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Five Clinical Post-Anesthesia Practice Guidelines for RNs

Higher Education Articles July 31, 2013

Professional Competence and Public Safety

According to an American Nurses Association’s Position Statement approved in May 2008 and titled Professional Role Competence, “the public has a right to expect registered nurses to demonstrate professional competence throughout their careers.” Responsibility for this assurance of professional competence is shared among:

  • The profession itself, through constant self-evaluation
  • Individual registered nurses (RNs) through independent learning and investigation
  • Professional nursing organizations such as those that establish practice guidelines for specific clinical situations
  • Credentialing, licensing and certification organizations such as some states’ requirements to a minimum number of Continuing Education (CE) courses for license renewal
  • Regulatory agencies, such as state Boards of Nursing and their regulations controlling licensure
  • Employers through orientation, seminars and policy and procedure manuals
  • Other key stakeholders

A Working Definition of Practice Guidelines

The Agency for Healthcare Research and Quality (AHRQ) is a national agency that helps ensure public safety through its National Guideline Clearinghouse (NGC), “a public resource for evidence-based clinical practice guidelines.” As noted by the NGC, a clinic practice guideline is not synonymous with any of the following terms used in by multiple authors in many different contexts:

  • Guideline
  • Protocol
  • Practice parameter
  • Pathway
  • Standard

Instead, the NGC relies on specific “Inclusion Criteria” as determined by the Institute of Medicine (IOM). This institution defines clinical practice guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Thus, a clinical practice guideline is an objectively derived and statistically significant proven rule of thumb that leads patient care under specific circumstances.

Five Summarized Practice Guidelines – Clinical Practice Guideline #1: American Society of Perianesthesia Nurses Pain & Comfort Clinical Guideline: Preoperative Phase Assessment

  • Vital signs, including pain and comfort goals
  • Medical history
  • Pain history
  • Pain behaviors /expressions or history
  • Analgesic history
  • Patient’s preferences
  • Pain/comfort acceptable levels
  • Comfort history
  • Educational needs
  • Cultural language preference, identification of personal beliefs, and resulting restrictions
  • Pertinent laboratory results


  • Identify patient, validate physician’s order and procedure
  • Discuss pain and comfort assessment
  • Discuss with the patient and family … information pain intensity using numerical or FACES rating scales and available pain relief and comfort measures
  • Discuss and dispel misconceptions about pain and pain management
  • Encourage the patient to take a preventative approach to pain and discomfort by asking for relief measures before pain and discomfort are severe or out of control
  • Educate purpose of intravenous or epidural patient-controlled anesthesia (PCA) as indicated; educate about the use of non-pharmacological methods
  • Discuss potential outcomes of pain and discomfort treatment approaches
  • Establish pain relief/comfort goals with the patient
  • Arrange interpreter throughout the continuum of care as indicated
  • Utilize interventions for sensory-impaired patients
  • Report abnormal findings including laboratory values
  • Arrange for parents to be present for children

Expected Outcomes

  • Patient states understanding of care plan and priority of individual needs
  • Patient states understanding of pain intensity scale, comfort scale, and pain relief/comfort goals
  • Patient establishes realistic and achievable pain relief/comfort goals
  • Patient states understanding or demonstrates correct use of PCA equipment as indicated
  • Patient verbalizes understanding of non-pharmacologic methods of alleviating pain and discomfort

Clinical Practice Guideline #2: American Society of Perianesthesia Nurses Pain & Comfort Clinical Guideline: Post-anesthesia Phase I Assessment

  • Refer to preoperative phase assessment, interventions and outcomes data
  • Type of surgery and anesthesia technique, anesthetic agents, reversal agents
  • Analgesics
  • Pain and comfort levels on admission and until transfer to a receiving unit or discharge home
  • Assessment parameters
    • Functional level and ability to relax
    • Pain: type, location, intensity
    • Self-report of comfort level using a numerical scale or other institutional approved instruments
    • Physical appearance
    • Other sources of discomfort
    • Achievement of pain relief/comfort treatment goals
  • Age, cognitive ability and cognitive learning methods
  • Status/vital signs
  • Airway patency, respiratory status, breath sounds, level of consciousness, and pupil size as indicated and other symptoms related to the effect of medications
  • Blood pressure
  • Pulse/cardiac rhythm unit
  • Oxygen saturation
  • Motor and sensory functions post-regional anesthesia technique


