and affect
final results. Postoperative retching or vomiting may cause hematoma or stress a
suture line.
Hypoventilation may result when a sedated patient’s face is obscured by
surgical drapes, leading to hypoxemia. Having one of the patient’s hands exposed,
using pulse oximetry, and maintaining voice contact, if appropriate, aid monitoring.
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Gynecologic Procedures
Laparoscopic and laser surgery techniques have broadened the scope of

ambulatory gynecologic procedures that are suitable for the ambulatory setting.
Consequently, the following complications associated with gynecologic procedures
may be characteristic of these techniques:
Inadvertent injury to such abdominal structures as the bladder, bowel, and

blood vessels during laparoscopy may occur, resulting in bleeding or
infection.
Embolism may result secondary to gas infused during hysteroscopy or the
creation of the pneumoperitoneum necessary for abdominal laparoscopy.
Perforation of the uterus may occur during intrauterine procedures.
Systemic fluid absorption during intrauterine flushing, as during endometrial
ablation, may result in severe electrolyte imbalance and fluid overload.
Trendelenburg position may compromise ventilation, especially in obese

patients.
Lithotomy position may result in nerve injury affecting the legs if not carefully
managed.
The rate of unplanned hospital admission following ambulatory gynecologic

surgery is 0.80% (Martın-Ferrero et al., 2014).
Orthopedic Procedures
Since the development of the arthroscope, many orthopedic procedures that

formerly required hospitalization for surgical exposure of the joint (i.e., arthrotomy)
are now being done as ambulatory procedures. Immediate and delayed potential
complications of arthroscopic surgery include
bleeding into the joint,

systemic local anesthetic toxicity,
infection, and
neurovascular injury secondary to the use of a pneumatic tourniquet.
The rate of unplanned hospital admission following ambulatory orthopedic

surgery is 0.79% (Martın-Ferrero et al., 2014).
Thyroid Surgery
The development of minimally invasive surgical approaches and ultrasonic

technology for intraoperative bleeding control have made it possible to perform
thyroid surgery in the ambulatory setting for carefully selected, otherwise healthy
individuals. However, the major complications associated with thyroid surgery
remain, which include
injury to the laryngeal nerve,
hemorrhage,
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upper airway injury, and

hypocalcemia.
The rate of unplanned hospital admission following ambulatory total

thyroidectomy and partial thyroidectomy surgery is 1.6% (Orosco, Lin, &
Bhattacharyya, 2015). Laryngeal nerve damage affecting the vocal cords is
assessed as soon as the patient is able to speak, and upper airway injury may be
expected to manifest soon after extubation. The most common diagnosis at
emergency department examination or direct hospital admission was hypocalcemia
(20.8% of revisits), followed by wound hematoma/seroma/bleeding (Orosco et al.,
2015).
Urologic Procedures
Endoscopic procedures account for a large number of ambulatory urologic

procedures. Associated complications include
systemic absorption of irrigating fluids, resulting in serious electrolyte

imbalance, including hyponatremia;
hemorrhage;
infection; and
injury to the bladder, ureters, or urethra.
Volume Depletion
Volume depletion may result from extensive blood loss during surgery or
inadequate fluid replacement. Postoperative bleeding may require a return to
surgery. Such bleeding may be readily observable, as with a hematoma forming in
the area of operation or a tonsillectomy patient coughing up blood. Covert bleeding
may be identifiable only by characteristic signs of impending hemorrhagic shock,
including hypotension, tachycardia, pallor or cyanosis, oliguria, or restlessness and
apprehension. Intraoperative and postoperative patient monitoring for blood loss
includes visual assessment of the surgical field and surgical sponges and volume in
the suction canisters. Most ambulatory surgery procedures are minimally invasive
and are not associated with blood loss. If a patient reports signs and symptoms of
bleeding during the follow-up postoperative phone call, the nurse reports this
information to the surgeon immediately.
Surgical Site Infection
In contrast to higher rates of infections following inpatient procedures, the rate

of surgical site infections (SSIs) following ambulatory surgery is very low at 3.09%
(Owens, Barrett, Raetzman, Maggard-Gibbons, & Steiner, 2014). Most SSIs occur
within 2 weeks after surgery; therefore, Owens et al. suggest earlier access to a
clinician or member of the surgical team (i.e., telephone check-in prior to 2 weeks)
may help identify and treat ambulatory surgery SSIs. Rhee et al. (2015) concluded
many ambulatory surgery SSIs are superficial in depth, limited to the incision, and
do not require hospitalization for treatment. The ambulatory surgery nurse asks the
patient about signs and symptoms of SSIs during postoperative follow-up phone
calls and reports any indicators to the surgeon and to the ambulatory surgery
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clinical manager. Most ambulatory surgery facilities track confirmed surgical site
infections and conduct a root-cause analysis to determine the origin.
ANESTHETIC COMPLICATIONS AND PREVENTION
Aspiration
Aspiration of gastric contents is a potentially fatal complication of anesthesia

(Robinson & Davidson, 2014). When gastric contents are regurgitated into the
hypopharynx and then inhaled into the lungs, consequences include
bronchospasm, pneumonitis, or atelectasis.
Aspiration is a potential problem in deeply sedated and anesthetized patients
who are unable to maintain a patent airway and have obtunded gag and cough
reflexes that prevent clearing the airway. Although aspiration of blood or other
foreign material may seriously interfere with oxygenation, aspiration of strongly
acidic gastric fluid is corrosively damaging as well. As little as 25 ml of gastric fluid
with a pH of 2.5 may result in severe pneumonitis. Aspirated solids obstruct the
tracheobronchial tree, resulting in atelectasis, and may require bronchoscopy for
evacuation.
Clinical signs of atelectasis are usually immediately apparent, whereas signs of
acid pneumonitis may not occur for several hours. Signs of pneumonitis may
include cyanosis, tachycardia, tachypnea, rales, and rhonchi (Robinson &
Davidson, 2014). Severe cases may develop into pulmonary edema with
hypoxemia. For mild cases, treatment is largely supportive to ensure adequate
oxygenation. The effectiveness of steroid therapy is controversial with no evidence
to support use, but antibiotics may be necessary to control secondary infections
(Robinson & Davidson, 2014). Massive aspiration may require controlled ventilation
and positive end-expiratory pressure (PEEP) to provide adequate arterial
oxygenation.
Patients at the greatest risk for perioperative aspiration include those with a
hiatal hernia; gastroesophageal reflux disease; increased intra-abdominal pressure,
such as morbid obesity and pregnancy; bowel obstruction; noncompliance with
nothing-by-mouth status; and emergency circumstances (Robinson & Davidson,
2014). Endotracheal intubation after rapid-sequence anesthetic induction is usually
indicated for these patients. Postoperatively, extubation or deflation of the cuff
should be done with the patient placed on his or her side and is not advisable until
consciousness and laryngeal reflexes have returned (Robinson & Davidson, 2014;
Morgan, Mikhail, & Murray, 2006).
Prophylactic Medications
The following medications are used prophylactically to lessen the possibility of

aspiration:
Histamine-2 (H2)-receptor antagonists, such as cimetidine (Tagamet),

ranitidine (Zantac), or famotidine (Pepcid), may be given IV, but usually they
are given orally the evening before surgery and 1 to 2 hours before induction
to inhibit gastric acid secretion. H2-receptor antagonists only affect the pH of
gastric acids secreted after administration.
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Metoclopramide (Reglan) given orally 1 to 2 hours or IV 45 minutes before

induction accelerates gastric emptying.
Nonparticulate antacids, such as Bicitra or Polycitra, neutralize acidity. Given
orally 30 minutes before surgery or induction, they do increase gastric
volume but are less damaging to the alveoli than particulate antacids, such
as magnesium hydroxide.
Sellick’s Maneuver
In situations where the possibility of regurgitation is increased, the nurse may be

asked to apply pressure to the cricoid cartilage (i.e., perform Sellick’s maneuver)
from the start of induction until the endotracheal tube cuff is inflated and proper
placement is verified (Armstrong et al., 2009; Stewart, Bhanaker, & Ramaiah,
2014). See Figure 10-1.
Finger pressure over the cricoid cartilage below the thyroid notch and
cricothyroid space compresses the esophagus against the sixth cervical vertebra,
decreasing the mechanical possibility of regurgitation of gastric contents into the
hypopharynx.
The use of cricoid pressure is controversial, as some clinicians believe the risk
for complications outweigh the benefits. Complications include cricoid cartilage
fracture, airway obstruction, esophageal rupture, and the potential for cervical spine
or laryngeal trauma when significant manipulation of the head occurs (Stewart et
al., 2014).
Difficult Airway and Failed Airway
Managing a difficult airway is common in anesthesia practice, and the inability to

intubate or ventilate occurs in approximately 1 in 1,000 attempts in the surgical
population (Seifert & Wadlund, 2015). Intubation failure, indicated by multiple
unsuccessful attempts to place an endotracheal tube and the inability to maintain
the patient’s oxygen saturation above 90%, is a perioperative crisis (Seifert &
Wadlund, 2015). Initial difficulties may be addressed with repositioning of the
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patient, but the most important assessment is ensuring the patient can be
adequately ventilated using a bag valve mask (BVM; Seifert & Wadlund, 2015). If
the BVM is adequate, then the anesthesia provider has time to consider alternative
plans, but if the BVM is not adequate, then a laryngeal mask airway (LMA) should
be used. If the LMA placement is unsuccessful, the anesthesia provider will attempt
video laryngoscopy, such as with a GlideScope®, followed by bronchoscopic
intubation or transtracheal jet ventilation if needed. Finally, if all else fails, the
surgical team can prepare to place a surgical airway via cricothyroidotomy. The
circulating nurse preps the patient’s neck for sterile placement by the surgeon. This
would only be done in an emergency if there were no other way to maintain
adequate oxygen saturation. More commonly, if the patient presents with a difficult
airway and the anesthesia provider is unable to intubate the patient successfully,
the operative procedure would be canceled and rescheduled at an inpatient facility.
Malignant Hyperthermia
Malignant hyperthermia (MH) is a hypermetabolic, hyperthermic syndrome that

develops in genetically predisposed individuals when they are exposed to volatile
inhalation anesthetics or the depolarizing muscle relaxant succinylcholine. The
word malignant refers to the seemingly uncontrollable hyperthermia, which had a
mortality rate of 70% to 80% when the syndrome was first identified in the 1960s.
Advances since then have reduced the mortality rate to approximately 10%, but a
successful outcome depends on early recognition and aggressive treatment. It is
not associated with carcinoma.
MH may occur regardless of gender and age. Many people with the inherited
predisposition also exhibit other inherited skeletal muscle abnormalities, such as
congenital myopathies and some muscular dystrophies (Seifert, Wahr, Pace,
Cochrane, & Bagnola, 2014). These individuals tend to be prone to joint
dislocations and are frequently intolerant to caffeine-containing foods.
Some muscle diseases have been associated with a high incidence of MH or
MH-like occurrences, including Duchenne’s muscular dystrophy, myotonia,
osteogenesis imperfecta, central core disease, congenital muscular dystrophy, and
King-Denborough syndrome. Even patients with less common myopathies may
demonstrate MH-like episodes that respond to treatment with dantrolene
(Dantrium), that occur during general anesthesia without the use of potent
inhalation agents or succinylcholine (Seifert et al., 2014). Because MH does not
develop with every anesthetic exposure, susceptible individuals may have no family
history (Seifert et al., 2014).
MH is characterized first by an unexpected rise in end-tidal carbon dioxide and
muscle rigidity (Seifert et al., 2014). Hypercarbia, hypoxia, metabolic and
respiratory acidosis, tachypnea, dysrhythmias, and an increase in body
temperature will likely occur in the patient suffering from MH. Temperature increase,
which may go as high as 109°F, may be missed early in MH development due to
the decrease in body temperature that is associated with anesthesia and surgery.
Rigidity of the masseter muscles of the jaw (i.e., trismus) after receiving
succinylcholine during halothane anesthesia may be one of the first signs of
imminent MH, especially in children. However, rigidity also occurs in 1% of normal
children. Temperature may rise as much as 1.8°F (1°C) every 5 minutes after the
attack is established; however, fever is a late and inconsistent sign of
hypermetabolism, so routine temperature monitoring is of little value for very brief
anesthetics (Seifert et al., 2014). The Malignant Hyperthermia Association of the
United States (MHAUS) advises that the core temperature should be monitored in
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all patients given general anesthesia lasting more than 30 minutes. Appropriate
sites for continuous electronic core temperature monitoring include the esophagus,
nasopharynx, tympanic membrane (with probe in contact with the membrane),
bladder, and the pulmonary artery (Malignant Hyperthermia Association of the
United States, n.d.).
Immediate treatment of MH consists of
discontinuing known anesthetic triggering agents;
hyperventilating the patient with 100% oxygen at a high flow rate;

calling a code blue and concluding surgery as quickly as possible;
administering IV dantrolene, calling 911, and calling the MHAUS hotline (1-
800-644-9737) for additional advice; and
using cooling measures on the patient if his or her temperature is above
100.4°F (38°C), which include
applying ice packs to the body’s surface;

applying iced irrigating solutions to the stomach, bladder, and open
body cavities as necessary to maintain the patient’s temperature
below 104°F (40°C);
administering iced IV fluids; and
providing heat exchange with a pump-oxygenator.
Central venous access, arterial cannulation for blood samples, a core

temperature probe, and indwelling urinary catheterization must be established.
Intubation is necessary for airway control and hyperventilation. Sodium bicarbonate
is given to treat acidosis and hyperkalemia; mannitol or furosemide (Lasix) may be
indicated for diuresis to avoid renal failure caused by the end products of cell
degeneration.
To deal with the multifaceted treatment of MH, additional skilled personnel will
be needed immediately. The reconstitution of dantrolene is a time-consuming
process that requires the concerted efforts of more than one person to complete
the task as quickly as possible. All perioperative nursing personnel should be
familiar with this procedure. Newer formulations of dantrolene are more soluble,
making previous recommendations to warm the sterile water unnecessary
(Malignant Hyperthermia Association of the United States, n.d.).
An adequate supply of dantrolene (at least 36 20-mg vials), refrigerated IV
solutions, ice, and other appropriate supplies should always be immediately
available wherever general anesthesia is administered, including in office-based
settings (Seifert et al., 2014).
If the surgery cannot be completed immediately, anesthesia must be maintained
by IV agents. Barbiturates, opioids, propofol, etomidate, droperidol, and
nondepolarizing muscle relaxants are considered safe for the MH patient.
Dantrolene, which blocks calcium release, is the mainstay of treatment.
Elevated temperature should drop as the drug takes effect. The drug is
administered IV incrementally to effect. An initial dose of dantrolene 2.5 mg/kg
repeated IV every 5 minutes until the crisis is resolved is recommended, and 10
mg/kg is usually the necessary dose needed to achieve response (Seifert et al.,
2014). Because MH may recur several hours after the first attack, the provider
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caring for the patient after the initial event may administer up to 30 mg/kg over 24
hours (Seifert et al., 2014).
Although dantrolene is the only specific drug for treatment of MH and must be
used, patients receiving calcium channel blockers, such as verapamil, may suffer
from serious cardiac depression and dangerously high levels of potassium from the
drug combination. For the same reasons, calcium channel blockers are
contraindicated in the treatment of the tachycardia and dysrhythmias that may
occur with MH (Seifert et al., 2014). Theophylline, aminophylline, epinephrine, or
digoxin may intensify an MH attack (Seifert et al., 2014).
Emergency consultation is available 24 hours a day at 1-800-644-9737 (1-800-
MH-HYPER), the hotline provided by the MHAUS. Instructions for therapy should
be kept with the supplies, and every ambulatory facility, including office-based
settings, should have established guidelines for preoperative management of the
MH-susceptible patient so that all precautions are taken to avoid a life-threatening
crisis. All personnel should be prepared to safely treat an MH crisis. The anesthesia
department should be notified as soon as the procedure is scheduled. Because of
the intensity involved in treating an occurrence, mock departmental drills are
recommended (see Chapter 12). The MHAUS explains these procedures in
manuals for hospitals, ambulatory surgery centers, and offices doing outpatient
surgery.
Individuals with confirmed MH are advised to wear medical alert identification
(ID). They and their first-degree relatives should register with the North American
Malignant Hyperthermia Registry. A variety of educational materials are available
for medical professionals and MH-susceptible individuals and their families from
MHAUS by phone (800) 98-MHAUS, fax (607) 674-7910, or the Web at
http://www.mhaus.org. The organization also sponsors a medical ID program.
ALLERGIC REACTIONS
Anaphylactic Reactions
Anaphylactic reactions (e.g., anaphylaxis, anaphylactic shock) are severe, life-

threatening, generalized, or systemic hypersensitivity reactions (Nel & Eren, 2011).
The incidence of perioperative anaphylaxis varies from 1 in 6,000 to 1 in 20,000
surgeries (Nel & Eren, 2011; Sampathi & Lerman, 2011). Cardiac arrest occurs in
0.7% to 10% of reactions in the operating room with the most common trigger of
anaphylaxis in the perioperative period being neuromuscular blocking drugs
(approximately 60% of reactions) followed by latex (12% to 16% of reactions) and
antibiotics (8%; Sampathi & Lerman, 2011). Initially, these reactions may be
extremely difficult to recognize in a patient under heavy sedation or general
anesthesia because symptoms are similar to those seen with many other situations
associated with surgery and anesthesia. Anaphylaxis occurs swiftly and
systemically and can affect one or more organ systems. Clinical presentation of
anaphylaxis can be found in Table 10-1.
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Anaphylaxis results from an antigen-antibody reaction that develops because of

previous exposure to the antigen, such as a drug or protein, causing sensitization.
Cross-sensitization may occur from a different substance that has a structure
similar to that of the antigen; for example, exposure to environmental chemicals
and some cosmetics, which have quaternary ammonium ions, can cross-sensitize
the patient to a neuromuscular blocking agent (Nel & Eren, 2011). Anaphylactic
reactions may occur within minutes of exposure, with severity ranging from mild
urticaria to shock and death. Histamine is released by mast cells and the antigen-
antibody reaction also causes a release of leukotrienes, prostaglandins, and kinins.
Treatment, which must be rapid and comprehensive, includes these actions:
Discontinue administration of the suspected cause if it can be identified

quickly.
Change to a different class of anesthetic agents if the cause of allergic
reaction is unknown.
Administer oxygen by face mask if there is no edema or airway obstruction,

or intubate and control ventilation.
Expand circulatory volume with IV fluids, bearing in mind that plasma volume
expanders may be causative agents.
Provide pharmacologic support, including
IV epinephrine,
IV aminophylline,
IV diphenhydramine or cimetidine, and
IV corticosteroids.
Cessation versus continuation of surgery will be decided by the anesthesiologist

and surgeon based on patient response to treatment.
Epinephrine, a bronchodilator, is very effective in treating anaphylaxis because
of its ability to bind with alpha- and beta-adrenergic receptors, producing
vasoconstriction, which increases blood pressure and heart rate. As soon as the
patient responds to initial treatment, a histamine-1 (H1)-receptor blocker and
corticosteroids should be given intravenously (Nel & Eren, 2011). Antihistamines
are able to block the effects of already released histamine at receptor sites.
Corticosteroids stabilize mast cells, reducing the inflammatory reaction.
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Many agents commonly used in healthcare settings have been linked to

anaphylactic reactions. The intravenous route of medication administration is
associated with sudden reactions when an allergen is introduced (Nel & Eren,
2011). Contrast media used in radiology is frequently associated with allergic
reactions. Substances used during surgery, such as neuromuscular blocking
agents, bone cement, dextrans, antibiotics, protamine, streptokinase, and blood
products, may also cause allergic reactions. The following drugs may act as foreign
substances that precipitate reactions:
neuromuscular blocking agents (see Chapter 5);
IV anesthetics such as barbiturates, propofol, and etomidate;

opioids such as morphine, meperidine, codeine, and fentanyl;
local anesthetics of the amino ester type such as procaine; and
antibiotics (all classes).
A thorough preoperative assessment is a key factor in identifying the patient

who may be at risk so that preventive measures may be considered in
perioperative planning. A known history of atopy, such as bronchial asthma, would
be a consideration in the rapid differential diagnosis of the cause that should be
made during surgery or anesthesia. Multiple surgical procedures (causing possible
sensitization), reactions during dental or radiologic procedures, or episodes of
related symptoms, including respiratory distress, are all important considerations.
For individuals identified as being predisposed to allergic reaction, intradermal
tests, basophil histamine-release tests, and radioallergosorbent testing (RAST)
may be used for evaluation. The RAST results are not as accurate for a specific
antigen as those achieved with an intradermal test using an extract of an allergen.
However, the RAST evaluates the number of antibodies produced by the immune
system, and elevated levels of certain antibodies may identify particular allergies
(Nel & Eren, 2011). Pharmacologic preoperative prophylaxis with histamine-release
antagonists and corticosteroids may decrease the severity of a reaction.
Latex Allergy
The ambulatory surgery facility establishes policies to promote a latex-safe

