Pre-op Assessment & Education and Discharge Assessment for the

Perianesthesia patient

1:45 – 3:00 PM

Objectives

• Describe preparation considerations for any patient having a procedure either in the ambulatory or hospital setting. (i.e. interventional radiology, pain clinic, office surgical procedures, endoscopy suites)

• Describe the Joint Commission identified expectations regarding education standards

• Recognize readiness for discharge after a procedure/surgery

Preoperative Nursing • Assessment

– Allergies & intolerances

– Pregnancy • Data collection/documentation

– Previous surgeries/anesthetics

– Family health history

– Current medications • Illicit meds

• Tobacco

• Naturals - herbals

• Signed and witnessed consents (Anesthesia, Surgery)

• Physiologic assessment - Systems

• Psychosocial assessment

• Spiritual/cultural assessment

Anesthesiologists meeting with Patients

• Educate about anesthesia, periop care and pain management

• Obtain pertinent info about medical history, physical and mental conditions

• Determine tests & consultations needed • Choice of care plans guided by patient choices &

risk factors • Obtain anesthesia informed consent • Minimize resource utilization yet achieve good

outcome

American Society of Anesthesiologists (ASA) states:

• No routine lab or diagnostic screening of patients is necessary, but should instead be based upon the patient’s specific clinical risk factors

• Tests should be ordered when the results may influence decisions during the course of the operation.

• Hemoglobin: Procedures with expected significant blood loss Patients with history of anemia or suspected anemia

• Basic Metabolic Panel (NA, K, CL, BUN, CR, Glucose, CA) Patients on diuretics Patients on digoxin All patients with known renal disease All diabetics All patients with bowel obstruction

• Comprehensive Metabolic Panel Basic Metabolic panel plus CO2, ALB, Alkaline Phosphatase,

Aspartate aminotransferase (AST-SGOT); Alamine aminotransferase (ALT-SGPT), Bilirubin and Total Protein.

Use for all patients with known liver and chronic renal disease

Coagulation

• PT, PTT, Platelets

• Patients with history of abnormal bleeding

• PT, INR (International Normalized Ratio) for patients on Coumadin

• PTT: Patient on heparin therapy

• Pregnancy;

• Any female of child-bearing age who could be pregnant.

• Patient must give verbal consent.

• The Discussion and consent or refusal should be documented.

• Blood Glucose: On all diabetics • Type and Screen/Type and Hold/Type and Crossmatch. • Patients who

– have donated their own blood – may receive blood. – may experience large blood loss – Have D&C for miscarriages

• EKG: • Males greater than 45 years

Females greater than 55 years History or symptoms of cardiac disease Significant pulmonary disease Cocaine Abuse

Electrocardiogram (EKG, ECG)

• History or symptoms of cardiac disease

• Significant pulmonary disease

• Cocaine Abuse

• Males greater than 45 & Females greater than 55

• Hyperlipidemia

• Tobacco abuse > 20 yr

• CVA, TIA

• Diabetes

• Chronic renal disease

• Obesity: Males > 115 kg

Females > 90 kg

• Chest X-Ray:

-Symptoms of pulmonary disease -Productive cough with fever

-Airway Obstruction -Cardiac Disease -Malignancy -History of heavy smoking

Signs of Heart Disease

CHF

Cardiomegaly

Digoxin therapy

• Cervical Spine: Mobility of neck?

Additional Testing

• Stress testing:

– Exercise: difficult to get complete test results

– Pharmacological: Dobutamine or Adenosine

– Stress Echo: Use with Dobutamine

• Echocardiography: Assessment Left ventricular function or Vascular disease

– Ejection Fraction <35% may predict postop Heart Failure especially those with worsening dyspnea

Obesity

1. Common physical finding

2. Morbid obesity is a total body disease

3. Determine ideal body weight and the body mass index

Body Mass Index Weight (kg) OR Weight (lbs) X 703 Height (M2) Height (inches)2

Normal = <25

Overweight = 25-29

Lowest obese weight = 30

Class I = BMI 30-34.9

Class II = BMI 35 – 39.9

Class III = BMI 40 or greater

Morbid Obesity

1. Twice the ideal body weight

2. Physiologic changes – Altered blood volume

• Increased total volume

• Decreased ml / kg

– Increased O2 demand

– Increased work of breathing

– Decreased lung volumes

– Decreased pulmonary compliance

Morbid Obesity

Physiologic changes – Hypoventilation / hypoxemia / polycythemia – Coronary artery disease

• Congestive heart failure

– Fatty liver

– Diabetes

– Renal insufficiency

Even the easy things are difficult in the morbidly obese patient

Fasting and Medications

• Fasting guidelines relaxed

• Patient hydration improved

• Adults: high risk patients kept NPO (Hiatal hernia, reflux, pregnancy)

• Pediatrics

• Infants

Fasting Instructions

• AGE MILK/SOLID CLEAR LIQUIDS

• 0-6 months 4 hours 2 hours

• 6-36 months 6 hours 3 hours

• > 36 months 8 hours 3 hours

• Adults:

– NPO after Midnight ( 8 hour fast)

– Clear liquids up to 2-3 hours before surgery

– Oral meds up to 1 hour before induction with up to 4 ounces of water.

