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Chapter 3
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Phase I and Phase II


Recovery
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Theresa L. Clifford, MSN, RN, CPAN, CAPA

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As early as 1751, at the Newcastle Infirmary in New- the highest priority (American Society of PeriAnes-
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castle, England, rooms were reserved for patients thesia Nurses [ASPAN], 2015). During this phase
who had undergone major surgery or who were of care, perianesthesia nurses conduct assessments,
critically ill. Over 100 years later, Florence Nightin- engage in monitoring, and intervene to maintain
gale prepared separate rooms for patients who were airway patency and hemodynamic stability as well
experiencing the © immediate
Jones effects of anesthesia.
& Bartlett Learning, LLC as manage pain, fluids, thermal
© Jones comfort, and otherLearning, LL
& Bartlett
By the 20th century, there were records of
NOT FOR SALE OR DISTRIBUTION recovery aspects of patient care. The primary
NOT FOR SALEgoal is to fa-
OR DISTRIBUT
rooms at Boston City Hospital in Massachusetts, cilitate the transition of the patient from this level
Johns Hopkins Hospital in Maryland, Cook County of care to Phase II level of care in preparation for
Hospital in Illinois, and New Britain General Hospital discharge to home or to an inpatient setting for
in Connecticut (Barone, Pablo, & Barone, 2003). continued care.
©By the late
Jones & 1940s,
Bartlettthe Learning,
value of dedicated
LLC recov- © Jones & Bartlett Learning, LLC
ery rooms was gaining acceptance. An anesthe- 3.  What are the admission assessment
NOT FOR SALE OR DISTRIBUTION NOT FOR
recommendations SALEI level
for Phase OR DISTRIBUTION
of care?
sia study commission of the Philadelphia County
Medical Society reported that postoperative nurs- Multiple and concurrent assessments occur upon
ing care could have eliminated nearly one-third of admission to the Phase I level of care (ASPAN,
preventable postsurgical deaths during an 11-year 2015). A transfer of care report is delivered by the
period (Ruth,
© Jones & Bartlett Haugen,LLC
Learning, & Grove, 1947). © Jones & Bartlett
transferring Learning,
provider. LLC
This report may include, but
NOT FOR SALE OR DISTRIBUTION NOT is not SALE
FOR limited to,
OR information
DISTRIBUTION regarding preopera-
1.  How has the scope of perianesthesia services
tive history, type and length of anesthesia, medi-
evolved?
cations administered, type of procedure, relevant
The scope of perianesthesia services has expanded fluid status, and any actual or potential complica-
over the years in a number of ways. Advances in tions. The actual physical assessment of the patient
technology have © Jones
allowed for& Bartlett
more complexLearning,
proce- LLC © Jonesstatus,
includes ventilation and respiratory & Bartlett
vital Learning, LL
dures to be done NOT on an FOR
outpatient
SALE basis.
ORAdvances
DISTRIBUTIONsigns, pain and sedation levels,
NOTneurologic
FOR SALE andOR DISTRIBUT
in the development of anesthesia medications have neurovascular status, sensory motor status, integu-
allowed for more rapid induction and less recovery mentary and wound status, fluid status, and assess-
time. In addition, there has been a vast increase ments specific to the actual procedure.
in the volume of diagnostic and interventional
© Jones being
procedures & Bartlett Learning,
done using LLC
a range of anesthesia 4.  What are the most&common
© Jones Bartlettpatient care LLC
Learning,
techniques priorities during Phase I level of care?
NOT FORrequiringSALE OR closeDISTRIBUTION
intra and postprocedure NOT FOR SALE OR DISTRIBUTION
monitoring by perianesthesia nurses. The first priority for patient care in Phase I level