environment. An allergic reaction to latex, whether experienced by a patient or a
healthcare worker, can cause anaphylaxis. Latex exposure can occur through direct
contact and via airborne particles. Several studies have ranked natural rubber latex
as the second most prevalent cause of anaphylaxis in the operating room, second
only to neuromuscular blocking agents (Nel & Eren, 2011). With that said, the
incidence of perioperative latex allergy is currently trending downward because of
the reduction in the use of latex products in health care (Galvão, Giavini-Bianchi, &
Castells, 2014).
Anaphylactic response to latex may be confused with reactions to other
substances during surgery and anesthesia because the onset of symptoms may be
delayed for more than an hour after exposure (Sampathi & Lerman, 2011).
Latex sensitivity appears to develop with repeated exposures and may or may
not progress to a latex allergy. Although the incidence among healthcare workers is
greater than the general population, patients who undergo frequent procedures that
put them in contact with medical devices that contain latex have the greatest
incidence of latex allergic reaction. Children with spina bifida, meningocele, and
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urogenital abnormalities and adults with spinal cord injuries are believed to be
sensitized by frequent urinary catheterization, digital disimpaction with a latex-
gloved finger, and multiple surgeries that expose mucosal, serosal, parenteral, and
peritoneal membranes to latex (Nel & Eren, 2011). Antibodies to latex have been
detected in at least 78% of children with spina bifida (Sampathi & Lerman, 2011).
Symptoms of a reaction in an anesthetized patient are similar to those listed in
the previous section. Symptoms in a patient who is awake may be localized or
generalized and include
hives (urticaria);
pruritus;
rhinitis or watery, itchy eyes;

edema of the eyelids;
faintness;
shortness of breath;
wheezing;
nausea or vomiting;
abdominal cramps;
diarrhea; and
anaphylaxis.
Routes of exposure to latex include skin, mucous membrane, inhalation,

parenteral injection, ingestion, or wound inoculation. Type IV sensitivity, allergic
contact dermatitis, is not life threatening and occurs immediately upon skin contact
with latex. Another type of latex-associated dermatitis, irritant dermatitis, is more
likely due to sensitivity to chemicals used in the manufacture of latex items. This
type of reaction takes from 6 to 72 hours to develop and produces irritated, dry,
cracking skin (American Society of Anesthesiologists, 2005).
The ambulatory surgery facility should be committed to establishing a safe
environment for patients with a latex allergy. Each ambulatory surgical facility
should have established policies and protocols for care of the latex-sensitive
patient. Many commonly used supplies, anesthetic machines, ventilators, and other
equipment are latex-free. Even medication vials are manufactured with latex-free
stoppers (Sampathi & Lerman, 2011). A latex-free cart or kit is made available as a
quick, alternative resource to any stocked supplies that contain latex, and all supply
labels are examined for the manufacturer’s disclosure of the presence of latex.
Patients with latex allergies should be scheduled as the first case of the day or 2.5
hours after room latex exposure to avoid particle exposure from previous activities
(Sampathi & Lerman, 2011).
A thorough preoperative history, including possible occupational exposure and
suggestive symptoms of latex allergy, is important so that precautions and
preparations for a safe surgical procedure may be planned. The American Society
for Anesthesiologists (ASA) recommends that patients be questioned about itching,
rash, or wheezing after blowing up balloons or wearing latex gloves (Sampathi &
Lerman, 2011). Treatment for an anaphylactic reaction to latex is the same as
outlined in the above section.
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PATIENT AND CAREGIVER EDUCATION
P
atients who endure a complication or emergency will need the support of
the ambulatory surgery team and their significant others. The nurse, as the
patient advocate and in partnership with the physician, provides education
regarding the known cause of complications and emergencies and ways to avoid
their reoccurrence during future surgeries or procedures. Written instructions
regarding new onset of symptoms, such as new allergies and pathophysiologic
developments, are shared with the patient or caregiver, as well as any
recommended follow-up activities, such as reviewing the new findings with the
primary care physician.
SUMMARY
T
he perianesthesia nurse’s awareness and understanding of the variety and
scope of serious and life-threatening complications that may occur at any
time perioperatively is the best preventive measure for patient safety. Early
recognition of impending complications followed by effective treatment is key to
favorable patient outcomes. The ambulatory surgery nurse uses critical thinking
skills to assess the situation and respond appropriately in an effort to promote the
best possible outcome for the patient. Nurses working in an ambulatory surgery
center or an office surgery suite, and faced with a patient emergency, will call for
emergency assistance and transport the patient to the closest hospital while
implementing life-saving interventions. Nurses caring for patients in a hospital
outpatient department will call an emergency response team for assistance and
further evaluation of the patient. Many times the ambulatory surgery nurses will
accompany the physician in discussions with the patient’s family after the patient is
stabilized. The nurse offers support to the patient, the patient’s family, and the
perioperative team.
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EXAM QUESTIONS
CHAPTER 10
Questions 58–65
58. During laparoscopic surgery, why would a pneumoperitoneum be established?

a. This is an error that occurs and leads to a pulmonary embolism.
b. This is done to create a space for visualization, instrumentation, and
manipulation within the abdominal cavity.
c. This is done in response to inadequate ventilator exchange and
inadequate cardiac output.
d. A pneumoperitoneum is not established during laparoscopic surgery.
59. What are the symptoms of gas embolism?

a. Pain in the shoulder and neck
b. Head and neck swelling
c. Internal bleeding
d. Tachycardia, hypotension, cyanosis, and dysrhythmia
60. All of the following interventions are used to treat a gas embolism except
a. increasing ventilation to increase carbon dioxide excretion.
b. administering 100% oxygen.
c. implementing intraperitoneal normal saline infusion.
d. supporting blood pressure with vasopressors and IV fluids.
61. During a postoperative, follow-up phone call, a patient who had laparoscopic
pelvic surgery reveals she has abdominal pain at a 9 on a scale of 1-10 and her
abdomen is tender upon palpation. The nurse recognizes these symptoms as
a. to be expected after this type of surgery.
b. possible bowel injury.
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c. possible gas embolism.

d. irritation of the phrenic nerve.
62. What is one way a circulating nurse would know whether the operating
microscope’s light intensity is too high for the focal length?
a. The surgeon complains his or her hands are getting hot.
b. The patient complains of nausea and dizziness.
c. The surgeon complains he or she cannot see the field.
d. The anesthesia provider complains the room is too cold.
63. What is the ideal position for extubation or deflation of the endotracheal tube
cuff for a patient at risk for aspiration?
a. Trendelenburg
b. Supine
c. Prone
d. Lateral
64. According to the Malignant Hyperthermia Association of the United States

(MHAUS), core temperature should be monitored in
a. all patients during a surgical procedure.
b. all patients during procedural sedation.
c. all patients given general anesthesia lasting more than 30 minutes.
d. all patients given general anesthesia.
65. Which of the following are included in the clinical presentation of anaphylaxis?
a. Urticaria, hypotension, bronchospasm, and nausea
b. Hypertension, cough, abdominal cramps, and jaw rigidity
c. Hyperthermia, left shoulder pain, diaphoresis, and sore throat
d. Rash, hypercarbia, pneumonitis, and rhonchi
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CHAPTER 11
CONSIDERATIONS FOR SPECIAL

POPULATIONS
LEARNING OUTCOME
fter completing this chapter, the learner will be able to identify unique
A considerations and the required interventions relative to pediatric patient

populations, older adult patient populations, and patient populations with
special needs in the ambulatory surgical setting.
CHAPTER OBJECTIVES
A
1. Identify the developmental needs of pediatric patients at various ages.

2. Select appropriate perioperative nursing interventions for pediatric
ambulatory surgery patients.
3. Identify considerations that enhance the well-being and safety of geriatric
patients perioperatively.
4. Explain age-related changes that may affect ambulatory surgery outcomes in
the geriatric patient population.
5. Summarize how the ambulatory surgery nurse ensures safe care for patients
who do not speak English, patients who are hearing impaired, and patients
with cognitive and physical disabilities.
INTRODUCTION
O
ne of the challenges of ambulatory surgical nursing is the need to care for
a variety of patients with special needs who, if hospitalized, would be
cared for by specialists. Age-specific and disease-associated
recommendations and precautions are offered throughout this course, but there are
special considerations for pediatric and geriatric patients, for hearing-impaired
patients, for patients who do not speak English, and for those who manage physical
or cognitive disabilities. The perioperative nurse understands and considers these
special needs in order to provide a safe and pleasant ambulatory surgical
experience. Some of these considerations are presented in this chapter.
PEDIATRIC PATIENTS
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n 2006, an estimated 2.3 million pediatric ambulatory surgery episodes

occurred in the United States involving children younger than 15 years old
(Rabbitts, Groenewald, Moriarty, & Flick, 2011). Compared with the 1.6 million
I
cases done in 1996, it is clear the number of pediatric surgical procedures
performed in ambulatory settings continues to grow (Rabbitts et al., 2011). As
outpatients, children are spared the anxiety and fears associated with being
separated from their families and have minimal disruption of their comfortable, daily
routine. Because of the large number of pediatric ambulatory procedures done,
some ambulatory facilities are devoted exclusively to children and are staffed by
professionals specializing in pediatrics.
However, most ambulatory surgical facilities treat adult and pediatric patients.
Because the developmental needs and physiologic, anatomic, and pharmacologic
characteristics of neonates, infants, and young children are considerably different
from those of adolescents and young adults, the perioperative nurse should be
familiar with developmental stages, normal ranges and values for vital signs, and
other parameters to develop an appropriate care plan and recognize deviations that
may require intervention. Ambulatory surgery facilities that care for adults and
pediatric patients have separate and distinct rooms in the postanesthesia area
devoted to children recovering from ambulatory surgery. This allows all patients to
recover safely and comfortably. Ambulatory surgery policies require child-sized
equipment be available to accommodate the smaller sizes needed for therapeutic
monitoring and care of children. Often, smaller apparatus, such as blood pressure
cuffs, can be used on petite adults as well.
Determining the pediatric patient’s weight in kilograms (dividing his or her weight
in pounds by 2.2) is an important safety precaution, considering that pediatric
medication dosages and intravenous (IV) fluid requirements are calculated in
kilograms. Kilogram scales are available that eliminate the possibility of conversion
errors. Dosages should be carefully checked before administration, and any order
that seems inappropriate should be questioned. Because emergency medications
are dosed according to weight, the ambulatory surgery nurse prepares a
customized emergency medication dosage information form for each pediatric
patient.
Psychologic Preparation
Psychologic needs vary with age, and as children grow older, their concerns
and reactions to the prospect of surgery change. Children are most psychologically
vulnerable during their first 3 years of life, when they’re too young to understand the
procedure but old enough to remember it. An unpleasant surgical experience may
cause subsequent visits to the doctor or hospital setting to be stressful challenges
for the child and parents; separation anxiety is greatest in this age group. Parents
should be cautioned not to say good-bye, but rather to tell the child they will be
waiting in another room. Children, especially up to 4 years of age, need frequent
reassurance that parents are waiting. This age group benefits from examining
(handling) strange new equipment and the use of “magical” equipment. They
should also be allowed to bring a favorite toy or stuffed animal with them to the
facility.
For children who are 4 to 7 years old, separation anxiety is less intense
because they are better able to understand that their parents will be waiting.
However, they also understand that something is going to be done to their bodies,
which is a frightening thought.
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Ideally, nurses and anesthesia providers involved in the child’s care can take a
few extra minutes to bond with the child (and parents) before the procedure; this
can build trust and make the whole experience much smoother for everyone
involved. For example, while the surgical team is completing their preoperative
safety checklist with the parent, one of the members of the team could be blowing
bubbles or playing with a stuffed animal with the young child. For an older child, the
nurse could ask about his or her school or favorite subjects or television shows.
This is just enough distraction to form a bond and enough levity to show the
parents (and the child) that the healthcare providers care enough to make the
situation pleasant for all involved.
Throughout the preoperative phase, the parents’ attitudes strongly influence the
child’s reaction and behavior. Children take their cues from their parents, so an
anxious parent may result in an anxious child. The preadmission nurse can provide
guidance to parents during the phone interview by offering ways to soothe their
child’s anxiety. Parents should talk openly and in a matter-of-fact manner about
what is going to happen, explaining each step in terms the child can understand.
When the child discerns that the surgery is nothing to fear because the parents are
not upset, the preparation is more likely to be better accepted and less stressful.
Children 4 to 7 years old benefit from rehearsing and role-playing, but they are
still young enough to be comforted by a favorite toy. They are curious about new
things (e.g., equipment) and will either believe or laugh at the idea of magical
effects.
During the school years, children are learning and developing their self-esteem.
Surgery may be interpreted as a threat to the integrity of their bodies, so they may
need to feel they have some control over circumstances associated with the
surgical experience. A preoperative visit to the ambulatory surgery facility is
especially helpful to this age group. It gives them a chance to ask questions
(control) and investigate.
Adolescents tend to give the impression that they do not care, yet they are very
concerned about the details of the surgery, especially if it will affect their body
image. Independence is important to them; they may prefer not to have a parent
assist them. They value privacy and confidentiality and are more prone to honestly
answer personal questions, such as those involving drug use, if parents are not
present.
Regardless of the patient’s age, parents assume considerable responsibility for
pediatric ambulatory surgical patients and may be quietly overwhelmed. They must
be integrated into the care plan and be kept well informed. Many facilities provide
age-appropriate books and videotapes that can be used in the home setting to
teach patients and parents as they prepare for surgery. The child and parents may
benefit from a tour of the ambulatory surgery facility well before the day of surgery.
The nurse guides the family through the center and uses props and toys to show
that the facility is inviting and safe.
One of the most difficult things for a parent to do is to relinquish care to the
perioperative staff. Parents should be made to feel that their trust is well placed and
that the child’s well-being and safety are the staff’s primary concern. They must be
well informed about perioperative proceedings and understand that complying with
preoperative and postoperative instructions is essential to a safe and uneventful
surgery.
Immediate Preoperative Preparation
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Preoperative Food and Fluid Intake
Children should be scheduled as early in the day as possible to avoid the

irritability and dehydration associated with withholding food and liquids. The
American Society of Anesthesiologists recommends no intake of solids, nonhuman
milk, or formula 6 hours before surgery; no intake of breast milk 4 hours before
surgery; and no intake of clear liquids 2 hours before surgery (American Society of
Anesthesiologists, 2011). To avoid dehydration, infants and toddlers may be
encouraged to take clear liquids 2 to 3 hours before the scheduled surgery, even if
they must be awakened to do so. A clear fluid restriction of 3 hours allows for last-
minute schedule changes, permitting patients to be moved up as long as they have
been on nothing-by-mouth (NPO) status for clear fluids for at least 2 hours.
Premedication
It is generally agreed that the best premedication for a pediatric patient is a

calm, supportive parent. For this reason, allowing a parent to be with the child
during anesthetic induction may permit omission or reduction of sedative or
anxiolytic premedication. Omitting premedication for pediatric outpatients usually
results in a more speedy return to preoperative status or home readiness.
Parental participation is at the discretion of the anesthesia provider and the
policy of the facility (Scully, 2012). The child’s expected response during anesthetic
induction must be explained to the parent in detail so that the parent may decide
whether he or she will be able to accept the experience without interference.
Although parents often request participation, most are unaware of the child’s
response to induction under inhalation anesthesia, and many individuals are not
able to remain calm as they watch, which may be disruptive to the process rather
than beneficial. There is insufficient scientific evidence validating whether parental
presence at anesthesia induction reduces anxiety in pediatric patients; however,
research shows distraction techniques, such as making it a game to blow into the
mask, is effective (Scully, 2012).
Available as a syrup, oral midazolam is the most commonly used pediatric
premedication in the United States (Scully, 2012). Other liquid oral medications,
given with a small amount of sweet liquid, are usually well tolerated. For
inconsolable or combative children, intramuscular (IM) ketamine may be chosen to
facilitate separation from the parents and transition into anesthetic induction. Nose
drops are another option that may be used with drugs such as midazolam,
ketamine, or sufentanil.
An alternative route for children weighing less than 20 kg is rectal
administration. Methohexital (Brevital) is usually effective within 10 minutes.
Midazolam may also be given rectally, but it may prolong recovery. Regardless of
which sedative is administered, the child should never be left unattended. Airway
obstruction, coughing, and hiccups may develop. In addition to the possibility of
oversedation, a disadvantage associated with rectal administration is defecation
and expulsion of an unknown amount of the drug before it is absorbed.
Anticholinergic medications, such as atropine, scopolamine, or glycopyrrolate
(Robinul), are commonly given preoperatively to decrease the possibility of
bradycardia occurring during some surgical procedures or general anesthesia
induction. These drugs also reduce respiratory secretions. Transdermal
scopolamine is believed to be beneficial in preventing nausea and vomiting,
especially if related to motion, and may be prescribed for ambulatory patients.
Although perioperative staff should monitor premedicated patients, parents who
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may also be with the child should be cautioned not to let a premedicated child run
and jump.
Intraoperative Phase
Before any pediatric procedure is started, appropriately sized equipment must

be available, including monitoring devices and emergency equipment. Adult-sized
blood pressure cuffs, pulse oximetry sensors, and even stethoscopes will not
provide accurate information. Most importantly, an assortment of child-sized
airways, masks, and other ventilatory support equipment must be at the site of all
preoperative, intraoperative, and postoperative care.
Toddlers are commonly anesthetized to the point of unconsciousness while
sitting on the anesthesia provider’s lap. Young children may be given the option of
sitting or lying on the operating table. They are typically allowed to hold the mask
themselves; volatile inhalation anesthetics produce unconsciousness within
minutes. Older children may accept venipuncture for IV induction. EMLA cream, an
eutectic mixture of local anesthetics, applied to the skin may make the venipuncture
more acceptable. However, it must be applied 1 hour before venipuncture to be
effective. Lidocaine iontophoresis, which uses electrical stimulation, reduces the
onset time to 10 minutes and increases the depth of dermal anesthesia to 6.4 mm
in that time versus a 5-mm maximum with EMLA. Supplemental regional
anesthesia decreases the general anesthetic requirement and provides pre-
emptive pain control for the postoperative period.
Postoperative Phase
Pediatric patients require diligent postoperative monitoring. Respiratory

complications are more common in children than in adults, so unless
contraindicated by the surgery, children should be placed on their sides to allow
secretions or blood to drain from the mouth as a precaution against aspiration or
laryngospasm. As reflexes return, laryngospasm may be caused by secretions
irritating the vocal cords. For surgical procedures that require tracheal intubation,
the child should be extubated either before the cough reflex returns or after
protective reflexes have returned, which is usually when the child is alert enough to
open his or her eyes.
Postoperative nausea and vomiting (PONV) is frequently more problematic in
pediatric patients largely because of the types of surgery performed in ambulatory
settings, such as strabismus correction and orchiopexy, and inhalation anesthesia.
The trend toward not requiring fluid intake until the child asks for something to drink
helps reduce the incidence, but medication may be required if nausea or vomiting is
severe or protracted. For children who have had throat surgery, such as a
tonsillectomy, analgesic rectal suppositories are an effective alternative to oral
medication, considering the surgery-associated swallowing and possible PONV.
The amount of pain experienced by different children who have undergone
similar surgical procedures differs widely. Children have fluctuating analgesia
requirements, so an effective pain management plan should include provisions for
breakthrough pain (Pagé, Stinson, Campbell, Isaac, & Katz, 2012).
Pain management in children may be compromised by the difficulty of assessing
its severity, especially in the very young. Depending on age, behavior assessment,
distraction techniques, or visual picture scales may be effective. For nonverbal
children or those with cognitive impairment, the caregiver should be assisted in
developing an individualized numeric rating scale for the child’s pain behaviors. As
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shown in Table 11-1, this assessment can be done using facial expressions, leg
activity, arm activity, crying, and consolability (FLACC), and the assessment can be
used throughout recovery and convalescence (Babl, Crellin, Cheng, Sullivan,
O’Sullivan, & Hutchinson, 2012). Again, in the phase II setting, the presence of a
parent may reduce both physiologic and psychologic distress.
Children old enough to understand the procedure should be told before surgery
that they will awaken in a different room and see unfamiliar faces. Nevertheless,
this is a frightening experience. Many facilities, after assessing the parents’
emotional states, allow the parents to be with the child as soon as he or she is
stable in phase I of recovery. Disorientation, hallucinations, and uncontrollable
movements may occur during emergence from general anesthesia, possibly due to
pain, sensory deprivation, or the unknown environment (Stamper, Hawks, Taicher,
Bonta, & Brandon, 2014).
Discharge
Parents are often anxious about their ability to provide adequate care
postoperatively. Detailed written and verbal instructions should be provided that
include what to observe for and what actions to take, as well as telephone numbers
for questions and emergencies. Ideally, comprehensive written instructions in
nonmedical language should be given to parents on a preoperative visit to the
doctor or the ambulatory facility. Although these instructions should be explained
again on the day of surgery before discharge, parents are often stressed and
anxious at that time. Parents should have received postoperative prescriptions prior
to the day of surgery so that they do not have to stop at a pharmacy on the way
home from the facility. They should be alerted that a fever greater than 100.4°F
should be reported to the surgeon. One of the advantages of ambulatory surgery
for pediatric patients is that postoperative circumstances allow patients to be active,
which encourages deep breathing and may help reduce low-grade fevers caused
by an immune system stress reaction.
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Because motion of the automobile during the drive home may provoke or
exacerbate nausea and vomiting, parents should be prepared. For small children
still marginally somnolent, it is important that parents be cautioned that the child’s
airway can be dangerously compromised if the head slumps forward when the child
is secured in a car seat. For all young children, a responsible adult should be
seated next to the child to monitor the head position to ensure airway patency and
deal with possible secretions or vomitus during the trip home. As with all
ambulatory surgical patients, parents should receive a follow-up phone call the next
day.
Respiratory Complications
Historically, uncuffed endotracheal tubes were used in the pediatric patient