  • Identify patient correctly; validate physician’s order, implement correct drug, dose, amount, route and time; include the type of surgery and surgical site as applicable
  • Pharmacologic
    • Mild to moderate pain — use nonopioids and may consider opioid
    • Moderate to severe pain — use multi-modal therapy
    • Utilize the three opioid groups appropriately
      • Non-opioids
      • U-Agonist opioids
      • Adjuvants
        • Multipurpose for chronic pain
        • Multipurpose for moderate to severe acute pain
        • Neuropathic continuous pain
        • Neuropathic lancinating pain
        • Malignant bone pain
        • Post-orthopedic surgery
  • Initiate and adjust IV and regional infusions as (PCA) as indicated and ordered, and based on hemodynamics status
  • Non-pharmacologic intervention used to complement, not replace, pharmacologic interventions
  • Administer comfort measures as needed
  • Physiological
  • Sociocultural
  • Psychospiritual
  • Environmental
  • Cognitive behavioral

Expected Outcomes

  • Patient maintains hemodynamic stability including respiratory/cardiac status and level of consciousness
  • Patient states achievement of pain relief/comfort treatments goals
  • Patient states he/she feels safe and secure with the instructions
  • Patient shows effective use of at least one non-pharmacologic method
  • Patient shows effective use of PCA as indicated and discusses results of regional techniques
  • Patient verbalizes evidence of receding pain level and increased comfort with pharmacologic and non-pharmacologic interventions

Clinical Practice Guideline #3 & #4: American Society of Perianesthesia Nurses Pain & Comfort Clinical Guideline: Post-anesthesia Phase II & III Assessment

  • Refer to preoperative phase and Phase I assessments, interventions and outcomes data
  • Achievement of pain/comfort treatment goals and level of satisfaction with pain relief and comfort management
  • Pain relief/comfort management plan for discharge and patient agreement
  • Educational and resource needs, considering age, language, condition and cognitive appropriateness


  • Identify patient correctly; validate physician’s order, implement correct drug, dose, amount, route and time; include the type of surgery and surgical site as applicable
  • Pharmacologic interventions
  • Continue and/or initiate non-pharmacologic measures from Phase I
  • Educate the patient and family/caregiver
    • Pain and comfort measures
    • Untoward symptoms to observe
    • Regional or local anesthetic effects dissipating after discharge
    • Availability of resource as needed
  • Discuss misconceptions, expectations and implement a plan of action satisfactory to patients
  • Address nausea with pharmacologic interventions and other techniques and discuss expectations

Expected Outcomes

  • Patient states acceptable level of pain relief and comfort with movement or activity at the time of transfer or discharge to home
  • Patient verbalizes understanding of discharge instruction plans
    • Specific drug to be taken
    • Frequency of drug administration
    • Potential side effects of medication
    • Potential drug interactions
    • Specific precaution to take when following medication
    • Name and telephone number of physician/resource to notify about pain, problems and other concerns
  • Patient states understanding or shows effective use of non-pharmacologic methods
  • Patient states achievement of pain/comfort treatment goals and level of satisfaction with pain relief and comfort management in the perianesthesia setting.

Clinical Practice Guideline #5: American Society of Perianesthesia Nurses Normothermia Clinical Guideline: PACU Post-anesthesia Phase I & II Patient Management Recommendations Assessment

  • Identify the patient’s risk factors for peri-operative hypothermia
  • Document and communicate all risk factor assessment findings to all members of the health care team
  • Measure patient temperature on admission to the PACU
    • If normothermic, continue to measure temperature at least hourly, at discharge and as indicated by patient condition
    • If hypothermic, measure temperature at a minimum of every 15 minutes until normothermia is achieved
  • Determine patients thermal comfort level
  • Assess for signs and symptoms of hypothermia


  • If the patient is normothermic, provide thermal comfort measures:
    • Implement passive thermal care measures
    • Maintain ambient room temperature at or above 24 C (75 F)
    • Assess patient thermal comfort level on admission, discharge, or more frequently as indicated
    • Observe for signs and symptoms of hypothermia
    • Reassess temperature if patients thermal comfort level changes and/or signs or symptoms of hypothermia occur
      • Implement active warming measures as indicated below
    • Measure patient temperature prior to discharge
  • If the patient is hypothermic, in addition to normothermic interventions, initiate active warming measures:
  • Apply forced-air warming system
  • Consider adjuvant measures
    • Warm intravenous fluids
    • Humidified warmed oxygen
  • Assess temperature and thermal comfort level every 15 minutes until normothermia is achieved
  • Discharge teaching: Instruct the patient responsible adult of method to maintain normothermia after discharge.

Expected Outcomes

  • Patient achieves normothermia before discharge from the Phase I and/or Phase II PACU
  • Patient verbalizes thermal comfort

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