of care is the establishment and maintenance of
2.  How is Phase I recovery defined?
a stable airway with adequate ventilatory sup-
Phase I is the level of care in which close monitor- port. Determination of hemodynamic stability
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ing is required LLC
and basic life-sustaining needs are ©of Jones
and & Bartlett Learning,
the initiation LLC
of any interventions to support
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19
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20 3  /  Phase I and Phase II Recovery

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NOT FOR cardiovascular function is also a priority. An-
SALE OR DISTRIBUTION NOTprovide
FOR care to two
SALE ORpatients who are described as
DISTRIBUTION
other clinical priority in Phase I is the provision follows:
of adequate pain and comfort measures and the
• One unconscious, stable, without artificial air-
evaluation of the effectiveness of any multi-
way, and over the age of 8 years and one con-
modal techniques, including pharmacologic or
scious, stable, and free of complications
nonpharmacologic © Jones & Bartlett
interventions. Learning, LLC
An additional © Jones & Bartlett Learning, LL
main concern is related • Two conscious, stable, and free of
NOTtoFOR the actual
SALEimpact of
OR DISTRIBUTION complications
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the surgical procedure and assessment of wound
integrity. • Two conscious, stable, 8 years of age and un-
der, with family or competent support staff
5.  What are some common potential complications present (ASPAN, 2015)
during Phase I level of care?
© Jones & Bartlett Learning, LLC © Jones
A patient–nurse ratio of&one
Bartlett Learning,
to one occurs at the LLC
NOT FORassociated
Complications SALE OR withDISTRIBUTION
Phase I level of care in- NOT FOR SALE OR DISTRIBUTION
time of admission until the patient is thoroughly
clude airway compromise, cardiovascular depression, assessed and determined to be stable, or if the pa-
pain, nausea, vomiting, delirium, and disturbances in tient has an unstable airway, or if the patient is 8
thermoregulation. years of age and under and unconscious. The most
seriously ill patients—those that are critically ill
© Jones &6. Bartlett
How longLearning,
does Phase LLCI last? © Jones & Bartlett Learning, LLC
and unstable—require two nurses for safe care and
NOT FOR Determining
SALE OR DISTRIBUTION
when the patient is ready to move NOT FOR SALE OR DISTRIBUTION
recovery.
from one phase of perianesthesia care to the next
is best determined by assessing the wide variety of 9.  What are equipment recommendations for Phase I
reactions and responses to the administration of level of care?
anesthesia, as well as the reactions and responses
© Jones & Bartlett Learning,Each
to the surgical/procedural experience. In addition
LLCpatient care area where©Phase JonesI care&isBartlett
provided Learning, LL
should have, but is not limited to, the following
to the individuality NOT FORaSALE
of patients, number ofORfac-DISTRIBUTION
equipment:
NOT FOR SALE OR DISTRIBUT
tors impact the overall readiness to move (Clifford,
2009). These may include variables such as prac- • General stock supplies for patient care, includ-
titioner preference in anesthetic choices, the need ing dressings
for preoperative anxiolytics, a history of prolonged • Supplies for emergency and preemptive
© Jones & Bartlett Learning, LLC
emergence, and the presence of preexisting medi-
© Jones & Bartlett Learning, LLC
bedside response, including oxygen delivery
cal NOT FORThe
conditions. SALE ORtoDISTRIBUTION
decision move a patient from NOT
devices, FORand
airways, SALE ORequipment
suction; DISTRIBUTION
for
one level of care to the next should be based on measuring vital signs, ventilation, and cardio-
clinical assessments and desired patient outcomes vascular monitoring
and criteria. The ASPAN Standards for Perianesthe- • Stock medications and intravenous fluids
sia Nursing Practice provide comprehensive lists of
© Jones &assessment
Bartlett Learning, LLC • Patient warming devices
criteria that can be used for discharge © Jones & Bartlett Learning, LLC
NOT FOR from
SALE ORI DISTRIBUTION
Phase and Phase II (ASPAN, 2015). NOT FOR SALE OR
• Adequately DISTRIBUTION
stocked age-specific emergency
carts
7.  What are the discharge assessment • Personal protective equipment (ASPAN, 2015)
recommendations for Phase I level of care?
10.  How is Phase II recovery defined?
Patients are generally assessed prior to discharge
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from Phase I level of care to determine the follow- Phase II is the level of care in which clinical care
NOT FOR SALE
ing: adequacy of airway and ventilatory status, OR DISTRIBUTION
and strategic planning are aimed NOTatFOR SALE OR DISTRIBUT
preparing
cardiac and hemodynamic stability, normothermia, the patient for return home or for transition to ex-
management of pain and comfort, integrity of sur- tended care for further observation.
gical wound and dressings, and fluid balance.