population because it was believed this minimized resistance of the endotracheal
tube, thus minimizing pressure trauma to the subglottis. It is now known that cuffed
tubes provide better ventilating conditions while protecting the patient’s airway
(Harless, Ramaiah, & Bhananker, 2014). Another advancement that has led to
fewer respiratory complications in pediatric patients is the laryngeal mask airway
(LMA). The LMA has a 95% to 98% success rate in achieving adequate ventilation
in children (Harless et al., 2014).
Pediatric Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) affects 4% of the pediatric population (Hill et al.,
2011). OSA in children is most commonly caused by hypertrophic tonsils and
adenoids; thus, adenotonsillectomy (T & A) is the most commonly utilized treatment
for pediatric OSA (Hill et al., 2011). The severity of the OSA may be an important
risk factor for developing respiratory complications after surgery.
The intermittent episodes of hypoxemia and hypercarbia experienced during
sleep adversely affect the quality of life and may have long-term effects for pediatric
patients.
The apnea-hypopnea index (AHI), defined as the number of apnea and
hypopneic episodes per hour of sleep, is a predictive measure for obstructive sleep
apnea in the pediatric population (Hill et al., 2011). An AHI of greater than 24 and
age less than 2 years are indicators for risk of airway complications (Hill et al.,
2011). The American Academy of Pediatrics recommends that all children be
screened for snoring and that those at high risk of OSA be referred to a sleep
specialist and possibly undergo a polysomnogram, which is considered to be the
most accurate diagnostic tool. The Academy also recommends tonsillectomy and T
& A to treat obstructive sleep apnea, as opposed to watchful waiting, with re-
evaluation after surgery (Garetz et al., 2015). Although a T & A may be curative for
some cases of pediatric OSA, these children have a high incidence of
complications postoperatively. Oxygen desaturation may occur as late as 8 hours
after the procedure, which may be caused by an inflammatory response that
developed over time due to snoring.
Children with OSA who have undergone coblation T & A, a newer technique
that utilizes bipolar cautery, had significantly better postoperative recovery. They
required less pain medication and experienced fewer complications. However,
regardless of surgical technique, all children younger than 3 years of age are more
prone to complications after tonsillectomy (Hill et al., 2011).
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Pediatric OSA patients require constant monitoring after surgery, and those with
severe OSA, significant medical comorbidities, or upper respiratory infections are
not suitable for ambulatory surgery (Hill et al., 2011; Brown, 2005).
GERIATRIC PATIENTS
y 2030, at least 20% of the United States population will be older than 65, and of
these, one in four individuals will be older than 85 years of age. Just as children
should not be considered miniature adults, older adults should not be
B
considered feeble adults. Although some geriatric patients may be fragile
and need gentle care, they deserve respect and emotional support. Some
may also need a nursing advocate. Preoperative teaching is particularly
important to allay fears and improve postoperative cooperation, as is formulating a
thoughtful plan for postdischarge care by considering the patient’s functional status
and assuring effective communication among the patient, family, and healthcare
providers (White et al., 2012).
Older patients benefit from avoiding hospitalization in many ways: There is less
opportunity to become disoriented due to unfamiliar surroundings, decreased
exposure to infection, decreased likelihood of serious postoperative respiratory
complications caused by inactivity, and less upset of comfortable daily routines.
Although a generalized decline in systemic function inevitably occurs with
advancing age, physiologic age (functional status) is more predictive than
chronologic age. The healthy, alert, active individual is more likely to tolerate the
stresses associated with surgery and anesthesia than is the stereotypical infirm
individual, regardless of chronologic age. Age-related disease, not age itself, is
primarily responsible for morbidity and mortality in older patients (White et al.,
2012). For example, atherosclerosis is pathologic; it is not found in healthy older
patients. Factors that increase surgical risk are related to systemic disease,
functional abilities, mental health, and nutritional status.
Nevertheless, the normal aging process causes a decreased margin of reserve
in organ function, resulting in less adaptability. After 50 years of age, lung
compliance decreases because of loss of parenchymal elasticity, loss of chest wall
expansion potential due to calcification of the costochondral joints, and decrease in
alveolar surface area (White et al., 2012). Reduced arterial compliance results in
increased afterload, elevated systolic blood pressure, and left ventricular
hypertrophy. Coronary artery disease is associated with advancing age. Loss of
arterial elasticity and compliance results from decreased elastin and collagen
production over time.
Hepatic and renal blood flow and decrease in tissue mass result in slower
biotransformation of drugs and delayed elimination. After the age of 80, functional
reserve declines more rapidly. Many geriatric surgical patients have mild to severe
metabolic and hemodynamic deficits.
Aging increases perception thresholds, including vision, hearing, touch, smell,
temperature, and proprioception. Still, pain is extensively processed; it may be
inappropriate to routinely withhold treatment for pain and anxiety to avoid drug-
induced complications. In an effort to minimize the adverse effects of opioids, a
multimodal analgesic plan that involves small doses of opioids, local anesthesia,
and nonsteroidal anti-inflammatory medications can optimize outcomes for older
patients undergoing ambulatory surgery (White et al., 2012).
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Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD)

are major concerns in older patients. POD is an acute, temporary change in
orientation and cognition, and POCD is a more subtle impairment in cognitive
performance (White et al., 2012). Risk factors for POD include age older than 70
years; self-reported alcohol abuse; poor cognitive status; poor functional status;
abnormalities of serum sodium, potassium, or glucose; noncardiac thoracic
surgery; and abdominal aneurysm surgery (White et al., 2012). Surgery as an
outpatient may reduce the incidence and severity of POD and POCD because the
patients will be given fewer medications and be able to return to their normal
surroundings within hours. The lack of control a hospitalized patient has adversely
affects the emotional state, performance, subjective well-being, and physiologic
function in the older patient. An outpatient setting that can provide the patient with
less loss of control and more autonomy should be beneficial (White et al., 2012).
In general, geriatric patients require lower doses of barbiturates, opioids, and
benzodiazepines than other patients. With increasing age, there is a decrease in
skeletal muscle mass, causing an increase in the proportion of total body fat.
Consequently, fat-soluble drugs accumulate in tissues and the brain, resulting in
delayed elimination. Older patients have a comparable level of sedation with
diazepam at plasma levels significantly lower than in younger patients (White et al.,
2012).
Geriatric patients, particularly if malnourished, may also have decreased plasma
proteins. With less protein available to bind to, more of the administered drug is
unbound in the plasma, resulting in increased effect. Albumin, which tends to bind
acidic drugs such as barbiturates and benzodiazepines, usually decreases with
age, so the dosage of these drugs should be reduced for geriatric patients.
Similarly, meperidine is normally less protein bound than morphine, resulting in a
more enhanced effect when plasma proteins are decreased.
In addition, because of slower circulation time, the full effect of an IV medication
may be delayed in older patients. To prevent overdosage, sufficient time should be
allowed to observe and evaluate the effect of an IV medication before any
additional administration.
Accepted estimates show that 40% of geriatric patients take five or more
different drugs per week and that 12% to 19% use 10 or more drugs in a week
(White et al., 2012). This polypharmacy, the term used to describe the use of
multiple medications (five or more) to treat chronic conditions, is the only patient
characteristic associated with adverse drug reactions in patients 65 years and older
(White et al., 2012). Medication interactions can contribute to delayed healing, so it
is very important that the ambulatory surgery team is aware of all prescription, over-
the-counter, and herbal medications taken by patients.
Preoperative Preparation
A well-conducted preoperative assessment is essential for the aging patient.

The ambulatory surgery team assesses the risks of the proposed operative
procedure, the planned anesthesia and analgesia regimen, and the patient’s
underlying medical condition. Optimization of coexisting diseases leads to better
outcomes for elderly ambulatory surgery patients (White et al., 2012). An accurate
preadmission interview and preoperative assessment of the patient’s physical and
functional status fosters the creation of an appropriate perioperative care plan,
including preoperative interventions and prophylactic therapies. The preadmission
interview should include questions to help identify those patients at risk of
developing POD and POCD. Diminished thirst, poor nutrition, and diuretic
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medication may cause dehydration, which must be considered for intraoperative

fluid management.
Older patients may be on several prescription medications and often may
neglect to mention over-the-counter medications, so these possibilities must be
investigated and documented in the preoperative assessment.
Intraoperative Phase
Every decade after 30 years of age is associated with a 7% increase in the

potency of inhalation anesthetics (White et al., 2012). Desflurane has been found to
contribute to a more rapid recovery compared with isoflurane and sevoflurane and
causes less fatigue in the first week after ambulatory anesthesia (White et al.,
2012).
Elderly patients can be sensitive to the central depressant effects of hypnotics,
benzodiazepines, and opioids; therefore, it is important to titrate by following the old
adage, “start small and go slow.” Smaller doses of propofol may not reliably
produce amnesia, so small doses of midazolam (0.5 mg to 1 mg IV) can be
administered before propofol sedation to obtain anxiolysis and anterograde
amnesia (White et al., 2012).
Unless regional anesthesia is supplemented with moderate to heavy sedation,
postoperative confusion may be less than after general anesthesia. With spinal
anesthesia, postdural puncture headache is less likely to occur, but urinary
retention is more likely. In all patient populations, including the elderly, major
morbidity and mortality after ambulatory surgery are rare (White et al., 2012).
Adverse cardiovascular events are more common in elderly patients with pre-
existing cardiovascular diseases, and respiratory events in the elderly are usually
associated with obesity, smoking, and asthma (White et al., 2012).
The elderly ambulatory surgery patient is at risk for perioperative hypothermia
due to a decreased basal metabolic rate. Lower core temperatures in the older
patient population translate to a decrease in shivering and an increased risk for
hypothermia. Fragile skin and limited joint mobility require special care to avoid
trauma from improper positioning. Decreased immune responsiveness is also
associated with aging, which increases susceptibility to infection and sepsis.
Postoperative Phase
In the postanesthesia care unit (PACU), older patients require careful monitoring
due to their diminished ventilatory responses to hypoxia or hypercarbia. According
to White et al. (2012), aging produces a twofold increase in the risk of airway
obstruction, hypoxemia, or carbon dioxide retention, and older patients are more
prone to cardiovascular and central nervous system events perioperatively but
have less nausea, shivering, and dizziness than younger adults do.
Postoperatively, ventilatory problems are disproportionately more common in
elderly patients (White et al., 2012). Patients suffering from Parkinson’s disease
have additional problems due to difficulty swallowing and managing secretions in
addition to an often-decreased respiratory effort.
Many older patients live with chronic lung disease, so a primary concern during
the immediate and extended postoperative period is to facilitate adequate
respiration and prevent dyspnea.
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To prevent atelectasis, it is essential that older patients be able to cough to keep

the airway clear. Ineffective coughing consumes energy and oxygen and may lead
to dyspnea. Instructing patients in effective cough techniques after several deep
breaths, while supporting the operative site if appropriate, should prove helpful.
Perhaps more easily remembered by the patient is “huff” coughing. In this method,
after a deep breath the patient audibly huffs on expiration. However, this method
requires the use of abdominal muscles during expiration and may be too
uncomfortable immediately postoperatively for certain procedures, even with
support of the incision. Patients may benefit from the use of an incentive spirometer
during the postdischarge period, as well as careful and supervised ambulation as
appropriate per the procedure done.
Self-care management strategies need to be emphasized in the PACU before
discharge. Simple, deliberate, deep sighing may be helpful in promoting lung
expansion.
Discharge
For many older patients who live alone, the postdischarge recovery period may
require assistance from community healthcare sources (see Chapter 9). Similarly,
for couples, the person who undergoes ambulatory surgery may be the primary
caregiver in the relationship and will have no reliable adult support after discharge.
Both of these circumstances require the nurse to act as advocate for the patient
and ensure that adequate care will be provided when the patient leaves the
ambulatory facility. The ambulatory surgery nurse’s goal is to identify, plan, and
provide nursing care to meet the needs of each patient. To create a safe discharge
plan, the nurse must find a balance between the patient’s normal circumstances
and the resources that are available and acceptable to the individual.
A responsible adult who will remain with the patient overnight must accompany
the patient home and preferably remain with the patient to monitor the extended
recovery period. These arrangements should be finalized preoperatively. Written
and verbal instructions are reviewed preoperatively and postoperatively with the
patient and caregiver. Large print instructions may be helpful for older patients. It is
important that the responsible caregiver, as well as the patient, verbally
demonstrate an understanding of these instructions because residual effects of
medications may affect the patient’s recall.
In addition, the patient and responsible adult should be provided with a 24-hour
emergency phone number and cautioned about the signs to monitor for and the
actions to take should they occur. The patient should receive a follow-up phone call
the next morning. With adequate planning and preparation, the older patient should
benefit from the minimal upset of daily routines that ambulatory surgery provides.
PATIENTS WITH SPECIAL NEEDS
T
he perioperative care of patients with special needs poses challenges for
the ambulatory surgical team that can be overcome through thorough
preadmission assessment, planning, teamwork, and patience. The
ambulatory surgery nurse strives to identify and manage barriers to providing care
when a patient with special needs requires ambulatory surgery. The ambulatory
surgery setting offers decreased patient stress and anxiety, as well as flexibility,
leading to positive patient outcomes.
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Barriers to Communication
Communication is crucial when providing care to ambulatory surgery patients.

Overcoming language barriers and providing culturally sensitive care are central to
establishing patient trust. Communication and the transfer of information rely on
clear language to avoid miscommunication. Communication between the patient
and healthcare provider may be influenced by social status, cultural background,
and language problems. Serious problems with miscommunication can develop
when the healthcare provider doubles as a medical interpreter. Healthcare
providers do not always have full understanding of medical terminology in another
language, including sign language, and may cause inaccurate translation of
healthcare information. According to Weldon et al. (2014), professional medical
interpreters are preferred, and in some instances required, because of the
improved communication, resource utilization, clinical outcomes, and satisfaction
with care; these professional medical interpreters are trained to maintain an
impartial role and use proven strategies to completely and accurately convey the
necessary communication between the patient and the healthcare provider. Studies
have shown that the risk of serious medical errors increases when a language
barrier is not handled by a professional medical interpreter but rather is addressed
by healthcare providers attempting to translate independently (Weldon et al, 2014).
Additional studies highlighted problems affecting quality and safety, decreased
resource utilization, and delays in care that occurred for patients who were not
provided professional medical interpreter services (Weldon et al., 2014).
Each patient is assessed for communication needs, and this assessment is
documented in the medical record, along with the patient’s preferred method of
communication. Upon identifying a language barrier, the ambulatory surgery nurse
reviews facility policy and arranges for professional medical interpreter services. A
bilingual patient may be asked which language he or she prefers to use during the
surgical visit. If needed, the interpreter reviews preadmission instructions with the
patient and assists the nurse in answering any questions the patient may have. The
professional medical interpreter may be present on the day of surgery, may be
available via interactive video capabilities, or may translate over the phone, if
appropriate. The nurse documents in the medical record all interpretation services
provided.
Physical and Cognitive Disabilities
The ambulatory surgery nurse assesses each patient for any cognitive
disabilities that may affect the patient’s understanding of the procedure and his or
her abilities to recover independently at home after the procedure. All ambulatory
surgery patients are discharged into the care of a responsible adult, but patients
with cognitive disabilities have special needs that require careful assistance and
monitoring to ensure the best outcome possible. The ambulatory surgery nurse can
assist by understanding how the patient learns best and providing information in a
way that is easiest for the patient to understand. Patients with cognitive disabilities
often rely on a caregiver even when surgery is not a factor, but some patients live
independently. The ambulatory surgery nurse assesses the patient’s abilities and
home support and then customizes care as needed. Dedicated caregivers are often
able to explain the patient’s needs throughout the ambulatory surgery visit because
they spend so much time caring for the patient otherwise. The FLACC Pain
Assessment Tool can be used for patients who are unable to verbally express a
numeric pain scale score.
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Patients with physical disabilities are cared for in the ambulatory surgery
environment through a team approach. The ambulatory surgery nurse focuses on
assessing the patient and then developing a plan to keep the patient comfortable
and safe at all times. Patients with physical disabilities are queried about
preferences related to ambulation, positioning, and care at home. The nurse
ensures the patient has enough support from the ambulatory surgery team before,
during, and after the procedure to optimize outcomes. The nurse also educates the
patient and caregivers about care at home. Similar to patients with cognitive
disabilities, care is customized according to a needs assessment that includes
participation from the patient and caregivers.
SUMMARY
P
ediatric patient populations, older adult patient populations, and patient
populations with special needs require focused assessment and
customized plans of care executed through team collaboration to ensure
successful results and positive experiences. Ambulatory surgery outcomes rely
heavily on thorough education of the patient and the patient’s caregivers. The
ambulatory surgery nurse uses critical thinking skills to assess patients and their
support systems and then creates a plan to optimize patient safety, comfort, and
education. The patient populations discussed in this chapter benefit from the
ambulatory surgery setting because it allows for a quick return to a familiar
environment.
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EXAM QUESTIONS
CHAPTER 11
Questions 66–72
66. Which pediatric age group is most at risk for separation anxiety?
a. 4 years old and under
b. 4 to 7 years old
c. Adolescent
d. School-aged
67. All of the following are appropriate nursing interventions for pediatric patients
except
a. arranging a tour of the surgery facility for the parents and child before the
day of surgery.
b. ordering and administering oral midazolam.
c. ensuring availability of appropriately sized medical equipment, such as
blood pressure cuffs.
d. providing detailed written and verbal instructions to the child’s parents.
68. A 2-year-old patient has just arrived in the postanesthesia care unit. The nurse
notes the patient occasionally grimaces and is restless and squirming in the
stretcher; the patient is awake, not crying, and calms down as the nurse talks
while patting the patient’s back. Using the Face, Legs, Activity, Cry,
Consolability (FLACC) Assessment Tool, what score is assigned to this patient?
a. 10
b. 2
c. 0
d. 4
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69. The geriatric patient population benefits from ambulatory surgery because of
all of the following advantages except
a. around-the-clock monitoring.
b. familiar surroundings that decrease disorientation.
c. increased activity that leads to less risk for respiratory complications.
d. decreased risk for infection.
70. Which of the following plans will help optimize outcomes for geriatric patients?
a. A tour of the surgery facility before the day of surgery
b. Providing the services of a professional medical sign language interpreter
c. A multimodal analgesic plan that involves small doses of opioids, local
anesthesia, and a nonsteroidal anti-inflammatory
d. Increased dosages of hypnotics, benzodiazepines, and opioids
71. During a communication assessment, the patient states she speaks Spanish
to her family but is also able to speak some English. What does the nurse do
next?
a. Arrange for a professional medical interpreter.
b. Ask the patient which language she prefers to use during the
preadmission interview and during the ambulatory surgery visit.
c. Cancel the case because no one on the ambulatory surgery team speaks
Spanish.
d. Ask the patient to bring a friend or family member to translate on the day
of surgery.
72. During the preadmission interview, the patient states his legs are sometimes
weak due to an old injury, and he uses a wheelchair. The nurse wants to assure
the patient is safe and comfortable, especially while transferring the patient from
chair to stretcher and back again. How can the nurse learn more about keeping
the patient safe and comfortable?
a. Ask the patient what his needs are, and develop a customized plan
together.
b. Copy a general care plan for paralyzed patients, and enter it into the
medical record.
c. Ask the patient to have his significant other contact you with details.
d. Cancel the case because this patient will require inpatient care.
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CHAPTER 12
REGULATORY AGENCIES AND