– No chewing gum or candy

Herbal Remedies

• Ginseng - Used to enhance energy. Stimulant + = tachycardia, BP when used with Ephedra, decrease effect of warfarin so blood clots, May lower blood sugar

• Ephedra - Used as diet aid interacts with inhalants = BP, & irregular heart rate. Causes vasoconstriction, Blood sugar

• Feverfew - Used for migraines inhibits platelet activity so patients bleed

ginseng

Herbal Remedies

• Garlic - Used to lower lipids inhibits platelet activity, May ↓effect of oral contraceptives, hypoglycemic

• Valerian - used as mild sedative Causes potential increase in effect of barbiturates, May negate therapeutic effects of meds containing phenytoin as well as effects of warfarin

• Ginkgo biloba - Circulatory stimulant Decreases platelet activity and clotting ability. risk of seizures

Herbal Remedies

• St. John’s Wort - used to treat anxiety and depression. May prolong effects of narcotics and anesthetics

• Echinacea - Used to enhance immune system. May cause hepatoxicity and liver damage

• Ginger - Used to treat nausea. May increase absorption of oral meds. Can increase bleeding time

Herbal Remedies

• Goldenseal - used as a diuretic and laxative. Can worsen edema and BP. effect of alcohol, antidyrhythmics, anticoagulants, beta blockers. Slow metabolism of benzodiazepines & may lower Blood sugar

• Licorice - Used to treat gastritis and duodenal ulcers. Can cause edema and chronic liver problems. Can increase risk of renal insufficiency. Hypertensive crisis if used with Ephedra & MAOI’s, or tricyclics

Telephone Interview

• Telephone call the day before surgery by nurse, anesthesiologist

• Arrival time given

• Instructions reviewed

• Directions reinforced

• Questions answered

Preoperative Nursing Assessment Components

• Patient questionnaires

• Individual Interveiws

• History & Physical

• Testing

• Teaching/education

• Evaluation

Preoperative Education

• Professional Responsibility

– Self-assessment

–Biases

–Patient Education

Do You have Biases?

• Alcohol Use?

• Children?

• Elderly?

• Ethnicity?

• Female/male hangups?

• Obesity?

• Religion?

Patient and Family Education

• Work to improve knowledge & skill

• Prevent biases from affecting your duty

Teach Specifics

• Who

• What

• Why

• When

• Where

• How

Who/What

• Confirm who is having surgery

• Speak directly with patient unless a child

• Who will accompany patient

• Confirm needed things to bring

–Photo ID

– Insurance card

–Advance Directives

– Specifics to surgery

–Button down shirt after shoulder surgery

– If Admit, Leave valuables at home

Why • Provide rationale for all instructions i.e. marking site

of surgery, antiembolic stockings, bowel preps

• Thrombus formation increases with

–Obesity

–Prolonged surgery

–Pelvic surgery

– Long bone trauma

–Positioning

–Vasodilation with inhalation or spinal anesthesia

When/Where

• Time of surgery

• Time to be present

• NPO

• Where to park

• Where to present for surgery

• Where family will wait

How

• How will the day go

• Approximation of time explanations

After Surgery Teaching

• Postoperative risk reduction

• Preparing patient for discharge

• Prevention of atelectasis & pneumonia

• Prevention of clot formation & embolism

• Prevention of infection to promote wound healing

Goals of Patient Education

• Increase patient’s self-worth

• Decrease anxiety

• Reduce facility & provider liability

• Reduce hospitalization costs

• amount of perceived immediate and residual pain

• compliance

Preoperative Education benefit for nurses and institution

• Prepared patient

• Increased job satisfaction

• Reduced potential for litigation

• Decreased complaints about care

• Decreased Length of Stay

• Compliance with the JC requirements

Learner Characteristics

Demographics Primary language Developmental

level Mental,

emotional, educational limitations

Motivation & attitude

Special learning considerations Reading level Sensory

limitations Preferred level of

learning Physical

condition

Trust vs Mistrust (0 – 1 year)

• Consider Growth & Development

• Anxiety & stranger anxiety

• Spend time getting acquainted

• Encourage use of new or familiar play objects

• Allow child to use transitional objects ( blanket, pacifier)

• Teach parents to participate in care

• Handle child gently & speak in soft tones

Autonomy vs. Shame & Doubt (1-3 years)