11.  What is the difference between Phase I and
© Jones
8.  What are the&staffing
Bartlett Learning, LLC
recommendations for Phase II? © Jones & Bartlett Learning, LLC
NOT
Phase FOR
I level SALE OR DISTRIBUTION
of care? NOT FOR SALE OR DISTRIBUTION
Phase I describes the level of care provided when
According to the ASPAN Standards for Perianes- a patient is emerging from surgical, diagnostic, or
thesia Nursing Practice, it is recommended that two interventional procedures that require the admin-
registered nurses, one of whom is a nurse compe- istration of general or regional anesthesia or mod-
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tent in Phase I level of care, be in the same room/ © Jones & Bartlett
erate sedation. Learning,
The primary goalsLLC
of nursing care
unit where a patient
NOT FOR SALE OR DISTRIBUTION is receiving Phase I level of NOT FOR SALE OR DISTRIBUTION and main-
during Phase I include the establishment
care (ASPAN, 2015). In general, one nurse can tenance of a stable airway; hemodynamic stability,
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3  /  Phase I and Phase II Recovery 21

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including blood pressure and heart rate; fluid resus- and dressings,
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transportation from the facility,
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citation; pain management; nausea and vomiting and knowledge of discharge instructions.
management; normothermia management; and
assessment for wound integrity and bleeding. “Con- 16.  How is “safe transportation” defined? SECTION
stant vigilance is required during this phase” (Clif- It is possible that, despite meeting the criteria
© Jones & Bartlett Learning, LLC
ford, 2009, p. 409–410).
Phase II describes theFOR
level of care provided when
for being discharged home, © ambulatory
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surgery pa- I
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tients may experience varyingNOTdegrees
FOR SALE OR DISTRIBUT
of sedation
the patient is being prepared for discharge to home and psychomotor impairment following anesthesia.
or an extended care environment. In this phase, the State regulatory agencies, accrediting organizations,
patient has a stable airway with good ventilatory and professional medical and nursing associations
status on room air (unless baseline status requires suggest that ambulatory surgery patients have a re-
© Jones &oxygen
supplemental Bartlett Learning,
at home), LLC pain
satisfactory sponsible © Jones accompany
individual & Bartletthim or
Learning, LLC
her home.
management
NOT FOR (as SALEdefined
ORbyDISTRIBUTION
the patient), satisfac- NOT can
This individual FOR SALEtoOR
function DISTRIBUTION
ensure that the
tory control of postoperative nausea and vomiting, patient is transported home safely, that the patient
appropriate ambulatory ability for procedure and can be assisted should minor issues related to pain
baseline, among other things (Clifford, 2009). or vomiting arise, and should be able to report any
postoperative/postprocedure complications.
12.  WhatLearning,
© Jones & Bartlett are the admission
LLC assessment © Jones & Bartlett Learning, LLC
recommendations for Phase II level of care?
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17.  What ORstaffing
are the DISTRIBUTION
recommendations for
Upon transfer to Phase II level of care, a transfer of Phase II level of care?
care report is delivered by the transferring provider. According to the ASPAN Standards for Perianesthe-
This report may include, but is not limited to, in- sia Nursing Practice, two competent personnel, one
formation regarding preoperative history; type and
© Jones & Bartlett Learning, of whom is a registered nurse
LLC competent
© Jones in Phase Learning, LL
& Bartlett
length of anesthesia; medications administered by II level of care, must be in the same unit where a
NOTand,
anesthesia providers; FOR SALE
during OR
Phase DISTRIBUTION
I level of NOT FOR SALE OR DISTRIBUT
patient is receiving Phase II level of care (ASPAN,
care, type of procedure, relevant fluid status, and SECTION
2015). In general, one nurse can provide care to
any actual or potential complications. The actual
physical assessment of the patient includes vital
three patients who are described as follows: over
8 years of age, or under 8 years of age with family II
signs, pain level, neurologic and neurovascular
© Jones & Bartlett Learning, LLC and present. A©patient–nurse ratio of one
Jones & Bartlett nurse to two
Learning, LLC
status, sensory motor status, integumentary patients is possible when one patient is 8 years of age
NOT FOR
wound status,SALE OR DISTRIBUTION
fluid status, and assessments specific NOT FOR SALE OR DISTRIBUTION
and under without family or support staff present
to the actual procedure. and during initial admission of the patient postpro-
13.  What are the most common patient care cedure. If any patient should become unstable and
priorities during Phase II level of care? require transfer to a higher level of care, the staffing
should allow for one nurse to care for one patient.