PROFESSIONAL ASSOCIATIONS AND
ORGANIZATIONS
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to identify and describe
the purpose of ambulatory surgery regulatory agencies and professional
specialty organizations.
CHAPTER OBJECTIVES
A
1. Explain the role of the Centers for Medicare and Medicaid Services (CMS)
in patient care at ambulatory surgery facilities.
2. Summarize CMS’s ambulatory surgery quality measures.
3. List professional associations and organizations that are relevant to
ambulatory surgery facilities and describe how they support patient care.
4. Describe the reason for on-site accreditation surveys and explain the
ambulatory surgery nurse’s role in the survey process.
INTRODUCTION
V
arious regulatory agencies help define quality standards and assure they
are met in providing care to patients in ambulatory surgery facilities. Some
agencies are state sponsored and others work on a federal level. These
agencies are responsible for enforcing standards that ensure safe care of the
patient. There are many regulatory agencies, and not all are mandatory. Below we
will discuss some of the most common agencies. There are also various
professional associations that assist healthcare providers by organizing and
publishing evidence-based practice guidelines and sharing information with the
ambulatory surgery community. Professional associations provide qualified opinions
to regulatory agencies as they develop standards of care.
CENTERS FOR MEDICARE AND MEDICAID SERVICES
T
he Centers for Medicare and Medicaid Services (CMS) is a federal agency
that is part of the Department of Health and Human Services. CMS is
involved in all healthcare transactions as either the largest payer, the
principal regulator, or both. Since its creation, CMS has not only advocated for
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patients but also invented payment methods, often setting the trend for private
insurance companies. In its newest role, CMS is governing quality indicators
among community healthcare systems, including ambulatory surgical facilities.
CMS authored quality indicators for healthcare facilities and linked them to
payments by rewarding high achievers and penalizing those who did not meet
targets. Since the inception of this program in 2007, medication errors, hospital-
acquired infections, and patient falls have measurably declined as healthcare
facilities work to improve processes and systems (Kelly, 2015). Quality standards
have risen and bad outcomes have been reduced throughout an industry that was
formerly engaged in plausible deniability when patient harm occurred (Kelly, 2015).
To learn more about CMS, visit http://www.cms.gov.
In 2012, CMS finalized its ambulatory surgery center (ASC) payment rule, which
required ASCs to report data on five quality measures beginning October 1, 2012,
or endure reductions in their 2014 Medicare payments. CMS, after a period of open
public comments, then added more quality measures in 2014 and 2015, which will
affect payments in 2016 and 2017. As of 2016, 12 ASC quality measures have
been finalized, and ASCs are required to report these to CMS or face payment
penalties. Reporting measures are selected based on priorities for improved
healthcare outcomes, quality, safety, efficiency, and satisfaction of patients (Brusco,
2012a). Similar standards and guidelines are applied to hospital outpatient
departments. Table 12-1 shows the 12 ASC quality measures required by CMS.
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Future quality measures being considered for inclusion in the program include
normothermia tracking, defined as the percentage of eligible ASC patients who are
normothermic within 15 minutes of arrival into the postanesthesia care unit (PACU),
and unplanned anterior vitrectomy, defined as the percentage of ASC cataract
surgery patients who experience an unplanned anterior vitrectomy in the ASC.
There has been some controversy surrounding the CMS quality measure
program because several professional associations have found that some
measures either do not reflect the quality of care in the ASC or are not within the
ASC’s control. For example, measures ASC-9 and ASC-10 were heavily lobbied
against because the physician, not the ambulatory surgery facility staff, advises the
patient when a colonoscopy is needed. ASC-11 was changed to a voluntary
measure just before final implementation because of the information presented to
CMS by ophthalmology and ambulatory surgery associations outlining flaws in the
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measurement requirements and pointing to exorbitant resource needs to gather the

data. To learn more about CMS quality measures, visit https://www.qualitynet.org.
CMS develops conditions of participation (CoPs) and conditions for coverage
(CfCs) that healthcare organizations must follow to begin and to continue
participating in the Medicare and Medicaid programs. These health and safety
standards set the foundation for improving quality and protecting the health and
safety of patients. CMS also ensures that the standards of accrediting
organizations recognized by CMS, such as The Joint Commission (through a
process called deeming), meet or exceed the Medicare standards set forth in the
CoPs and CfCs. ASCs that participate in the Medicare and Medicaid program must
meet or exceed the standards found in the CfCs. Hospital outpatient departments
must meet or exceed similar standards outlined in the CoPs.
Certification of ASC compliance with the regulatory standards is accomplished
through observations, interviews, document review, and medical record reviews.
The survey process focuses on an ASC’s delivery of patient care, including its
organizational functions and processes for the provision of care (Centers for
Medicare and Medicaid Services, 2015, April 15). An on-site survey of the ASC is
one method used to assess compliance with federal health, safety, and quality
standards that will assure that patients receive safe, quality care and services
(Centers for Medicare and Medicaid Services, 2015, April 15). To learn more about
CoPs and CfCs, visit https://www.cms.gov.
THE JOINT COMMISSION
T
he Joint Commission (TJC) is an independent, not-for-profit organization
that accredits and certifies 21,000 healthcare organizations, including
hospitals, ASCs, and office-based surgery suites (The Joint Commission,
n.d.a). TJC, approved by CMS to assess standards compliance at healthcare
facilities across the nation, is the oldest and largest standards-setting and
accrediting body in the healthcare industry. In order for a healthcare organization to
be accredited by TJC, it must prove continuous compliance with accepted
standards in operational systems critical to the safety and quality of patient care
(The Joint Commission, n.d.a).
At a minimum, TJC upholds CMS standards, but it also provides education,
performance improvement strategies, enhanced risk management efforts, and
quality resources and tools that help ambulatory surgery facilities continuously
improve performance and outcomes. Along with required standards, each year TJC
publishes National Patient Safety Goals (NPSG) for various healthcare settings.
The 2016 National Patient Safety Goals for the ambulatory care setting are listed in
Table 12-2.
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To learn more about The Joint Commission and National Patient Safety Goals,
visit https://www.jointcommission.org. It is important to note that these goals
change every year based on the trends and deficiencies that TJC sees throughout
the country and should be reviewed on an annual basis for changes.
ACCREDITATION ASSOCIATION FOR AMBULATORY

HEALTH CARE, INC.
T
he Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) was
founded in 1979 to “encourage and assist ambulatory health care
organizations to provide the highest achievable level of care for recipients in
the most efficient and economically sound manner. The AAAHC accomplishes this
by the operation of a peer-based assessment, consultation, education and
accreditation program.” (Accreditation Association for Ambulatory Health Care, Inc.,
n.d.). AAAHC differs from TJC in that their standards and services are focused
solely on ambulatory health care and do not accredit inpatient healthcare facilities.
Like TJC, AAAHC is approved by CMS to assess compliance with standards via
on-site surveys and continuous monitoring. AAAHC promotes patient safety, quality
care, and value for ambulatory health care through their accreditation process,
educational services, and research. AAAHC accredits close to 6,000 organizations
in a wide variety of ambulatory healthcare settings (Accreditation Association for
Ambulatory Health Care, Inc., n.d.). To learn more about AAAHC, visit
http://www.aaahc.org.
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AGENCY FOR HEALTHCARE RESEARCH AND

QUALITY
T
he Agency for Healthcare Research and Quality (AHRQ) is a federal agency
focused on improving the safety and quality of America’s healthcare system.
AHRQ uses evidence-based research and data to develop tools and
processes needed to improve the healthcare system. AHRQ strives to assist
patients, healthcare professionals, and policymakers in making informed healthcare
decisions. AHRQ works with the Department of Health and Human Services (HHS)
agencies, such as CMS, and other partners to make sure that the evidence is
understood and applied to achieve the goals of better care, smarter spending of
healthcare dollars, and healthier people (U.S. Department of Health and Human
Services, Agency for Healthcare Research and Quality, n.d.).
The 1999 Institute of Medicine (IOM; as of March 2016, the IOM is now the
Health and Medicine Division of the National Academies of Sciences, Engineering,
Medicine) report, To Err Is Human: Building a Safer Health System, detailed serious
patient safety problems in the U.S. healthcare system. AHRQ has responded to
those issues by working to improve the safety of the health care given to patients.
AHRQ has assisted the U.S. healthcare system in preventing 1.3 million errors,
saving 50,000 lives, and avoiding $12 billion in wasteful spending from 2010 to
2013 (U.S. Department of Health and Human Services, Agency for Healthcare
Research and Quality, n.d.).
AHRQ’s Safety Program for Ambulatory Surgery is a 4-year project projected to
be completed by the end of 2016. The project was created to improve the safety
culture, patient experience of care, and provider and staff satisfaction in ambulatory
surgery facilities (U.S. Department of Health and Human Services, Agency for
Healthcare Research and Quality, n.d.); further, the AHRQ (n.d.) states that the
educational collaborative model and multiple-participant project will implement a
surgical safety checklist-centered quality improvement intervention to reduce
surgical site infections (SSIs) and other major complications related to ambulatory
surgery while improving teamwork and communication. To learn more about AHRQ,
visit http://www.ahrq.gov.
CENTERS FOR DISEASE CONTROL AND

PREVENTION
T
he Centers for Disease Control and Prevention (CDC) is tasked with
protecting the American people from threats to health, safety, and security,
both foreign and domestic (Centers for Disease Control and Prevention,
2014). The CDC strives to increase the health security of our nation. As the nation’s
health protection agency, the CDC saves lives and protects people from health
threats. For the ambulatory surgery setting, the CDC provides valuable information
regarding best practices around surgical site infection prevention, safe injection
practices, medication safety, and overall patient and healthcare provider safety.
CMS requires that ambulatory surgery facilities implement CDC guidelines into
practice to meet or exceed standards of care. To learn more about the CDC, visit
http://www.cdc.gov.
WORLD HEALTH ORGANIZATION
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he World Health Organization’s (WHO) primary role is to direct and coordinate

international health within the United Nations’ system. The main areas of
T
focus include health systems, promoting health throughout one’s lifespan,
noncommunicable diseases, infectious diseases, corporate services, and
preparedness for, surveillance of, and response to disease or threat of
disease (World Health Organization, n.d.a). Like the CDC, WHO works to develop
guidelines based on evidence gathered through research. CMS requires healthcare
facilities to follow WHO guidelines to ensure the facilities meet or exceed standards
of care. WHO launched its Surgical Safety Checklist and Implementation Manual in
2007, and since 2014, CMS has required ASCs to annually report the use of a
surgical safety checklist. WHO also offers guidelines regarding surgical site
infection prevention and hand hygiene. To learn more about WHO, visit
http://www.WHO.int.
AMBULATORY SURGERY CENTER ASSOCIATION
T
he Ambulatory Surgery Center Association (ASCA) is the national
association that represents ASCs. ASCA’s focus is on providing advocacy
and resources to assist ASCs in delivering high-quality, cost-effective
ambulatory surgery to patients (Ambulatory Surgery Center Association, n.d.b).
ASCA is supported by ASCs nationally and develops relationships with legislative
and regulatory bodies in an effort to improve access to high-quality care while
reducing costs associated with health care. ASCA also offers educational resources
to ASC staff and to the public.
In 2015, U.S. Representatives Devin Nunes (R-CA) and John Larson (D-CT) in
the House and Senator Mike Crapo (R-ID) in the Senate introduced ASCA’s
Ambulatory Surgical Center Quality and Access Act of 2015 (H.R. 1453) to ensure
that the Medicare program and its beneficiaries continue to enjoy the high level of
care and cost savings that the more than 5,300 ASCs across the nation provide
(Ambulatory Surgery Center Association, n.d.b). The bill covers the following:
The Ambulatory Surgical Center Quality and Access Act of 2015 would move
the ASC reimbursement update from the Consumer Price Index for All Urban
Consumers (CPI-U) to the hospital market basket update, which better
measures the cost of practicing medicine.
This legislation would also require CMS to post similar quality metrics of
ASCs and hospital outpatient departments (HOPDs) online in a side-by-side
comparison. The publicly available data would include quality measures and
copay amounts for both sites of service in the same geographic area.
Currently, ASCs do not have a voice on the Centers for Medicare and
Medicaid Services’ Advisory Panel on Hospital Outpatient Payment, which
controls various aspects of physician payment rates. This legislation would
add an ASC industry leader to that panel.
The bill would also add transparency to the healthcare industry by requiring
the Centers for Medicare and Medicaid Services to disclose which criteria
they use to deny certain procedures from being performed in an ASC and by
requiring them to make publically available the results of quality reporting
measures that apply to both ASCs and HOPDs.
To learn more about ASCA, visit http://www.ascassociation.org.
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AMERICAN HOSPITAL ASSOCIATION
T
he American Hospital Association (AHA) is the national organization that
represents and serves hospitals, healthcare networks, and their patients.
AHA membership includes almost 5,000 hospitals and healthcare systems,
along with 43,000 individual members. Similar to ASCA, the AHA is focused on
legislative and regulatory relationships, as well as national health policy
development. The AHA’s mission is to advance the health of individuals and
communities (American Hospital Association, n.d.). The AHA is committed to
supporting hospitals as they strive to deliver the right care at the right time in the
right setting (American Hospital Association, n.d.). To learn more about the AHA,
visit http://www.AHA.org.
In August of 2014, TJC and the AHA published Reducing the Risks of Wrong-
Site Surgery: Safety Practices from The Joint Commission Center for Transforming
Healthcare Project. With the participation of eight U.S. hospitals and ASCs, this
project measured the risks of wrong-site surgery in the perioperative process,
pinpointed the specific factors that caused those risks, and developed specific
solutions to reduce them. To read this report, visit AHA’s Hospitals in Pursuit of
Excellence (HPOE) site at http://www.hpoe.org/resources/hpoehretaha-
guides/1668.
ASSOCIATION OF PERIOPERATIVE REGISTERED

NURSES
T
he Association of periOperative Registered Nurses (AORN) is a not-for-
profit professional membership association that represents perioperative
nurses in various practice settings by providing nursing education,
standards of care, and clinical practice resources (Association of periOperative
Registered Nurses, n.d.). AORN supports optimal outcomes for patients
undergoing operative and other invasive procedures through peer-reviewed
research that is published monthly in the AORN Journal. AORN has 41,000
registered nurse members who manage, teach, and practice perioperative nursing,
are enrolled in nursing education, or are engaged in perioperative research
(Association of periOperative Registered Nurses, n.d.).
In January of 2013, AORN started their ambulatory surgery division in an effort
to support perioperative nurses working in the ambulatory surgery environment.
AORN recognizes the need for highly skilled ambulatory surgery nurses who are
able to implement a broad range of nursing interventions while facing challenges
unique to their practice setting. The ambulatory surgery division of AORN focuses
on regulatory requirements, accreditation standards, risk management, and
infection prevention training (Association of periOperative Registered Nurses, n.d.).
To learn more about AORN, visit http://www.AORN.org.
AMERICAN SOCIETY OF PERIANESTHESIA NURSES
T
he American Society of PeriAnesthesia Nurses (ASPAN) is a not-for-profit
professional membership association that advocates for the interests of
nurses who practice in preanesthesia and postanesthesia care, ambulatory
surgery, and pain management. ASPAN has over 15,000 members and is the only
professional organization dedicated exclusively to nurses who practice in the
perianesthesia setting (American Society of PeriAnesthesia Nurses, n.d.). ASPAN
and its associated Journal of Perianesthesia Nursing provide members with the
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latest in perianesthesia education, research, clinical practice expertise, standards,

and advocacy (American Society of PeriAnesthesia Nurses, n.d.). ASPAN works
closely with AORN to monitor legislation at the federal and state levels to represent
the interests of the ambulatory surgery nursing community. To learn more about
ASPAN, visit http://www.ASPAN.org.
AMERICAN SOCIETY OF ANESTHESIOLOGISTS
T
he American Society of Anesthesiologists (ASA) is an association of
physicians focused on maintaining and raising the standards of the medical
practice of anesthesiology through education, research, and science
(American Society of Anesthesiologists, n.d.). ASA endorses and supports
ambulatory anesthesia and surgery. ASA encourages anesthesiologists to
participate in a leadership role in the hospital, ambulatory surgical facility, and
office-based settings, and to engage in facility accreditation as a means of
improving the quality of patient care (American Society of Anesthesiologists, n.d.).
Ambulatory anesthesia is the most widely practiced subspecialty of anesthesia in
the nation, yet there is a perception that anesthetic administration in ambulatory
centers is the same as inpatient care (Cutter, 2014). The members of ASA, AORN,
and ASPAN know that certain methods result in better outcomes and are a product
of specialized knowledge and techniques. To learn more about ASA, visit
http://www.ASAHQ.org.
NATIONAL PATIENT SAFETY FOUNDATION
T
he National Patient Safety Foundation (NPSF) was established in 1997 and
is focused on creating a world in which patients and those who care for
them are free from harm (National Patient Safety Foundation, 2016). NPSF
partners with patients and families, the healthcare community, and key
stakeholders to advance patient safety and healthcare workforce safety by
preventing harm through proven strategies. NPSF offers an extensive list of
educational resources, including publications, conferences, and webinars. To learn
more about NPSF, visit http://www.NPSF.org.
THE SURVEY PROCESS
T
he goal of an accreditation survey is to protect patients and personnel by
monitoring the ambulatory surgery facility’s compliance with standards of
care, regulations, and best practices. Accreditation directly affects the
facility’s eligibility to be reimbursed by third-party payers. Trained surveyors arrive
unannounced and are on-site for several days every 2 or 3 years, depending on
which accreditation organization an ambulatory surgery facility chooses to partner
with. In some cases, an accreditation survey may occur more often if serious
findings occurred in the past, if there were changes in ownership or complaints
from the public, or for auditing and validating purposes. The ambulatory surgery
facility team should practice in such a way that all standards are met or exceeded
and the organization’s policies are followed at all times.
Upon arrival, the ambulatory surgery nurse can expect the surveyors to conduct
an informative and concise entrance conference, at which time the purpose and
scope of the survey will be explained. Most likely, the facility’s administrator and
clinical manager will assist the surveyors throughout their visit. Among other items,
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the surveyors will request medical records, operating room schedules, meeting
minutes and supporting documentation, and policies and procedures. This
documentation helps the surveyors understand how the facility operates on a day-
to-day basis.
During the survey, the ambulatory surgery team works together as usual. The
surveyors will observe for policy and standards compliance. The ambulatory
surgery nurse may be approached by the surveyors and asked questions about
nursing practice. While responding to surveyor inquiries, it is important for the nurse
to be open and honest about the care given to patients in the facility. The nurse
knows patient care is a priority over surveyor needs, therefore, if necessary, the
nurse may politely explain to the surveyor that all questions will be answered after
essential patient care is complete. Depending on patient needs and staffing ratios,
the nurse may briefly transfer patient care to a colleague during an interview. The
surveyors will observe patient care throughout their visit and will make notes and
ask questions. The surveyors are observing for trends seen throughout their visit.
For example, if the surveyor notes that one clinician did not wash his or her hands
after removing gloves but all other clinicians practiced proper hand hygiene, the
surveyor can be reasonably assured the clinicians in the ambulatory surgery facility
practice proper hand hygiene. The surveyor may use this opportunity to educate
the staff, rather than documenting complete noncompliance with policy and
standards.
It is normal to feel anxious and intimidated during an on-site survey, but the
ambulatory surgery nurse knows the process is in place to assure safe patient care.
Surveyors from accrediting agencies such as TJC and the AAAHC are carefully
trained to provide education and consultative support to healthcare providers and
administrators. Federal surveyors from CMS and state agencies are
representatives of the regulatory agency and can provide nonconsultative
information upon request but are not permitted to provide consultative services. If
the surveyors identify any consistent lapses in standards, they will provide a written
report detailing those findings. The facility will have a preidentified amount of time
to correct the deviations.
The ambulatory surgery facility’s leadership team plays a key role in maintaining
the facility’s readiness for on-site surveys. Researching, writing, and implementing
facility-wide policies and procedures are based on the evolving standards of care
supported by several governmental and professional organizations. For this reason,
one of the most important management skills an ambulatory surgery leader has is
the ability to lead organizational change (Taylor, 2014).
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SUMMARY
P
rofessional associations focus on gathering evidenced-based research to
help create standards of care in ambulatory surgery and all types of
healthcare settings. Regulatory agencies consider guidelines created by
professional associations and other not-for-profit organizations when developing
final standards of care. These standards of care are monitored by regulatory
agencies and their associated accrediting agencies such as TJC and AAAHC. The
ambulatory surgery nurse can assist the leadership team by being continuously
prepared for on-site surveys. This is accomplished by participating in educational
opportunities offered by the ambulatory surgery leadership team and by taking
advantage of the external resources this chapter offers. Patient safety is a shared
goal among healthcare providers, professional associations, government
organizations, and regulatory agencies.
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EXAM QUESTIONS
CHAPTER 12
Questions 73–79
73. The Centers for Medicare and Medicaid Services is involved in health care in
all of the following ways except that
a. it is the largest payer.
b. it is the principal regulator.
c. it acts as a patient advocate.
d. it operates medical schools.
74. The Centers for Medicare and Medicaid Services Ambulatory Surgical Center
Quality Measures are based on
a. reimbursement data collected via insurance claims.
b. priorities for improved healthcare outcomes, quality, safety, efficiency, and
satisfaction of patients.
c. hospital outcomes and peer review data.
d. increasing healthcare costs and the creation of accountable care
organizations.
75. Which of the following is a Centers for Medicare and Medicaid Services
Ambulatory Surgical Center Quality Measure in 2016?
a. A Patient fall
b. A catheter-associated urinary tract infection
c. A central-line associated bloodstream infection
d. The Hospital Consumer Assessment of Healthcare Providers and
Systems
76. What is one way The Joint Commission is different from the Accreditation
Association for Ambulatory Health Care, Inc. (AAAHC)?
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a. AAAHC is approved by the Centers for Medicare and Medicaid Services

to assess compliance with standards.
b. AAAHC promotes patient safety and quality care.
c. AAAHC standards and services are solely focused on ambulatory health
care.
d. AAAHC does not conduct on-site surveys.
77. All of the following areas are a focus of The Joint Commission’s National
Patient Safety Goals except
a. patient identification.
b. patient falls.
c. infection prevention.
d. medication safety.
78. Which two organizations focus mainly on preventing the spread of disease?
a. The National Patient Safety Foundation and The Joint Commission
b. The Centers for Disease Control and Prevention and Accreditation
Association for Ambulatory Health Care
c. The Centers for Medicare and Medicaid Services and The Joint
Commission
d. The Centers for Disease Control and Prevention and the World Health
Organization
79. During an accreditation survey at an ambulatory surgery facility, a surveyor

approaches a nurse and asks a question about patient care. How should the
nurse respond?
a. The nurse should be open and honest about the care provided to patients
at the ambulatory surgery facility.
b. The nurse should inform the surveyor that he or she is not allowed to
discuss the topic and exit the conversation.
c. The nurse should refer the surveyor to the clinical manager and disclose
nothing.
d. The nurse should ask the surveyor to sign a confidentiality agreement
before answering any questions.
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CHAPTER 13
PATIENT SAFETY, RISK

MANAGEMENT, QUALITY
ASSESSMENT, AND PERFORMANCE
IMPROVEMENT
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain how patient
safety, risk management, quality assessment, and performance
improvement are integral parts of perioperative practice.
CHAPTER OBJECTIVES
A
1. Summarize required elements for safe patient care in the ambulatory

surgery environment.
2. Identify outcomes to be expected from a risk management program.
3. List tools used to assess quality, lead performance improvement, and explain
how to implement strategies.
4. Identify the nurse’s role in patient safety, risk management, quality
assessment, and performance improvement.
INTRODUCTION
H
ealthcare providers and the public are familiar with the Institute of
Medicine’s 1999 report, To Err is Human: Building a Safer Health System.
It was in this report that the Institute of Medicine claimed medical errors
caused 44,000 to 98,000 preventable deaths every year (Kohn, Corrigan, &
Donaldson, 2000). The figure was staggering, and it was front-page news.
Newspaper headlines and nightly news programs repeated the explosive statistics
for weeks, months, and years. Almost overnight, public and professional awareness
of the patient safety movement spread across the country to millions of people.
How do we prevent medical errors? Why do medical errors continue to go
unreported? How much of a challenge is patient safety? How does the U.S. health
system improve patient safety today and in the future? Obtaining a valid estimate of
medical errors is difficult. Calculating the occurrence rate of medical errors depends
on how the information is gathered and who determines whether a preventable
error has occurred (Leape, 2008). Traditionally, healthcare providers have been
punished for making errors. The stigma and actual or perceived punishment for
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being involved in an error thus affect whether events are reported at all. Some
errors go unnoticed by the provider and the patient, especially if there is no injury.
The National Academy of Sciences’ Institute of Medicine defines safety as
“freedom from accidental injury,” not freedom from errors (Leape, 2008). Leape
(2008) points out that our safest industry, commercial aviation, has numerous errors
but few crashes. For this reason, some health policy researchers prefer to focus not
on errors but on preventable injuries. Focusing on risk management, quality
assessment, and performance improvement will make the healthcare system better
and safer every day.
PATIENT SAFETY
I
ncreasing patient safety in ambulatory surgery requires a focus on developing a
systematic national data collection process for reporting sentinel or “never”
events, increasing communication and standardization in the operating room to
improve situational awareness, and implementing more effective systems to help
minimize elements of human fallibility (Berger, Greenberg, & Bilimoria, 2015). The
Joint Commission has found that inadequate communication was a recurring theme
across root cause analyses of sentinel events. Communication and teamwork are
essential during surgical and other invasive procedures. The ambulatory surgery
care episode involves processing multiple sources of information in a short time;
therefore, standardized and synchronized actions and communications are required
for success. An example of this is the Minnesota time-out process presented in
Chapter 7. Nurses are central to the work of ambulatory surgery facilities and are
central to promoting a culture of safety. A culture of safety is an all-inclusive
understanding of the values, benefits, and norms essential to an organization in
addition to what attitudes and behaviors related to promoting patient safety are
appropriate and expected (Wagner, 2014). However, the ambulatory surgery
environment is composed of individuals with varying backgrounds, experience
levels, and disciplines working under time constraints and, sometimes, a high level
of uncertainty. Systems engineering is entering the world of surgery and is
introducing methods to accurately measure problems, effective communication
solutions, and standardization of processes. These efforts will help prevent
variations in care, leading to the best possible outcome for every patient during
every care episode.
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Safety Drills
The ambulatory surgery nurse will participate in various drills, the purpose of
which is to ensure readiness by demonstrating and reinforcing a standardized
response to emergencies. Perhaps the most familiar drill is for a code blue, often
defined as any situation requiring immediate intervention in order to prevent serious
consequences to the patient (Lanfranchi, 2013). In many ambulatory surgery
facilities, especially freestanding ambulatory surgery centers and office-based
surgery suites, a code blue is handled by the surgery team, not by a specialized on-
site team of responders, and emergency medical services are called to the scene
for transport to the hospital. During code blue drills, nurses should consider special
factors, such as the patient not being in a supine position, the locations of incisions,
and organization of the team, to allow for easy entry of the paramedics. An actual
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code blue during ambulatory surgery is a very low-volume, high-risk event;

therefore, drills for these situations are usually conducted quarterly under the
guidance of an anesthesiologist and expert nurse. The ambulatory surgery team
reviews the facility’s code blue policy, practices using the defibrillator, acts out
simulated code blue scenarios, and discusses ways to mitigate any problem areas
noted during the simulation. A scenario that teams routinely focus on during code
blue drills in ambulatory surgery is malignant hyperthermia (MH). This emergency
requires a standardized and well-rehearsed response.
Common emergency drills that may be conducted in the ambulatory surgery
setting are listed in Table 13-1. Drill requirements and color coding may vary among
organizations. The ambulatory surgery nurse becomes familiar with the facility’s
planned emergency response systems by reviewing policies, procedures, and
emergency management plans and by participating in drills. The Joint Commission
and Centers for Medicare and Medicaid Services require the organization to
manage safety and security risks (The Joint Commission, 2015).
Safety Huddles
Safety huddles are a tool used to increase patient safety awareness. Huddles
are an easy and practical way to communicate safety issues to those delivering
hands-on patient care. In the spirit of learning and improving, everything from close
calls to minor annoyances to potentially catastrophic events should be discussed at
safety huddles (Institute for Healthcare Improvement, 2004). Participants should be
encouraged to speak up about safety concerns. Evidence shows that safety
huddles make a difference. The American College of Surgeons’ National Surgical
Quality Improvement Program found the rate of surgical site infections declined
after safety huddles were implemented (Institute for Healthcare Improvement,
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2004). All healthcare disciplines can participate in safety huddles, and the forum
should be constructed in a way that levels the playing fields. Until a novice nurse
can correct an experienced surgeon and that conversation goes smoothly without
covert or overt retaliation, patients will continue to be harmed.
It is important for senior leadership to support patient safety initiatives, but it is
clinical managers who can have the greatest impact. Clinical managers act as the
bridge between senior leaders and the front lines of patient care. Clinical managers
are in the perfect position to engage clinicians in patient safety efforts. Clinical
managers should lead by example by noticeably prioritizing safety over productivity.
Patient safety improvement goals should be established at the same level as
strategic organizational goals (Federico & Bonacum, 2010). Clinical managers are
charged with fostering an environment that supports open communication and is
characterized by a culture of teamwork (Federico & Bonacum, 2010). If clinical
managers understand systems engineering, they will be able to recognize why
defects exist and what processes should be modified to eliminate them (Federico &
Bonacum, 2010).
Safety Debriefing
Safety debriefing refers to the practice of re-examining situations with the goal
of reflecting on processes used to help develop appropriate competencies for future
similar situations (Arora et al., 2012). Debriefing allows participants to discuss their
performance and perspectives with other participants and leaders to identify gaps
and strategies for improvement, as well as reflect on what went right. Educationally
effective debriefing coupled with robust tools for event assessment allows the
surgical community to identify, aspire to, measure, and share best practices (Arora
et al., 2012). Hot debriefing occurs immediately after an event and focuses on team
members’ reactions to events; cold debriefing occurs after objective performance
data have been collected and studied. Debriefings are associated with an
improvement in performance (Couper & Perkins, 2013).
A Just Culture
In a just culture, the organization is open to learning from mistakes, creates a

fair and open communication environment, designs safe systems processes, and
balances behavioral choices resulting in unexpected outcomes by recognizing them
as human error, at-risk behavior, or reckless behavior. Open conversations about
medical errors leads to future improved outcomes through contemplative analysis.
For this reason, ambulatory surgery team members must be assured that the
organization is committed to learning through support of a fair and open culture. If
fear of punitive action remains prevalent in the organization, then team members
will not share errors, questionable process work-arounds, or concerns. Access to
decision makers is crucial to encouraging team members to share actual patient
events and to offering rational solutions for prevention. From this accessibility, key
stakeholders will be able to identify potential errors and redesign relevant system
solutions when errors actually happen. Finally, it must be clear that a just culture is
not a punitive culture, but it is also not a blame-free culture. Human error may be a
slip in judgment that leads to an outcome that was not intended by the individual
(Shabel & Dennis, 2012). Faulty systems often set up healthcare providers to fail,
and much can be learned by these events. Further down the continuum are at-risk
behaviors that occur when individuals make decisions that they believe contain little
to no risk but are subtle drifts from policy. These work-arounds can be the most
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difficult to manage because the system process may push team members toward
shortcuts that undermine known safeguards. The ambulatory surgery leader
analyzes these safeguards for effectiveness when in use. For example, a
preoperative nurse might choose to skip checking a high-risk drug with another
nurse due to perceived or actual time constraints. The ambulatory surgery leader
must ask what can be done to foster a culture of safety rather than a culture of
speed. Finally, reckless behavior occurs when an individual consciously
acknowledges the risk of his or her behavior but performs the action anyway
(Shabel & Dennis, 2012). This deliberate behavior is best managed with
disciplinary action.
RISK MANAGEMENT
S
ince the release of To Err is Human: Building a Safer Health System, public
and private efforts to collect more and better data on preventable medical
errors have increased. The current challenge faced by the healthcare
community is ensuring the integrity of the data and compiling it in such a way that it
can be used for systems improvement (Youngberg, 2011). A wide variety of patient
safety data collection methods exists in the ambulatory surgery environment,
including paper systems, hotlines, web-based models, and anonymous reporting.
The various tools make it difficult to aggregate, track, and trend near-miss events
and actual events (Youngberg, 2011). Without a standard process for tracking and
analyzing preventable medical errors, the healthcare community cannot identify its
vulnerabilities. Youngberg (2011) points out that medical errors can only be
corrected if they are fully reported, fully understood, and, most importantly, fully
acted upon.
Evidence shows that the best way to instill a culture of safety is by being open
and honest; therefore, the data collected by organizations about preventable
medical errors should be broadly shared (Youngberg, 2011). Through the sharing of
these data, organizations across the United States can successfully create
benchmarks. Creating benchmarks promotes learning throughout the healthcare
community and works to prevent an unsafe culture of blame and secrecy
(Youngberg, 2011). Internal benchmarks are established to create improvements
over time. External benchmarks are established to demonstrate that processes and
systems in an organization are best practices when compared with other similar
organizations (Youngberg, 2011). Establishing external benchmarks also identifies
areas that need to be improved and where learning opportunities exist.
An ambulatory surgery risk management plan focuses on minimizing the
adverse effects of loss (meaning all loss, including life, limb, emotional, financial,
etc.) through identification and assessment of actual and potential losses, loss
prevention, risk financing, and claims control. The purposes of a risk management
plan are to (1) reduce and, when possible, eliminate the risk of injury to patients,
visitors, and employees; (2) to protect the centers’ financial resources; and (3) to
contribute to quality health care. The risk management plan complies with
regulatory requirements by including investigation and analysis of sentinel events,
trending and analysis of all events, and appropriate measures to minimize identified
risk.
Event Reporting
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The purpose of the event report is to record occurrences in an effort to identify

trends and initiate process improvement or redesign. It is also utilized to tailor
ongoing healthcare provider educational programs. Reporting of such occurrences
is not used to place blame but to further efforts at error reduction. An event is
defined as that which is unusual or not consistent with the routine care of the
patient or operations of the facility. An event may involve patients, visitors,
physicians, employees, students, and volunteers, as well as equipment that
potentially or actually may have caused harm to anyone or a condition that did or
may present a safety hazard. A near miss is an error that happened but did not
reach the patient. It is the result of a mistake or process error, but since it is caught
before it reaches the patient, it may also be referred to as a good catch (Putnam,
2015). The context of a near miss can offer valuable learning opportunities for
healthcare providers when identified and evaluated.
Some people are reluctant to report near-miss events and actual events of
preventable medical errors for several reasons. They fear punishment from
regulatory actions, they do not believe it is worth the effort, or they simply feel they
do not have time. Ambulatory surgery organizations work to create a data collection
system that promotes transparency, learning, and improvement (Youngberg, 2011).
The goal of reporting near-miss and actual, preventable medical errors is to
analyze and mitigate safety problems. Furthermore, according to Youngberg
(2011), organizations should ensure that internal data is effectively shared with
external voluntary organizations such as The Joint Commission and the
Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). Youngberg
(2011) recommends streamlining reporting efforts to minimize the burden for
healthcare staff and minimize duplication of effort while maximizing the benefits.
Sentinel Events
Sentinel events, also called never events, are defined in ambulatory surgery as
serious, preventable surgical events that can impose a high physical and emotional
toll on patients, their families, and perioperative personnel (Berger, Greenberg, &
Bilimoria, 2015). Some events – such as wrong-patient, wrong-site, and wrong-
procedure events; retained surgical items; and fires in the operating room – may
cause irreversible damage.
The term sentinel, in this context, denotes the need for immediate attention and
investigation. Identification and reporting of a sentinel event may result in The Joint
Commission issuing a sentinel event alert to hospitals, ambulatory facilities, home
care agencies, nursing homes, and behavioral healthcare institutions as
appropriate, particularly if multiple, similar events are reported. A sentinel event
alert database, which is available online, supplies detailed information regarding
the underlying cause of each event. Examples of past sentinel event alert topics
include the safe use of health information technology, prevention of unintended
retained foreign objects in surgery, and medical device alarm safety. The full list
and alerts can be accessed at
https://www.jointcommission.org/sentinel_event.aspx. Facilities accredited by The
Joint Commission are expected to review alerts, assess their own processes
against the alert recommendations, and make appropriate changes to prevent
future similar occurrences. The Joint Commission sentinel event reporting process
is voluntary. Ambulatory care facilities must be aware of their state’s reporting
requirements, what is considered a sentinel event by state definition, and the steps
required for reporting and follow-up should an event occur.
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When a sentinel event occurs, root cause analysis guides the design of future
prevention efforts (Putnam, 2015). The aim of root cause analysis is to identify the
cause or causes of a problem in the process or structure of an organization and
determine prevention strategies (Chung & Kotsis, 2012). This technique is central
to a systems approach and avoids blaming individuals for errors. Root cause
analysis participants work to discover facts about what happened, why it happened,
and what should be done to prevent it from happening again. The keys to a
successful root cause analysis that results in measurable performance
improvement are changes in clinical processes and a high level of support from
management and front-line staff (Chung & Kotsis, 2012).
Root Cause Analysis
Techniques for analyzing systemic failures include root cause analysis (RCA)
and Failure Mode and Effects Criticality Analysis (FMECA). An RCA identifies the
factors that resulted in a near-miss or actual, preventable medical error by using a
structured approach to examine each step in the process (Youngberg, 2011). The
goal of the analysis is to identify what behaviors, actions, inactions, or conditions
need to be modified to prevent the event or a similar event from recurring
(Youngberg, 2011). During an RCA, participants may also identify processes that
worked, especially when analyzing a near-miss event. The RCA should focus on
the set of circumstances that led to failure rather than identifying the individuals
involved and blaming them for the event (Youngberg, 2011). An FMECA is a
proactive approach to identifying certain systems processes that could lead to
failure (Youngberg, 2011). The adage “an accident waiting to happen” comes to
mind. The FMECA should be performed before a new process is launched and
again immediately after the process is in use.
Grievance Processes and Corporate Responsibility
Patient-centered care requires collecting patient-reported information about

health care. This may be done through standardized patient experience surveys or
as a result of a formal grievance initiated by the patient. Patient complaints and
grievances often generate a focused, professional peer review and a root cause
analysis. Ambulatory surgery leaders must have well-defined processes that use a
systematic approach for responding to patient and family complaints and
grievances, which include timeframes for responding and guidelines for the scale of
response. The ambulatory surgery team must track and trend complaints and
grievances and robustly call attention to opportunities for improvement. Any
complaint shared with the ambulatory surgery nurse is handled directly by the
nurse whenever possible and reported to the clinical manager or administrator, who
also responds immediately as needed.
All ambulatory surgery team members must be expected to adhere to high
standards of competent and ethical behavior while diligently observing existing
regulations and statutes. Regulations and statutes are ever changing; thus, a
corporate compliance program becomes increasingly helpful in promoting
competency while minimizing the potential for purposeful or inadvertent practices
that place the provider and organization at risk. Education is the foundation of
proper corporate conduct.
Team Member Safety
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Studies released in 2011 found that nurses experience more musculoskeletal

disorders, are at greater risk for acquiring tuberculosis and blood-borne pathogen
infections, and have more occupational allergies than the general public (Letvak,
2014). Nurses who work with pain and/or depression are more likely to make
medication errors (Levtak, 2014). The American Nurses Association (ANA; n.d.)
defines a healthy nurse as one who “actively focuses on creating and maintaining a
balance and synergy of physical, intellectual, emotional, spiritual, personal, and
professional well-being. A healthy nurse lives life to the fullest capacity, across the
wellness/illness continuum, as they become stronger role models, advocates, and
educators, personally, for their families, their communities and work environments,
and ultimately for their patients” (Levtak, 2014). The implication in this definition is
that nurses must take an active role in ensuring their own health, despite the
physical and emotional demands of the profession. Wellness and fitness programs,
massage, cognitive therapy, and safety debriefings have been found to improve
health in nurses (Levtak, 2014). Perhaps one of the most taxing components of
ambulatory surgery nursing is the lifting associated with prepping and transferring
anesthetized patients. The ambulatory surgery nurse practices proper ergonomics
by using correct body alignment and asking for assistance when performing these
actions. Transfer boards and mats are used to avoid not only injuries to team
members but also patient injuries. Ambulatory surgery nurses are also exposed to
a patient’s body fluids during surgery. It is imperative that nurses wear proper
personal protective equipment (PPE), including eye protection, when they are in
danger of accidental exposure from the surgical field. Circulating nurses and
postanesthesia care nurses may be exposed to patients who are affected by
various anesthetic medications that cause disorientation or delirium. These patients
may unknowingly lash out at nurses. The nurse works to protect the patient from
injury by padding side rails and ensuring full range of motion without restriction (i.e.,
no limbs caught in the side rails) while preventing the patient from falling. The
priority of the nurse is to ensure no harm comes to the patient, but of equal priority
is to ensure the safety of the ambulatory surgery team. The nurse must not
sacrifice his or her own health.
QUALITY ASSESSMENT AND PERFORMANCE

IMPROVEMENT
T
he Centers for Medicare and Medicaid Services require the ambulatory
surgery organization to develop, implement, and maintain an ongoing, data-
driven quality assessment and performance improvement (QAPI) program
(Centers for Medicare and Medicaid Services, 2015). The organization takes a
proactive and comprehensive approach to improving the quality and safety of the
surgical services it delivers by implementing a systems approach to evaluations of
processes. Ambulatory surgery nurses can participate in this initiative by identifying
problems that have occurred or that potentially might occur because of system
processes. The ambulatory surgery team works to identify the root cause of
problems and avoids superficially addressing issues. The organization must have
an effective system in place for identifying problematic events, policies, or
practices; developing detailed actions to remedy them; and, finally, following up on
these actions to determine whether they were effective in the forecasted
improvement. The goal of the program is to demonstrate measurable improvement
in patient health outcomes and improve patient safety by using quality indicators or
performance measures associated with improved health outcomes and by the
identification and reduction of medical errors. Each team member of the ambulatory
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surgery organization has a direct role in quality assessment and performance

improvement processes. By recognizing that each job task has the ability to affect
the overall quality of the patient care provided, each team member comes to
understand that every action has the capability to improve or lessen the quality of
patient care. Quality assessment and performance improvement is not the role of a
supervisor but the role of each team member.
The following is the 10-step quality assessment and performance improvement
method developed by the AAAHC:
1. Identify the purpose of the activity.

2. Identify the performance goal, which the organization will compare against its
current performance in the area of study.
3. Identify what data will be collected.
4. Determine how the data will be collected: The data must describe the
frequency, severity, and source of the problem.
5. Analyze data and determine conclusions.
6. Compare initial performance versus performance goal.
7. Develop and implement corrective action and behavior change.