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The focusLearning, LLC
of care during Phase II is preparation of © Jones & Bartlett Learning, LLC
NOT FOR SALE
the patient for returning home or for transitioning NOT
OR DISTRIBUTION to FOR SALE
18.  What OR DISTRIBUTION
are equipment recommendations for
extended care for further observation. Adequate pa- Phase II level of care?
tient knowledge for continued care at home requires
Each patient care area where Phase II care is pro-
thorough patient/family teaching and documenta-
vided should have, but is not limited to, the follow-
tion of learning regarding discharge instructions.
© Jones & Bartlett Learning, LLC
ing equipment: © Jones & Bartlett Learning, LL
14.  What are some
NOT FORpotential
common SALE OR DISTRIBUTION NOT
• General stock supplies FOR SALE
for patient OR DISTRIBUT
care includ-
complications during Phase II level of care? ing dressings
Common issues requiring interventions during • Supplies for emergency and preemptive bed-
Phase II level of care include pain and nausea. Pro- side response, including oxygen delivery de-
longed
© Jonesdrowsiness may also
& Bartlett occur as well
Learning, LLCas a per- vices,
© airways,
Jones & andBartlett
suction Learning, LLC
SECTION
sistent sore throat. • Equipment for measuring vital signs
NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
15.  What are the discharge assessment • Stock medications and intravenous fluids III
recommendations for Phase II level of care? • Patient warming devices
Patients are generally assessed prior to discharge • Adequately stocked age-specific emergency
© Jones & Bartlett Learning, LLC
from Phase II level of care to determine the © Jones &carts
follow- Bartlett Learning, LLC
ing: adequacy of
NOT FOR SALE OR DISTRIBUTION pain and comfort interventions, NOT FOR• Personal
SALE OR protective equipment (ASPAN,
DISTRIBUTION
hemodynamic stability, integrity of surgical wounds 2015)
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22 3  /  Phase I and Phase II Recovery

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In addition, the unit should have adequate supplies NOT
NOT FOR SALE OR DISTRIBUTION REFERENCES
FOR SALE OR DISTRIBUTION
for transferring the patient from the unit.
American Society of PeriAnesthesia Nurses. (2015).
19.  What does the term “blended unit” mean? 2015–2017 Perianesthesia nursing standards, practice rec-
ommendations and interpretive statements. Cherry Hill, NJ:
A “blended unit” is a unit that cares for patients Author.
who are preparing for© Jones & Bartlett Learning,
surgery (preoperative phase), LLC C. P., Pablo, C. S., & Barone,
Barone, © Jones & Bartlett
G. W. (2003). A Learning, LL
NOT(Phase
recovering from surgery FOR ISALE OR DISTRIBUTION
and/or Phase history of the PACU. JournalNOT FOR SALE
of PeriAnesthesia OR DISTRIBUT
Nursing,
II), and/or who have recovered from surgery and 18(4), 237–241.
are waiting for an inpatient bed. As a result of the Clifford, T. (2009). Practice corner. Journal of PeriAnesthe-
expanding scope of services provided by postanes- sia Nursing, 24(6), 409–410.
Ruth, H., Haugen, F., & Grove, D. D. (1947). Anesthesia
thesia care units, patients arriving in postanesthesia
study commission. Journal of the American Medical As-LLC
care©units
Jones & longer the
are no Bartlett Learning, LLC
traditional postsurgi- © Jones & Bartlett Learning,
sociation, 135(14), 881–884.
NOT FOR
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It is not uncommon to find patients in NOT FOR SALE OR DISTRIBUTION
various stages of recovery from various levels of
anesthetics administered for the purpose of inter-
ventional or diagnostic radiologic procedures, from
sedation provided for endoscopic or colonoscopic
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Bartlett Learning,
or for LLCmonitoring.
postprocedural © Jones & Bartlett Learning, LLC
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