8. Remeasure.
9. Analyze new current performance versus past performance.
10. Communicate study findings throughout the organization.
(AAAHC, 2015)
FOCUS-PDSA
Figure 13-1 shows a process used when implementing quality assessment and
performance improvement.
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FOCUS-PDSA is a problem-solving method used to improve a process by

concentrating on how something is done, not who does it. Each letter in the
FOCUS-PDSA acronym represents a step accomplished by a team or individual
trying to figure out how to change the process to make it run more smoothly. Those
who do the same process day after day determine ways to change the process to
make it easier and faster by streamlining steps.
Listed below are brief descriptions of each step as represented by a letter:
Find an opportunity:
Quantify the need.
Narrow the scope.
Start opportunity statement (identify key customer, name process with
beginning and end).
Set indicators.
Organize to improve:
Is a team needed?
Select key players, suppliers, and customers.
Set ground rules.
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Establish timelines.
Clarify current process:
Map out current process.

Talk with customer.
Correct easy problems.
Understand variation:
Identify variation in the process.
How does your process vary from customer needs?

Develop problem statement: measurable, specific, and states the plan.
Select improvements:
Find root causes.
Quantify the improvement goal.
Find potential solutions.
PDSA: Plan your Actions, Do the Actions, Study the Results, Act on your
Conclusions.
Six Sigma and Lean Methodologies
Six Sigma and Lean are improvement methodologies that use a systematic and
reproducible approach to improving quality. The aim of Six Sigma is to improve
quality by identifying and correcting the causes of errors. Lean uses an ongoing
cycle of improvement to focus on determining process pathways that provide value
with each step and eliminate waste (Mason, Nicolay, & Darzi, 2015). Lean is
complementary to Six Sigma, and they are often combined to create a five-stage
system known as DMAIC (define, measure, analyze, improve, and control). Lean
and Six Sigma have been proven to demonstrate significant improvements when
utilized in the surgery environment, and these methodologies are flexible to the
department in which they are applied (Mason et al., 2015). At the core of Lean and
Six Sigma is the recognition that variation in systems and processes increases
costs and reduces the quality of care; hence, these methodologies reduce
variability while enhancing quality, improving timeliness, and reducing costs
(Southard, Chandra, & Kumar, 2012)
Leadership Rounding
Directors, managers, and administrators perform leadership rounding to

promote increased levels of teamwork and communication by developing a
cohesive team that is motivated to achieve shared goals. Leaders need to know
what is happening in the ambulatory surgery department in order to make informed
decisions about strategic initiatives. One of the best ways to gain insight into day-
to-day patient care activities is to observe directly and engage both patients and
team members in conversation (Winter & Tjiong, 2015). Routine leadership rounds
help build trust by demonstrating to team members and patients that the quality of
work being performed is a priority. Leaders may join the team in a safety huddle,
lead a safety debriefing, present a team member safety in-service, or simply join
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the team for lunch. The leader may engage patients and their families by asking
specific questions designed to determine their satisfaction with the care they are
receiving. These questions will allow leaders to identify problems and resolve
issues.
Patient Experience
The patient experience is about a new level of customer service that promotes
consumer loyalty. The goal is to move from patient satisfaction to patient loyalty by
exceeding expectations in the environment of care and in interactions with every
person. Patient loyalty means that patients are delighted with the care they receive
and will recommend the ambulatory surgery facility to others. The need for patient
loyalty comes from the shift to a consumer-driven market in all of health care. A
consumer-driven market requires a focus on building customer relations and means
that being a consumer’s first choice for care is the key to the success of the
ambulatory surgery facility.
The patient experience is defined as the sum of all interactions, shaped by an
organization’s culture, that influence patient perceptions across the continuum of
care (Billingsley, 2015). The focus of the patient experience movement is to
improve the experience of the patient and family throughout the healthcare
process. The Institute for Patient- and Family-Centered Care (IPFCC) identifies the
key concepts of patient experience as respect, dignity, information sharing,
participation, and collaboration (Institute for Patient- and Family-Centered Care,
n.d.).
The Consumer Assessment of Healthcare Providers and Systems’ Outpatient
and Ambulatory Surgery Survey (OAS CAHPS) will collect information about
patients’ experiences of care in hospital outpatient surgery departments (HOPDs)
and ambulatory surgery centers (ASCs; Centers for Medicare and Medicaid
Services, 2015). The Centers for Medicare and Medicaid Services implemented
this survey on a voluntary basis in January of 2016. Patients 18 years old and older
who are undergoing ambulatory surgeries or procedures are eligible for the survey.
The survey asks about patients’ experiences with their preparations for the surgery
or procedure, check-in and preoperative processes, cleanliness and privacy of the
surgery facility, the surgery facility staff, discharge from the facility, and preparation
for recovering at home. The survey also asks about patient-reported health
outcomes resulting from the surgery or procedure. It is anticipated the OAS CAHPS
survey will most likely be mandatory in 2018 and will affect HOPD and ASC service
reimbursements in 2020. This program is already mandatory for inpatient hospital
care.
SUMMARY
T
he first priority of risk management, quality assessment, and performance
improvement is a commitment to meet the patient’s needs and treat each
patient safely with concern, respect, and dignity. Each patient is entitled to
quality health care in an optimal setting and must receive safe, efficient, and
compassionate care that is cost-effective, appropriate, and timely. The ambulatory
surgery nurse is dedicated to the highest standards of quality care and professional
performance. Teamwork is essential and is best accomplished with an
interdisciplinary approach. Patient and family education is an integral part of care,
and the ambulatory surgery team is accountable to patients, their families, and
each other.
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A commitment to safety and quality begins with leadership and permeates the
ambulatory surgery environment. A progressive environment and adequate
resources are essential in the pursuit of excellence in patient care and safety, as
well as team member safety. Ambulatory surgery nurses are encouraged to be
involved in identifying opportunities for improvement, innovation, and solutions.
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EXAM QUESTIONS
CHAPTER 13
Questions 80–86
80. How can ambulatory surgery organizations increase patient safety?

a. Increase communication and standardization in the operating room.
b. Refrain from sharing information about sentinel events.
c. Ensure only members of leadership participate in safety initiatives.
d. Conduct root cause analyses that lead to placing blame on one person or
one group of people.
81. Ambulatory surgery organizations conduct routine drills for emergency

situations for all of the following reasons except
a. to ensure readiness for emergencies.
b. to practice standardized responses to emergencies.
c. to provide education to team members about emergencies.
d. to determine responses to high-volume, low-risk situations.
82. Safety debriefing is best described as

a. focused on minimizing the adverse effects of loss through identification
and assessment of risk financing.
b. a forum to communicate safety issues to those delivering hands-on
patient care.
c. the practice of re-examining situations with the goal of reflecting on
processes.
d. a serious, preventable, surgical event that can impose a high physical and
emotional toll on patients.
83. An ambulatory surgery risk management plan focuses on minimizing the

adverse effects of loss through all of the following except the
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a. identification of the patient’s insurance company

b. identification of potential losses.
c. assessment of loss prevention strategies.
d. assessment of claims control.
84. What is the purpose of an event report?

a. Identifying errors made and assigning blame
b. Identifying trends and initiating process improvement or redesign
c. Providing regulatory agencies with data about errors so they can pursue
reprimands
d. Ensuring the event is documented and never discussed
85. The ambulatory surgery nurse participates in a Plan-Do-Study-Act cycle. He or

she starts with the plan section, which includes
a. collecting data to identify the root cause.
b. evaluating the results and analyzing the solution.
c. clearly defining the problem and setting a measurable goal.
d. implementing changes and adjusting as needed.
86. All of the following information will be assessed in the Consumer Assessment
of Healthcare Providers and Systems’ Outpatient and Ambulatory Surgery
Survey (OAS CAHPS) except
a. preparation for surgery.
b. check-in and preoperative processes.
c. preparation for recovering at home.
d. identification and correction of the causes of errors.
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CHAPTER 14
ANCILLARY PROGRAMS, SPECIAL

PROCEDURES, AND SPECIAL
EQUIPMENT
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain ancillary
support services, special procedures, and the use of special equipment in
ambulatory surgery organizations.
CHAPTER OBJECTIVES
A
1. Summarize ancillary programs and explain their relevance to ambulatory

surgery organizations.
2. List special procedures that may be done in the ambulatory surgery setting
and summarize the role of the ambulatory surgery nurse during these
procedures.
3. Identify special equipment reserved for use in surgical and nonsurgical
procedures and explain nursing interventions to keep the patient and team
members safe.
INTRODUCTION
T
he ambulatory surgery nurse has the opportunity to work in various service
lines simultaneously, including orthopedics, general surgery, endoscopy,
ophthalmology, plastic surgery, urology, and many more. Within the practice
of ambulatory surgery nursing, there are various programs that enhance surgical
care and promote patient safety. Ambulatory surgery nursing is not strictly limited to
surgery because nurses in this environment may also provide care to patients
undergoing nonsurgical procedures. Along with this expansive nursing practice
comes the use of special equipment reserved for surgical and nonsurgical
procedures.
ANCILLARY SUPPORT SERVICES
Radiology
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Since radiologic technology may be used during ambulatory procedures, the

ambulatory surgery nurse needs to be knowledgeable about the risks related to
radiation and the ways to adequately protect patients and healthcare providers from
unintended radiation exposure. Ionizing radiation exposure during therapeutic,
diagnostic, and interventional procedures may cause injury; therefore, the
ambulatory surgery team works to keep radiation exposure as low as reasonably
achievable (ALARA) by managing time, distance, and shielding. The benefits
provided by radiologic technologies used during ambulatory procedures include the
ability to confirm diagnoses by direct imaging of a patient’s anatomy, the ability to
see movement in real time, the ability to confirm the progression of surgery, and the
ability to accurately place implantable instrumentation (Fencl, 2015). Potential
dangers range from swelling and erythema to cancer and genetic effects (Fencl,
2015).
Ambulatory surgery organizations must have a radiation safety program that
minimizes patient and personnel exposure to radiation, includes processes to
confirm the integrity of protection devices, and outlines precautions taken during
radiation exposure of patients or personnel who are pregnant (Fencl, 2015). The
radiation safety program is established by a radiation safety officer, ambulatory
surgery nurses, radiologists, physicians, and anesthesia professionals and revolves
around the principles of ALARA: time, distance, and shielding. The surgeon and
radiology technologist deploy radiation for the shortest amount of time needed to
adequately view the operative field (time). Team members maintain the greatest
distance possible from the radiation beam when it is used (distance). All team
members in the room wear lead aprons and thyroid shields during use of radiation
technology (shielding). In an effort to minimize radiation exposure, most ambulatory
surgery policies require posting a sign on the outside of the procedure room door
alerting others when radiation is in use and will place additional lead aprons
immediately outside of the room.
The ambulatory surgery team takes care during positioning of the patient to
ensure areas that do not require radiation exposure are not in the path of the
radiation beam. The ambulatory surgery nurse should take care to avoid exposing
an embryo or fetus to radiation. Pregnancy status for all premenopausal patients is
confirmed, and positive results are reported to the surgeon and anesthesia care
provider. If the team determines the procedure will continue as planned, the
ambulatory surgery nurse will place lead shielding between the fetus and the
source of radiation. Measures taken to protect patients from direct and indirect
radiation exposure are documented on the operative record. Pregnant ambulatory
surgery team members wear a double-thickness apron that provides coverage for
the entire abdomen. Ambulatory surgery team members wear dosimeters at a
consistent location for each procedure: generally, one dosimeter is worn inside the
lead apron and one on the collar or shoulder region outside of the lead apron. The
radiation safety officer can monitor the radiation exposure of each individual
through the dosimeter and intervene if levels of radiation exposure are nearing
maximum levels.
Biomedical Engineering
The ambulatory surgery organization has a biomedical equipment management

plan that creates a framework from which to promote safe and effective use of
medical equipment and provide a safe environment for patients, team members,
healthcare providers, and visitors. This plan also provides policies for a uniform
method of equipment selection and acquisition, medical equipment inventory
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management, orientation and training of users, medical equipment maintenance

management, performance standards, and emergency procedures. The plan is a
collaborative effort involving many different individuals and departments, including
biomedical engineers, the clinical manager, facility engineers, risk managers, the
administrator, ambulatory surgery nurses, and physicians. Some biomedical
engineering departments employ nurses within their departments to manage
compliance and support users. Policies address specific procedures in the event of
equipment failure, when and how to perform emergency clinical interventions when
medical equipment fails, availability of back-up equipment, and how to obtain repair
services. Ambulatory surgery team members review medical equipment hazard
alerts and recalls. Nurses using equipment need to be aware of compliance tags,
expiration dates for inspections, and the process for always removing equipment
from patient care areas (and obtaining replacements) should equipment inspections
be outdated.
Pharmacy
Drugs and biologicals provided in the ambulatory surgery environment must be

provided safely and in an effective manner consistent with generally accepted
professional standards of pharmaceutical practice. Ambulatory surgery centers
(ASCs) must designate a specific licensed healthcare professional, usually a
registered nurse, to provide direction to the ASC’s pharmaceutical service. That
individual must routinely be present when the ASC is open for business, but
continuous presence is not required, particularly when the ASC is open for longer
periods of time to accommodate the recovery of patients for up to 24 hours
(Centers for Medicare and Medicaid Services, 2015). This role is most often fulfilled
by a registered nurse who works for the ASC and may also care for patients. This
designated pharmacy nurse is responsible for ordering medications, educating
fellow team members about pharmaceuticals, and, upon leadership approval,
updating the center’s formulary. Ideally, the ASC and physician’s office surgery
suites will contract with a consultant pharmacist who provides oversight or
consultation regarding pharmaceutical services and guides the designated
pharmacy nurse. In some states, a contracted consultant pharmacist is required in
ASCs. Hospital outpatient surgery departments (HOPDs) are supported by hospital
pharmacy services and may have designated pharmacists assigned specifically to
the ambulatory suites.
Collaboration between the ambulatory surgery team and pharmacists is a
critical component in reducing the risk of perioperative medication errors (Hicks,
Wanzer, & Denholm, 2012). Pharmacists are trained to detect potential medication
errors and communicate contraindications of medications and drug-to-drug
interactions. Consultant pharmacists who have contracted with ASCs to provide
pharmacy oversight will survey the ASC pharmacy at least monthly, and they are
involved in planning the formulary, obtaining medications, reviewing standard
forms, and monitoring the use of automated dispensing devices, as applicable. The
consultant pharmacist will review narcotic administration records and compare
them with medical records to ensure accuracy and safety.
Infection Surveillance, Prevention, and Control
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Ambulatory surgery organizations must maintain an infection control program

that seeks to minimize infections and communicable diseases. The ambulatory
surgery environment can present unique challenges for infection control because
patients are often prepped and recovered in common areas. Surgical preparation
rooms, operating rooms, and procedure rooms are used many times a day
(between appropriate cleaning); patients with infections and communicable
diseases may not be identified; and impaired skin integrity leads to a risk for
infection (Centers for Medicare and Medicaid Services, 2015). Furthermore, due to
the short period of time patients are in an ambulatory surgery facility, the follow-up
process to identify any associated infections requires gathering information after
the patient’s discharge, rather than directly.
In some ASCs in the mid-2000s, poor infection control practices related to
injections of medications, saline, or other infusible medications resulted in the
transmission of communicable diseases, such as hepatitis C, from one patient
infected with the disease before ambulatory surgery to other ASC patients.
The purposes of an ambulatory surgery infection surveillance, prevention, and
control plan are to
1. reduce the risk of healthcare-acquired infections to the lowest possible rate,

improving overall patient care;
2. prevent, identify, and control the potential for infections of all types;
3. reduce the potential for occupationally acquired infections for the staff; and
4. reduce the cost of health care.
Many ASCs will contract with an independent infection control professional who
has special training in infection control, epidemiology, or microbiology but will
designate a nurse with infection control training as the on-site infection control
coordinator. This partnership between the infection control professional and
infection control nurse coordinator is ideal for implementing and maintaining an
effective infection surveillance, prevention, and control program. Often, the
designated infection control nurse coordinator in the ASC also performs the duties
of a preoperative nurse, circulating nurse, or postanesthesia care nurse, along with
coordinating the infection control program.
The infection control nurse in the ambulatory surgery environment must have
additional training in infection control and works closely with the infection control
professional, facility staff, and management in an advisory capacity. The infection
control nurse assists leadership in an annual review of the infection control program
and policies and performs an annual risk assessment survey. This nurse may
perform periodic environmental rounds to ensure compliance with infection
prevention techniques. The nurse follows up with the surgeon’s office every month
to gather information about any possible surgical site infections. If an infection is
identified, the nurse reviews the case and analyzes the data collected with the
guidance of the infection control professional. The goal is to identify the cause of
the infection and prevent reoccurrence if possible. The infection control nurse also
provides annual and ongoing infection prevention education to the ambulatory
surgery team.
Bone and Tissue Implantation
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The ambulatory surgery organization follows guidelines that ensure bone and
tissue implantations meet acceptable norms of technical and ethical performance
and comply with professional and regulatory standards. It is the responsibility of the
organization to confirm that tissue suppliers are registered with the U.S. Food and
Drug Administration (FDA) as a tissue provider and maintain a state license when
required. The receipt, tracking, and storage of room temperature allograft, freeze-
dried graft, and frozen tissue must be handled by the organization via a
standardized process.
Incoming tissue is received and inspected by a person trained by the
ambulatory surgery organization. When fresh, frozen allograft tissue arrives to the
operating room, it should be in a cooler containing dry ice to last 24 hours. The
person receiving the tissue checks the package for any breaks and confirms the
package is intact. Next, the tissue received is verified as the tissue that was
ordered. The following information is confirmed and documented upon receipt:
1. date received and/or stored,

2. name of the person receiving and inspecting the tissue,
3. tissue original numeric or alphanumeric donor and lot identification number,
4. expiration date,
5. vendor or source facility,
6. description of the tissue,
7. tissue reorder number,
8. inspection result (pass/fail), and
9. status of the tissue (on hand, on consignment, implanted, explanted,
returned, discarded, or transferred).
If a loss of integrity during shipping is identified, the tissue is not used and is
returned to the vendor, if possible, or discarded, and the information is
documented.
Before use, implantable tissue and bone are always verified visually and
verbally by the surgeon. The ambulatory surgery circulating nurse documents the
implantation of bone and tissue in the medical record by noting the implant type,
implantation date, surgeon, procedure, location of implantation in the patient, any
adverse problems, and the serial number and lot number of the bone or tissue.
Vendor Support
Vendor representatives are subject matter experts skilled at guiding surgeons in

the optimal techniques used when working with instruments, equipment, or
implantable devices (Plonien & Williams, 2014). The ambulatory surgery team is
accountable for recognizing and reducing risks to patients by ensuring vendor
representative expertise and adhering to ethical and corporate compliance. Vendor
representatives collaborate with the ambulatory surgery team to provide instruction
and guidance in the technical use and application of their products. The
representatives explain the purpose of the product, teach quality control measures,
and proper cleaning and care of the product. Controversy can arise when the
vendor representative’s motive is to orchestrate a hard sell of the product. This
behavior can cause a distraction and result in unsafe conditions. Extraneous
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activity as simple as a sidebar conversation, the most likely distraction, can lead to
errors (Plonien & Williams, 2014). Fraud and dishonest advisement by vendors has
resulted in harmful outcomes for patients. For this reason, the ambulatory surgery
team ensures a structured process exists to provide education within operative or
other invasive procedure settings (Plonien & Williams, 2014).
Vendor representatives act as advisors only, and their role is to assist in
ensuring the safe and effective use of devices and technology. They are not
permitted to engage in the surgery, practice nursing, or make medical decisions,
and they cannot have direct patient contact. They may be involved in remote
calibration or adjustment of medical devices to the specification of the surgeon
and/or manufacturers’ guidelines. Many ambulatory surgery organizations use
outside credentialing companies to verify that vendor representatives are safe to
allow in the operating room. Vendor verification companies gather information
about credentials, training, immunization records, criminal background checks, and
whether the person is on any watch lists for exclusions related to healthcare fraud.
Ambulatory nurses need to understand their organization’s policy regarding vendor
access and be familiar with the process of utilizing vendor expertise while
protecting the privacy of patients and the integrity of the operating or procedure
suite.
SPECIAL PROCEDURES
Lithotripsy
Shock wave lithotripsy (SWL) was introduced in 1980 and remains the least
invasive therapy for treatment of urinary stones. Lithotripsy creates fluid shock
waves that are transmitted through the patient’s body to cause fragmentation of
kidney stones. SWL is an outpatient procedure, and the anesthesia used varies
according to the needs of the patient, the preferences of the physician and
anesthesiologist, the type of lithotripter, and the power settings used. Anesthesia
may range from topical anesthetics to procedural sedation to general anesthesia.
Reduction of patient movement is linked to more consistent and sustained targeting
of the stone (Pearle, 2012). The pain associated with lithotripsy treatment is greater
when the lithotripter aperture is smaller and, thus, more concentrated on the
specific area of skin where the shock waves enter the patient’s body (Pearle, 2012).
Contraindications include active urinary tract infection, coagulopathy, distal
obstruction, and pregnancy.
The ambulatory surgery team positions the patient according to the location of
the stone. The supine position is favorable for renal and most ureteral calculi,
except for those located in the middle ureter and in patients with horseshoe,
transplanted, or pelvic kidneys. These patients should be treated in the prone
position due to the more anterior location of the ureter or kidney. Once positioning
on the lithotripter table is complete, the patient is coupled to the lithotripter by
means of a water cushion coated with an acoustic gel that enables the shock
waves to be delivered to the patient without changes in acoustic density. The
physician and lithotripter technician use fluoroscopy or ultrasonography to target
the stone and move the table until the stone matches to the focal point of the
lithotripter. Generally, the physician will start with 60 to 120 shock waves per minute
for a total of 1,000 to 2,000 shocks (Pearle, 2012). The U.S. Food and Drug
Administration sets the maximum number of shock waves for each lithotripter that
has been approved as safe for the public. The physician aims to deliver only as
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many shock waves as necessary to pulverize the stone in an effort to limit injury to
the patient’s kidney.
Upon discharge, most ambulatory surgery patients will need a prescription for
an analgesic. The patient will also be given a strainer to collect stone fragments
that appear during voiding and will be retained for later analysis. Patients are
instructed to watch for signs of infection or obstruction, and they are informed that
mild hematuria and flank soreness are to be expected. The patients must inform
the physician of any gross hematuria or severe pain. Repeat lithotripsy may be
considered in 2 weeks or more for stones that failed to fragment.
Gastrointestinal Endoscopy
Gastrointestinal (GI) endoscopy growth has been facilitated by evolving medical

technologies and driven by the payment policies of the Centers for Medicare and
Medicaid Services (CMS) and commercial payers (Deas & Sinsel, 2014). CMS
approved colonoscopy for colorectal screening in 2001. Publicized breaches in
endoscope reprocessing have intensified the focus on infection prevention in the
ambulatory surgery environment.
A colonoscopy is an endoscopic examination of the colon from the rectum to the
cecum or terminal ileum using a colonoscope. The bowel wall is observed for
abnormalities such as bleeding, polyps, inflammation, or tumors during the insertion
and withdrawal of the colonoscope. The direct visualization allows for biopsies,
excision of polyps, dilatation, decompression, and fulguration of bleeding sites. An
upper endoscopy procedure allows direct visualization of the esophagus, stomach,
and proximal duodenum using an endoscope. This procedure allows the physician
to diagnose, treat, and document abnormalities through the use of biopsy, brush
cytology, polypectomy, electrocautery, dilatation, sclerosing of varices, foreign body
removal, and photography. The nurse assists the patient with proper positioning
and ensures safety and support; the nurse also provides education related to the
procedure that will be performed.
In many cases, the physician will remove a specimen for laboratory testing. The
physician will determine if specimens removed during the procedure will be sent to
an appropriate pathology lab or discarded. Specimens that are to be analyzed must
be transported to the designated laboratory in a timely manner. Specimens are
always handled using standard precautions and using aseptic technique so as not
to contaminate them. They are clearly and accurately labeled and identified in the
presence of the patient. In general, the circulating nurse is responsible for labeling,
packaging, and documenting all specimens, as well as entering pertinent data
about the specimens into a log for tracking before their transport to the lab.
The American Society for Gastrointestinal Endoscopy (ASGE) has been
instrumental in creating guidelines that identify acceptable practices in the
endoscopy suite. These guidelines provide evidence-based standards of practice
regarding safety during GI endoscopy performed in a dedicated GI endoscopy unit,
which is separate from the rigorous standards required for the surgery department.
ASGE addresses standards related to traffic patterns, personal protective
equipment, safe handling of potentially contaminated equipment or surfaces,
staffing patterns, and sedation.
SPECIAL EQUIPMENT
Lasers
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Lasers are a valuable tool in the operating room; however, there are some
safety concerns associated with their use. Therefore, the ambulatory surgery nurse
takes proper precautions to reduce risks to patients and ambulatory surgery team
members. The word laser is an acronym for Light Amplification by the Stimulated
Emission of Radiation. The different wavelengths emitted by various lasers have
different effects on tissues; thus, the wavelength of the laser determines the
application of appropriate safety measures. Physicians use medical lasers to seal
small blood vessels and decrease edema and pain that would otherwise be
associated with the surgery if an alternative to the laser were used.
The ambulatory surgery nurse implements safety measures to minimize
hazards associated with laser use. Lasers can cause injury to the cornea and retina
from direct viewing or scattered beams. Lasers can burn tissues because they are
thermal in nature. This thermal property creates toxic surgical smoke that must be
removed by the use of a smoke evacuation system. Lastly, lasers are a potential
ignition and fire source because of the intense heat they produce. (See Chapter 7
for more information on preventing surgical fires.)
The ambulatory surgery organization develops a laser safety program with input
from physicians, nurses, risk managers, and anesthesia providers who are focused
on patient and team member safety. A laser safety officer, who may be an
interested ambulatory surgery nurse, is designated and has training in safe laser
practices (see Case Study 14-1). Safety processes include controlling access to
laser use, protecting patients and team members from unintended exposure to the
laser beam, providing safety eyewear, and protecting the team members and
patients from surgical smoke, as well as electrical and fire hazards. Members of the
ambulatory surgery team wear high-filtration masks and laser safety goggles during
laser use and post a laser-specific sign on the outside of the procedure room to
indicate the type of laser in use and the specific safety precautions needed upon
entry. Other practices that prevent unintentional laser exposure include placing the
laser in stand-by mode when not in use, placing the foot switch near the operator
and confirming comfortable operational ability, and using only nonreflective
instruments near the laser use area. The laser is never activated in the presence of
flammable gases. Moist sponges are kept near the surgical site, and water is
available for extinguishing flames. The patient’s eyes are protected by glasses if
the patient is awake, by wet pads if asleep, and by metal corneal shields if the laser
treatment area is around the eyes. The circulating nurse documents all safety
measures taken to protect the patient.
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Electrosurgical Units
Electrosurgical units (ESUs) are used for surgical cutting or to control bleeding
by causing coagulation at the surgical site. They deliver high-frequency electrical
currents and voltages through an active electrode, causing desiccation,
vaporization, or charring of the target tissue. The monopolar electrosurgical circuit
is composed of a generator, an active electrode, the patient, and the patient
dispersive electrode as shown in Figure 14-1. The generator of the ESU is the
electricity source. Electrosurgical units can cause burns at the dispersive electrode
site, fires, electrical shock, explosions, and interference with medical devices, such
as pacemakers.
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Ambulatory surgery nurses are diligent in monitoring for unintentional activation

or unsafe practices. The ESU is mounted on a tip-resistant cart and protected from
liquids. Alarms and activation indicators alert users to proper use or errors. The
physician using the ESU will request the lowest setting to achieve the desired
effect; however, consistent requests for higher settings in a short amount of time
are investigated by the nurse. The entire ESU and accessories for cord
connections and adequate placement of the dispersive electrode are examined for
defects. It is important to ensure that the ESU is not used in the presence of gases
or in an oxygen-enriched environment. When working near the head and neck
region, the active electrode should be used as far away as possible from an oxygen
source. The ambulatory surgery nurse coordinates with the anesthesia care
provider to minimize oxygen concentration. The nurse is expected to observe the
sterile field when the ESU is in use and, when necessary, remind the surgeon,
technician, or assistant that the active electrode should be placed in a
nonconductive safety holster when it is not in use (Spruce & Braswell, 2012).
Smoke evacuators (such as a local exhaust ventilation, wall-suction system with an
in-line filter) are used to reduce the potential adverse effects of surgical smoke on
personnel and patients.
When monopolar electrosurgery is used, a dispersive electrode is placed with
uniform contact on the patient’s skin. To prevent a possible burn from directed
current, the nurse ensures the patient does not contact any metal devices, such as
the bed, stirrups, positioning devices, jewelry, or safety strap buckles. The ideal
placement of the dispersive electrode is over well-perfused muscle where the skin
is clean, dry, intact, and on the same side of the surgery, as close as possible to the
site of surgery. Unlike monopolar electrodes, bipolar electrodes have two poles and
the current flows between the two poles and back to the ESU, eliminating the need
for a dispersive electrode.
Pneumatic Tourniquets
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Ambulatory surgery nurses are likely to work with pneumatic tourniquets during
orthopedic, podiatric, and plastic surgery cases. Pneumatic tourniquets are used to
provide a nearly bloodless surgical field or to facilitate intravenous regional
anesthesia to a patient’s extremity. A pneumatic tourniquet system consists of a
pressure regulated control unit, tubing, and an inflatable tourniquet cuff. The cuffs
inflate with air, oxygen, or nitrogen to a preset pressure to compress the patient’s
blood vessels during surgical procedures, thus ensuring a bloodless operative field.
The role of the ambulatory surgery nurse is to confirm the appropriate size and
shape of the cuff based on the size and shape of the affected extremity and to
prepare the necessary equipment before the patient comes into the operating
room. The nurse collaborates with the surgeon and anesthesia care provider to
determine the lowest cuff pressure setting possible based on the patient’s systolic
blood pressure or limb occlusion pressure (Hicks & Denholm, 2013). Low-lint
padding is used between the cuff and the patient’s skin, and the cuff is draped to
mitigate the risk of fluid accumulation under the cuff. The nurse ensures that
pressure displays on the pneumatic tourniquet pump machine are visible, and
audible alarms are activated at a volume that can be heard by the ambulatory
surgery team. The nurse monitors the total inflation time and communicates the
duration of the inflation time to the ambulatory surgery team at regular, established
intervals. Tourniquet pressure is activated and deactivated at the direction of the
surgeon or anesthesia care provider. The nurse documents the size and shape of
the cuff used, the total tourniquet inflation time, and the pressure settings.
SUMMARY
T
he ambulatory surgery nurse becomes versatile in providing care to patients
undergoing various types of surgical and nonsurgical procedures. Guidance
provided by experts in ancillary fields such as radiology and infection
prevention is a valuable asset to the ambulatory surgery organization and the
patients served. As innovation and technology continue to expand in surgery and
procedural suites, the ambulatory surgery team will be responsible for ongoing
education regarding the related patient safety measures. At the same time,
education of ancillary services, procedures, and equipment also focuses on team
member safety.
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EXAM QUESTIONS
CHAPTER 14
Questions 87–93
87. In an effort to keep radiation exposure as low as reasonably achievable, the

ambulatory surgery nurse implements all of the following principles except
a. time.
b. distance.
c. shielding.
d. rounding.
88. What is the goal of the biomedical engineering program in the ambulatory
surgery organization?
a. To promote safe and effective use of medical equipment
b. To provide evidence-based standards of practice regarding safety during
gastrointestinal endoscopy
c. To implement safety measures to minimize hazards associated with laser
use
d. To reduce the potential adverse effects of surgical smoke to personnel
and patients
89. Which of the following team members would be most appropriate to provide
direction to the ambulatory surgery center’s pharmaceutical service?
a. The surgery scheduler
b. A medical assistant
c. A registered nurse
d. A radiologist
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90. The ambulatory surgery nurse reviews the medical record of a patient
scheduled for lithotripsy. The nurse notes the physician documented that the
patient has a ureteral calculi located in the middle of the ureter. How should the
patient be positioned during the lithotripsy to optimize outcomes?
a. Prone
b. Supine
c. Trendelenburg
d. Right lateral
91. After transporting a patient who had a colonoscopy to the postanesthesia care
unit, the nurse returns to the procedure room, labels the specimens, prepares
them for transport to the lab, and documents details in the specimen log. What
safety measure did the nurse neglect to implement?
a. The specimens are labeled by the physician.
b. Specimens are labeled in the presence of the patient.
c. The specimens are handed off to the postanesthesia nurse during patient
handoff.
d. The specimens are labeled by the medical records custodian.
92. Under local anesthesia only, an adult patient is having a laser procedure of the
foot. What safety measure does the nurse take to protect the patient’s eyes?
a. The nurse applies wet pads to the patient’s eyes.
b. The nurse inserts metal corneal shields to each eye.
c. The nurse instructs the patient to close her eyes.
d. The nurse puts laser safety glasses on the patient.
93. All of the following are interventions performed by the nurse when using a
pneumatic tourniquet on a patient except
a. confirming the appropriate size and shape of the cuff.
b. preparing the necessary equipment before the patient comes into the
operating room.
c. determining when to activate and deactivate tourniquet pressure.
d. using low-lint padding between the cuff and the patient’s skin.
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CHAPTER 15
AMBULATORY SURGERY
LEADERSHIP AND GOVERNANCE
LEARNING OUTCOME
A
fter completing this chapter, the learner will be able to explain ambulatory
surgery center leadership and governance, including its structure and
common committees.
CHAPTER OBJECTIVES
A
1. Explain the role of the Quality Assessment and Performance Improvement

committee and describe how nurses contribute.
2. Describe the structure of an ambulatory surgery organization and articulate
the purpose of the medical executive committee and the governing body.
3. Identify opportunities for ambulatory surgery nurses to be involved in

leadership roles.
INTRODUCTION
A
mbulatory surgery organizations leverage the knowledge and expertise of
multidisciplinary stakeholders to optimize patient care. The philosophy is to
provide individualized care for every patient and family, taking into
consideration the essential role that the family or other supporting adults play in the
patient’s overall experience. The ambulatory surgery organization’s primary duty is
to provide a knowledgeable and clinically competent team to deliver patient care in
a courteous and family-oriented atmosphere. The ambulatory surgery team
ensures that the quality standards, as determined by regulatory agencies,
professional organizations, and the community, are met or exceeded.
QUALITY ASSESSMENT AND PERFORMANCE

IMPROVEMENT COMMITTEE
T
he mission of the ambulatory surgery Quality Assessment and Performance
Improvement (QAPI) committee is to improve patient outcomes by
developing, implementing, and maintaining an ongoing, data-driven program
that addresses safety, service, patient outcomes, patient satisfaction, and financial
considerations. Active committee involvement of the ambulatory surgery
administrator, clinical manager, clinical team members, business office team
members, physicians, and patients is crucial for the success of the program. This
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committee is concerned with system processes and ways to optimize them;

therefore, ideas and viewpoints from all levels are needed. For these reasons, each
ambulatory surgery team member has a direct role in quality assessment and
performance improvement. The QAPI committee organizes clinical and
administrative standards of care, develops them into proposed policies, and
presents them to the medical executive committee and governing body for
approval.
The activity of the QAPI committee is not limited to designated meeting times;
rather, it is an ongoing and fluid process that constantly changes as the ambulatory
surgery team adapts to the changing needs of the patients. The QAPI committee
uses benchmarks to measure progress and provides data in a usable format that is
meaningful to the medical executive committee and governing body. The
identification of trends and variations over time is analyzed closely and used to
change processes and policies as appropriate. This committee also makes
recommendations regarding strategies for cost containment. By developing
improved processes, members identify and correct deficient patterns of care that
may result in sentinel events. The committee is also involved in educating
ambulatory surgery team members about performance improvement.
Often, a patient care nurse is appointed by the administrator as the QAPI
coordinator. This may also be a nursing position in the quality department of a large
organization that focuses on activities related to the practice of ambulatory surgery
and procedures. The coordinator integrates performance improvement activities
between the medical and clinical team members, facilitates improvement activities,
and reports results to staff and interdisciplinary teams.
MEDICAL EXECUTIVE COMMITTEE
T
he governing body of the ambulatory surgery center (ASC) appoints a
medical executive committee (MEC), whose members include administrative
and medical staff. These representatives may include the medical director,
administrator, clinical manager, risk manager, the MEC chairperson, and medical
staff from various ambulatory surgery service lines. The MEC is the coordinating
and advisory body for all programs that monitor or evaluate quality and
appropriateness of patient care. The MEC chairperson is a physician elected by the
medical executive committee and provides interim decision making for the medical
staff between official board meetings.
The MEC is concerned with performance improvement, risk management,
patient safety (see Chapter 12 for more information), compliance issues, and
professional peer review. Often, the committee will also include professional
consultants such as pharmacists, infection prevention professionals, patient safety
professionals, and medical records specialists. Members of the MEC serve as the
medical administrative liaison among medical staff, clinical staff, administrative
staff, and the governing body. The MEC members analyze data collected by the
QAPI committee and set priorities for organization-wide performance improvement
activities designed to improve patient outcomes. The committee members assist in
the creation of facility policies and procedures. During quarterly meetings, the MEC
members review event reports and identify trends or concerns. Along with MEC
recommendations, the MEC members share information gleaned from quarterly
MEC meetings and reviews with the governing body.
Medical Director
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The ambulatory surgery center medical director is a physician appointed to the

role by the governing body. Upon acceptance of this position, the medical director
acts as a liaison and advisor to the ambulatory surgery center team in an effort to
produce safe and reliable care. The medical director has overall responsibility for
the medical care provided in the center and is available to assist the staff in solving
patient care problems. Under the direction and support of the medical director,
ambulatory surgery nurses and physicians collaborate to provide continuity of care.
The medical director, who is a member of the credentials committee and
medical executive committee, offers recommendations regarding each medical staff
applicant to the ambulatory surgery center. Toward that end, the medical director
investigates any breach of ethics by the medical staff member and makes
recommendations to the MEC based on that investigation. The medical director
guides the clinical and medical staff by supporting the policies of the organization,
always focusing on safe patient care. The administrator and clinical manager work
closely with the medical director to ensure adherence to the adopted standards of
practice. At meetings, the QAPI committee reviews input regarding the views,
policies, needs, and grievances of the medical staff as communicated by the
medical director. The MEC and the governing body review the medical director’s
performance annually.
Credentials Committee
The ambulatory surgery center’s medical executive committee appoints

members to a credentials committee that includes representatives from various
service lines of the medical staff. The medical director, MEC chairperson, and
administrative staff may be included in this committee. In accordance with the
bylaws of the ambulatory surgery organization, the committee members are
responsible for coordinating and advising physicians for medical staff appointment,
reappointment, and extension of privileges. This committee is often chaired by the
medical director. The committee reviews applications for medical staff privileges
and assesses all available background information, including references from other
physicians. The committee is also available to implement plans to solve any
concerns that arise during the application process, such as activity regarding the
physician in the National Practitioner Data Bank.
GOVERNING BODY
T
he governing body of the ambulatory surgery center has ultimate legal and
ethical authority for the organization. This committee is concerned with the
organization’s goals, mission, scope of services, plan of care, and role in the
community. The governing body’s members oversee the medical staff and work to
ensure quality and safety for patients and ambulatory surgery team members.
Upon receipt of recommendations from the medical executive committee, the
governing body defines, implements, monitors, and maintains quality assurance
and performance improvement activities and policies. The governing body’s
members create and implement a strategic plan for the ambulatory surgery
organization.
The governing body establishes, approves, and amends medical staff bylaws,
rules, and regulations. They also have final approval over medical staff
appointments, reappointments, pharmacy formulary, allowable abbreviations, and
approved surgical procedures. Members of the governing body ensure adoption of
standards of practice from their accrediting agencies such as The Joint
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Commission, the Accreditation Association for Ambulatory Health Care, Inc., the
Centers for Medicare and Medicaid Services, the Association of periOperative
Registered Nurses, the American Society of PeriAnesthesia Nurses, the American
Society of Anesthesiologists, and other professional and regulatory organizations.
PROFESSIONAL PRACTICE EVALUATION
T
he medical staff of the ambulatory surgery organization is responsible for
reviewing the medical care provided in the facility. The goal of this peer
review process is to ensure positive patient outcomes and maintain high
standards of care. The ambulatory surgery organization provides a comprehensive
process for physician peer review that includes a proactive approach, or ongoing
professional practice evaluation (OPPE), and an event-related approach, or
focused professional practice evaluation (FPPE). This peer review process is
handled in a confidential manner and is shared in summary with the medical
executive committee and governing body. It is shared in detail if the physician
reviewer deems it appropriate.
Ongoing professional practice evaluations include random case reviews for
appropriateness of care, including a review of diagnoses and pathology as
applicable; the completeness of a medical history and physical exam; the
documentation of informed consent; the appropriateness of antibiotic selection; and
the appropriateness of patient selection.
Focused professional practice evaluations include a retrospective review of
specific outcome indicators recommended by the medical executive committee and
approved by the governing body of each ambulatory surgery organization. These
outcome triggers often include an unplanned admission to a hospital within 24
hours of discharge, an unplanned return to surgery, wrong patient/site/side/implant
events, any patient injury, a retained foreign object, a surgical site infection, and
any serious and unexpected cardiac, respiratory, or neurologic event, among
others. Organizations need to comply with the regulations and requirements of the
OPPE and FPPE. Organizations need to address the challenges of capturing
consistent and accurate practice data for individual physicians, establishing
consistent processes for performance based on standards of acceptable care, and
adopting meaningful criteria that affect practice. Reviews may incorporate patient
complaint data if attribution to a department or individual can be consistently
captured.
It is important for ambulatory surgery nurses to understand this process. Nurses
can contribute to ensuring positive patient outcomes by being transparent and
honest with leaders. The ambulatory surgery nurse understands that the
professional practice evaluation process is confidential and is an effective approach
to maintaining the highest standards of care.
CLINICAL LEADERSHIP IN AMBULATORY SURGERY
A
mbulatory and perioperative nurses are well positioned to assume
leadership roles such as a clinical manager, administrator, director, and
more. Nurses in leadership roles serve as patient safety officers, quality
assessment and performance improvement specialists, risk managers, infection
prevention nurses, and pharmacy nurses. Ambulatory surgery nurses can
contribute to the creation of relevant policies and procedures; they may head
programs responsible for laser safety, infection prevention, environment of care
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issues, and patient safety while still participating in hands-on patient care. In 2010,
the Institute of Medicine published The Future of Nursing: Leading Change,
Advancing Health, wherein the committee recommended expanded opportunities
for nurses to lead and collaborate with physicians and other members of the
healthcare team in conducting research and redesigning and improving practice
environments and health systems.
The lead ambulatory surgery nurse promotes teamwork and supportive
interpersonal dynamics. Building strong leadership in ambulatory surgery includes
the ability to engage team members and secure their support. The current
challenges in patient care before, during, and after surgery cannot be managed
alone; rather, with a shared vision, a multidisciplinary team works together toward a
common mission. To secure the support of the ambulatory surgery team, a leader
focuses on team building, motivation, and staff satisfaction and retention and
collaborates with the team to accomplish positive outcomes. A leader guides the
team toward the common goal of fewer patient complications and greater patient
satisfaction while achieving lower rates of nurse burnout and turnover and higher
team satisfaction (Zook, 2014).
The ever-changing standards of care coupled with the growing demands for
improved quality and safety make the ability to lead organizational change
exceptionally important. In addition, ambulatory surgery organizations face a
pressing need to continuously improve financial performance while swiftly adopting
new practices. Ambulatory surgery nurse leaders balance competing demands by
accomplishing transformational change focused on creating an environment that
responds effectively to new advancements in care and technology, patients’ needs,
regulatory changes, an ever-changing and diverse patient population, and market
adjustments. The strong guidance of nurse leaders can alter work patterns, clinical
practices, team morale, and, ultimately, patient outcomes. Nurse leaders who
succeed in transformational change are able to influence others to such a degree
that they affect long-term commitment to their shared visions (Taylor, 2014). A
nurse leader in ambulatory surgery empowers other team members by listening to
their ideas and viewpoints and takes action to implement their suggestions
whenever possible. Nurse leaders who are supportive and who provide a clear
mission and set of values are able to influence change throughout the ambulatory
surgery organization and beyond (Taylor, 2014).
The Competency and Credentialing Institute has created several certificate
programs for ambulatory surgery nurse leaders or aspiring leaders, including the
Certificate Program for Surgical Services Management and the Certified
Perioperative Clinical Nurse Specialist. The Board of Ambulatory Surgery created
and supports the Certified Administrator in Ambulatory Surgery program. The
Association of PeriOperative Registered Nurses (AORN) has developed the
Ambulatory Administrator Skills Course.
Ambulatory surgery nurse leaders will earn the respect and trust of their team
by navigating change from the front lines of patient care. Leaders show up for the
uncomfortable moments, whether those are serious patient situations or
unannounced on-site surveys. Leaders are strong advocates for their team and for
their patients. Ambulatory surgery leaders continually promote innovation, as
innovation was the creative foundation of ambulatory surgery.
SUMMARY
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ositive patient outcomes are the result of effective medical, technological,

and nursing interventions. The ambulatory surgery organization’s leaders
P
ensure patients’ rights and dignity and provide care in a confidential and
supportive manner. The structure of the organization allows for input from all
disciplines. Nurses who participate in direct patient care have unique insight into
the needs of the patients they treat; thus, their guidance in shaping policies and
procedures is valuable and leads to the success of the organization. Nurses who
lead and manage collaboratively with physicians and other members of the
healthcare team are contributing to the current and future health needs of the
population.
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EXAM QUESTIONS
CHAPTER 15
Questions 94–100
94. All of the following ambulatory surgery roles are actively involved in the Quality
Assessment and Performance Improvement committee except
a. nurses.
b. physicians.
c. patients.
d. vendors.
95. A nurse in the ambulatory surgery center has identified a process

improvement opportunity. Which committee should the nurse present her
findings to first?
a. The medical executive committee
b. The governing board
c. The Quality Assessment and Performance Improvement committee
d. The credentialing committee
96. The ambulatory surgery medical executive committee is responsible for all of
the following except
a. monitoring and evaluating quality and appropriateness of patient care.
b. performance improvement and risk management.
c. patient safety, compliance issues, and professional peer review.
d. the ultimate legal and ethical authority for the organization.
97. Which committee establishes, approves, and amends medical staff bylaws,
rules, and regulations?
a. The governing body
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b. The medical executive committee

c. The credentialing committee
d. The Quality Assessment and Performance Improvement Committee
98. An ambulatory surgery nurse interested in a leadership role can serve as all of
the following except as the
a. clinical manager.
b. medical director.
c. infection prevention nurse.
d. Quality Assessment and Performance Improvement coordinator.
99. In the 2010 Institute of Medicine report, The Future of Nursing: Leading
Change, Advancing Health, the committee recommended which of the
following?
a. Expanding physician involvement in nursing practice
b. Minimizing nursing practice to prevent nurses from working to the full
extent of their education and training
c. Minimizing action to support nurses’ completion of a transition-to-practice
program
d. Expanding opportunities for nurses to lead and manage collaborative
efforts with physicians and other members of the healthcare team
100. All of the following are benefits of strong leadership in the ambulatory surgery
environment except
a. fewer patient complications.
b. greater patient satisfaction.
c. more sentinel events.
d. lower rates of nurse turnover.
This concludes the final examination. To complete the exam, login to

your account at http://www.westernschools.com
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RESOURCES
SUGGESTED READING
Ambulatory Surgery Center Association. (n.d.). ASC Quality and Access Act of
2015 (H.R. 1453/S. 2071). Retrieved from
http://www.ascassociation.org/govtadvocacy/legislativepriorities/hr1453
ASC Quality Collaboration (n.d.). ASC quality measures and guide. Retrieved
from http://ascquality.org/qualitymeasures.cfm
Centers for Medicare and Medicaid Services. (2015, April 15). CMS conditions
for coverage for ambulatory surgical centers: Interpretive guidelines.
Retrieved from http://www.ascassociation.org
Centers for Medicare and Medicaid Services. (2016). Ambulatory surgical center
quality reporting specifications manual (Version 5.1).
http://www.fsasc.org/assets/ASC%20Specification%20Manual.pdf
Institute of Medicine. (2010). The future of nursing: Leading change, advancing
health. Retrieved from http://nationalacademies.org/hmd/reports/2010/the-
future-of-nursing-leading-change-advancing-health.aspx
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human:
Building a safer health system. Committee on Quality of Health Care in
America, Institute of Medicine. Washington, DC: National Academies
Press.
Mason, S. E., Nicolay, C. R., & Darzi, A. (2015) The use of Lean and Six Sigma
methodologies in
surgery: A systematic review. The Surgeon, 13(2), 91-100.
Maurice, E. (2015). Timely patient discharge from the ambulatory surgical
setting. AORN Journal, 102(2), 185-192.
Metzner, J., & Domino, K. B. (2015). Moderate sedation: A primer for
perioperative nurses. AORN Journal, 102(5), 526-535.
Owens, P. L., Barrett, M. L., Raetzman, S., Maggard-Gibbons, M., & Steiner, C.
A. (2014). Surgical site infections following ambulatory surgery procedures.
JAMA, 311(7), 709-716.
Phillips, N. (2013). Berry and Kohn’s operating room technique (12th ed.). St.
Louis, MO: Mosby.
Rothrock, J. C. (2015). Alexander’s care of the patient in surgery (15th ed.). St.
Louis, MO: Mosby.
Serino, M. F. (2015). Quality and patient safety teams in the perioperative
setting. AORN Journal, 102(6), 617-628.
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GLOSSARY
AAAHC: Accreditation Association for Ambulatory Health Care.

ACS: American College of Surgeons.
AED: Automatic external defibrillator.
agonist: A pharmacologic agent that has an interaction with, and an affinity and
efficacy for, receptors to produce a response.
AHA: American Hospital Association.
AHRQ: The Agency for Healthcare Research and Quality.
ALARA: The principles of time, distance, and shielding from radiation.
analgesia: Reduction of pain perception.
anesthesia: Loss of feeling or sensation; frequently used to refer to insensibility
to pain.
anoxia: Reduction of oxygen in body tissues below physiologic levels.
antagonist: An agent that nullifies the action of another agent.
antibody: Complex molecule (immunoglobulin) produced by the lymph system
in response to an antigen.
anticholinergics: Pharmacologic agents that block the effects of
parasympathetic nerves.
antigen: A chemical substance or small organism whose entry into the body
provokes an immune system response and the formation of an antibody or
immunoglobulin.
antisialagogue: A drug that inhibits excessive salivary secretion.
anxiolytics: Pharmacologic agents that reduce anxiety and nervous excitement.
AORN: Association of periOperative Registered Nurses.
apnea: A cessation of breathing; the absence of respiration.
APS: American Pain Society.
arteriosclerosis: Thickening, hardening, and loss of elasticity of the arterial
walls.
ASA: American Society of Anesthesiologists.
ASA physical status: A classification system developed by the American
Society of Anesthesiologists that ranks viable patients from P1 to P5, with
the ascending numbers indicating increasing risk of morbidity and mortality
during surgery and anesthesia.
ASC: Ambulatory Surgery Center.
ASCA: Ambulatory Surgery Center Association.
ASPAN: American Society of PeriAnesthesia Nurses.
aspiration: Inhalation of foreign material into the respiratory passages.
ASPMN: American Society for Pain Management Nursing.
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atelectasis: Collapse of alveolar sacs in the lungs.

atherosclerosis: An accumulation of fatty deposits (plaque) along the interior
walls of large- and medium-sized arteries.
benzodiazepines: A group of pharmacologic agents that produce dose-related
sedation, anxiolysis, and amnesia. Minor tranquilizers.
BMP: Basic metabolic profile.
BMV: Bag mouth valve.
bronchospasm: A severe constriction of the bronchial tree.
BUN: Blood urea nitrogen.
butyrophenones: A group of major tranquilizers pharmacologically and clinically
similar to phenothiazines.
capnography: Measurement of carbon dioxide tension or content in exhaled
breath using infrared light technology.
CBC: Complete blood count.
CDC: Centers for Disease Control and Prevention.
CMS: Centers for Medicare and Medicaid Services.
COPD: Chronic Obstructive Pulmonary Disease.
CPAP: Continuous positive airway pressure.
CPI-U: Consumer price index for all urban consumers.
CPT: Current procedural technology code.
credentials: Professional credentials of a practitioner regarding education,
training, experience, and performance.
dermatome: An area of the body that is innervated from one spinal root.
DNR: Do not resuscitate.
DVT: Deep vein thrombosis.
dysphoria: Restlessness, agitation, exaggerated feelings.
dysrhythmia: A disturbance of rhythm.
ECG: Electrocardiogram.
embolus: A single mass of tissue, fat, clotted blood, or a bubble of air or gas
that travels through the circulatory system.
endoscopy: Visualization of the interior of a body cavity using a lighted
instrument.
endotracheal intubation: Insertion of a specialized tube through the
nasopharynx or oropharynx and between the vocal cords into the trachea
to establish a controllable, patent airway.
epidural anesthesia: Loss of sensation produced by the injection of a local
anesthetic outside the dura mater but within the spinal canal.
ESU: The electrosurgical units used for surgical cutting or to control bleeding by
causing coagulation at the surgical site.
FDA: U.S. Food and Drug Administration.
general anesthesia: Pharmacologically induced unconsciousness and
insensibility to pain.
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governing body: This committee has ultimate legal and ethical authority for the
ambulatory surgery center organization. This committee is concerned with
the organization’s goals, mission, scope of services, plan of care, and role
in the community.
hemostasis: Stopping bleeding or hemorrhage.
HIPAA: Health Insurance Portability and Accountability Act.
HOPD: Hospital Outpatient Department.
hypercapnia/hypercarbia: An excessive amount of carbon dioxide in the blood;
a carbon dioxide pressure greater than 45 to 50 torr.
hyperkalemia: An excessive amount of potassium in the blood.
hyperpnea: Increased depth of respiration.
hypertension: A systolic blood pressure greater than 140 mmHg and a diastolic
blood pressure greater than 90 mmHg or a blood pressure 30% greater
than the patient’s preoperative baseline blood pressure.
hyperventilation: An increased rate and depth of breathing that results in an
abnormal lowering in arterial carbon dioxide content.
hypnotics: Pharmacologic agents that can produce a state of central nervous
system depression similar to sleep.
hypocapnia/hypocarbia: A subnormal amount of carbon dioxide in the blood.
hyponatremia: Decreased concentration of sodium in the blood.
hypopharynx (laryngopharynx): The lowest portion of the pharynx, which
leads to the larynx and esophagus.
hypotension: A systolic blood pressure less than 90 mmHg and a diastolic
blood pressure less than 60 mmHg or a blood pressure 30% less than the
patient’s preoperative baseline blood pressure.
hypothermia: Low body temperature.
hypoventilation: A reduced rate and depth of breathing that results in a
decrease in arterial oxygen content and an increase in carbon dioxide
content.
hypovolemia: Decreased circulating blood volume.
hypoxemia: An inadequate oxygen supply in the blood; an arterial oxygen
pressure of less than 60 torr.
hypoxia: Reduced oxygen content or tension, as in inspired air or body tissues.
inhalation anesthesia: A state of general anesthesia produced by inhalation of
a vaporized volatile liquid anesthetic or gaseous anesthetic.
ischemia: Localized deficiency of blood supply chiefly caused by contraction or
obstruction of a blood vessel.
laparoscopy: Endoscopic examination of the interior of the abdomen by means
of a laparoscope.
laryngospasm: A severe constriction of the larynx.
larynx: The organ of voice production. A musculocartilaginous structure located
at the top of the trachea below the base of the tongue, anterior to the
esophagus, and covered by the epiglottis during swallowing.
laser: Light amplification by the stimulated emission of radiation.
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LMA: Laryngeal mask airway.

local anesthetic: An agent whose anesthetic action is limited to an area of the
body determined by the site of injection or application.
MAC: Monitored anesthesia care.
Medical Executive Committee (MEC): This committee is the coordinating and
advisory body for all ambulatory surgery center programs that monitor or
evaluate quality and appropriateness of patient care.
MH: Malignant hyperthermia.
minor: A person under the age of 18 years old.
monitoring: Clinical assessment by direct observation or mechanical devices.
neuromuscular blocking agents (NMBAs): Pharmacologic agents that block
transmission of impulses at the neuromuscular junction, causing paralysis
of striated muscles.
NPO: Nothing by mouth.
NPSF: National Patient Safety Foundation.
NPSG: National Patient Safety Goals.
NSAIDs: Nonsteroidal anti-inflammatory drugs.
opioid: Any agonist drug with morphine-like activity.
orthostatic hypotension: A fall in blood pressure, associated with dizziness,
that occurs upon standing or sitting upright.
OSA: Obstructive sleep apnea.
oximetry: A photoelectronic measurement of the oxygen saturation of arterial
blood.
PACU: Postanesthesia care unit.
PEEP: Positive end-expiratory pressure.
pharmacokinetic: Relating to the amount of time a drug and its metabolites
interact in the body after administration by any route.
pharynx: The portion of the airway between the nasal cavity and the larynx;
consists of the nasopharynx, oropharynx, and hypopharynx
(laryngopharynx). Commonly referred to as the throat.
phenothiazines: A group of potent tranquilizers with antipsychotic action that
often also exhibit antiemetic and antihistaminic effect.
pneumonitis: Inflammation of the lung.
pneumothorax: An accumulation of air or gas in the pleural cavity; results in a
progressive increase in intrapleural pressure with lung collapse and
impairment of circulation.
POCD: Postoperative cognitive dysfunction.
POD: Postoperative delirium.
PONV: Postoperative nausea and vomiting.
procedural sedation/analgesia: A state of minimally depressed consciousness
in which the patient independently maintains airway control and responds
appropriately to physical stimulation and verbal commands.
prophylaxis: Prevention or protection against occurrence, injury, or disease.
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proprioception: Awareness of movement and position.

pruritus: Uncomfortable sensation of the skin leading to the urge to scratch.
PSDA: Patient Self-Determination Act.
Quality Assessment and Performance Improvement (QAPI) committee: A
committee charged with improving patient outcomes by developing,
implementing, and maintaining an ongoing, data-driven program that
addresses safety, service, patient outcomes, and financial considerations.
rales: Abnormal breath sounds produced by the flow of air through alveoli and
bronchioles that are constricted by spasm or filled with secretions.
regional anesthesia: Loss of sensation in a particular area of the body.
regurgitation: A backward flow, as with the flow of undigested food or gastric
fluid into the esophagus.
rhonchi: A coarse, rattling sound usually caused by secretions in the bronchial
tubes.
root cause analysis: A process of identifying the cause(s) of variation in
performance.
SBAR (situation, background, assessment, recommendation): A technique
for communicating critical information that requires immediate attention
and action concerning a patient’s condition.
sedatives: Drugs that promote calmness and drowsiness and may produce
some degree of amnesia and altered time perception.
sentinel events (also known as never events): Events that are defined in
ambulatory surgery as serious, preventable surgical events that can
impose a high physical and emotional toll for patients, their families, and
perioperative personnel.
somnolence: Prolonged or unnatural sleepiness or drowsiness.
spinal anesthesia: Loss of sensation and motor paralysis produced by the
injection of a local anesthetic agent into the subarachnoid space around
the spinal cord; also referred to as subarachnoid or intrathecal anesthesia.
SSI: Surgical site infection.
stridor: A harsh, high-pitched respiratory sound associated with severe upper
airway obstruction.
tachypnea: Excessively rapid rate of respiration (more than 25 breaths per
minute in adults).
TIVA: Total intravenous anesthesia.
TJC: The Joint Commission.
trachea: The cartilaginous tube extending from the larynx to its division into the
mainstem bronchi.
vasopressor: An agent that produces systemic arterial vasoconstriction
resulting in a rise in blood pressure.
wheeze: A high-pitched, whistling sound characterizing an obstruction or spasm
of the lower airways.
WHO: World Health Organization.
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Ambulatory Surgical Care, 3rd Edition

Ambulatory Surgical Care

Upon successful completion of this course, continuing education hours

ABOUT THE 3RD EDITION AUTHOR

ABOUT THE 1ST AND 2ND EDITION AUTHOR

Nance A. Seiple, RN, CRNA, MEd, is an independent medical communications

Nance A. Seiple has disclosed that she has no significant financial or

ABOUT THE PEER REVIEWER

Nurse Planner: Patricia Hojnowski-Diaz, MS, MBA, RN

The planner who worked on this continuing education activity has

Copy Editor: Graphic World, Inc.

Indexer: Dianne L. Schneider

COPYRIGHT© 2017—S.C. Publishing. All Rights Reserved. No part(s)

Begin this course by completing the pretest. Compare your answers to

1. What is one advantage of ambulatory surgery centers?

4. The preoperative nurse completes a deep vein thrombosis (DVT) assessment

5. Procedural sedation is defined as

6. During administration of a local anesthetic, the nurse suspects local anesthetic

7. According to The Joint Commission (TJC), in what instance is site marking

9. Which of the following would qualify a postoperative patient to transition from

10. Thirty minutes after intravenous administration of an antibiotic, the patient

1. Discuss the emergence, advantages, and challenges of ambulatory

3. Identify preoperative patient assessment requirements performed by

4. Recognize the various anesthetic agents and techniques used in the

8. Identify unique considerations relative to pediatric, geriatric, and special

9. Identify influential ambulatory surgery regulatory agencies and

1. Summarize the history and evolution of ambulatory surgery.

3. Discuss the various roles found in the ambulatory surgery setting.

HISTORY AND EVOLUTION OF AMBULATORY CARE

A 2012 survey of 201 freestanding ASCs across the country – representing

TYPES OF AMBULATORY SURGICAL FACILITIES

Hospital Outpatient Departments

The earliest ambulatory surgeries were performed in hospital-based facilities.

Ambulatory Surgery Centers

Office-Based Surgery Suites

The growth in the volume and complexity of office-based surgical procedures

ROLES IN AMBULATORY SURGERY

team members usually report to the ambulatory surgery administrator or director

Ambulatory surgery facilities should maintain accurate preference cards

THE REVENUE CYCLE

outsource this task to dedicated billing companies or handle it in-house with a

THE FUTURE OF AMBULATORY SURGERY

4. What activities generally occur in an ambulatory surgery business office?

5. How can an ambulatory surgery nurse contribute to inventory management?

6. Reimbursement to the ambulatory surgery facility is linked to

PATIENT SELECTION AND

1. Discuss appropriate ambulatory surgery procedures and patients.

3. Describe preadmission testing considerations and articulate requirements

4. Assess patient and caregiver learning needs.

1. To provide for a collaborated effort to gather information about the patient’s

5. To increase communication among all members of the multidisciplinary

6. To identify and reduce potential complicating factors specific to the individual

THE SELECTION PROCESS

<TABLE 2-1 WILL BE VIEWABLE AFTER PURCHASE>

The American Society of Anesthesiologists (ASA) has designed and used a

1. generally result in extensive blood loss,

2. require major or prolonged invasion of body cavities,

3. directly involve major blood vessels,

4. are generally emergent or life-threatening in nature,

5. commonly require systemic thrombolytic therapy,

3. Infants at risk for apnea, children who are febrile or dehydrated

4. Age limits if defined in each ASC’s Plan of Care

5. Known recent exposure to chicken pox or other highly communicable