• Children strive to maintain autonomy

• Give simple, direct and honest explanations

• Strong fear of abandonment

• Psychosocial skills are developing

• Play can be useful to anxiety (puppets, coloring books

• Toddlers need to play with medical equipment

Autonomy vs. Shame & Doubt (1-3 years)

• Let child make appropriate choices i.e. choose side of body for injection

• Explain things in brief nonthreatening terms; simple neutral words child understands

• Sitting at child’s level is helpful

• Invite parents to join in play

• Use play therapy as an emotional outlet to test child’s sense of reality

• Use words child understands

Initiative vs. Guilt (3-5 Years)

• Strives for sense of control, purpose, independence

• Body integrity is major issue

• Child may develop fear of bodily harm & mutilation

• Imagination consumes child’s thinking

• Magical thinking (Assumption reality & fantasy are the same; Child can magically influence)

• Information must be factual, nonthreatening, direct and related in simple terms

Initiative vs. Guilt (3-5 Years)

• Child masters experiences through use of imagination

• Role modeling

• Opportunities to make choices

• Play

• Let child handle equipment before procedure

• Use dolls to show anatomic sites and procedures

Industry vs. Inferiority (6-12 years)

• Skill acquisition characterizes this development stage

• Choices - allows child measure of control ( walk or ride; flavored anes mask)

• Thinking is concrete - children tend to be quite literal

• “put to sleep” may be associated with pet euthanasia

Industry vs. Inferiority (6-12 years)

• Use body models to explain

• Explain logically why a procedure is necessary

• Describe sensations to anticipate

• Encourage active participation

• Praise for cooperating with a procedure

Identity vs. Role Confusion (12-18 years)

• Adolescents seek identity in midst of physical & emotional changes

• Feelings of low self-esteem & self-consciousness typical

• Give scientific explanations, using body diagrams, models or videotapes

• Provide privacy

• Personal questions (I.e. drugs, ETOH, sexual activity) should be done in absence of parents if honest answers expected

Identity vs. Role Confusion (12-18 years)

• Encourage patient to express concerns about surgery especially as it relates to body image and peer conformity (encourage artwork, writing)

• Use books, diagrams

• Offer appropriate praise

Adults & Child Learner

• Even with preparation, separation anxiety for both child and parent is real

• See an increased trend for parents with child during induction especially ages 1-5

• Having parent dress in OR attire in front of child is important for child to be able to recognize parent

Child’s Experience

Behavior can be altered for days, weeks or months after surgery.

More positive the experience the less likely the child will have negative behavioral response.

Some negative behavioral response include: -nightmares, -eating problems, -separation anxiety, -withdrawal, -apathy, -escalated fear of physicians; -increased rebelliousness toward parents and

guardians

Principles of Adult Learning

Knowles: Focus on facilitating the acquisition of the content by the learner not just on transmitting the content.

Adults & Child Learner • Adult

Internal motivation

Self-direction

Role of experience as a learning resource

Difficult to accept New concepts

Problem centered orientation to learning

• Child

Does not assume responsibility for learning (Dependent on adult)

Less experience to rely on

Open to new concepts

Subject centered

Elderly Patients

• Less formal education • Sensory deficits can interfere with ability to

learn • Barriers to Learning

– Physiological – Emotional – Cultural – Environmental – Language barriers – Inadequate or poor teaching

Previous experience Prior education Patient perception and expectations Potential misinformation Psychosocial Health beliefs Attitudes Stress Coping Skills Social support Anxiety

Present Knowledge

Learning Environment

• Conducive to learning

• Quiet, private

• Decrease anxiety

• Facilitate learning

• Family oriented

• Lack of physical/mental barriers

Hurried environment leaves patients feeling confused and rushed through

the system jeopardizing the essence of patient focused

preoperative care

Expected Behaviors

• NPO

• Medications

• Leave valuables, jewelry at home

• Ride home

• Responsible caregiver

Postoperative Behaviors

• Alterations in comfort (pain, sore throat) • Passive exercises • Ambulation • Deep breathing & coughing • Dressing care • Diet • Signs & symptoms • Nausea & vomiting • Emergency contacts

Education Materials

• Written: handouts, booklets

• Teaching models: joints, ear, eye, devices, etc.

• Demonstration: physical skills

• Audiovisual programs: videotapes, slides, photographs

Teaching Methods/Materials

• Individual • Group • Tours (4-12 year olds) • Play Therapy (3-7 years of age) • Written (5-6th grade level) • Models ( 3-6 year olds) • Films – Videos (7 – 12 years old) • Demonstrations • Teleconferencing

Day of Surgery

• Greatest need: psychosocial

• Less emphasis on information, skills

• More on reassurance, support

• Limit to essential

• Include family or companion

Advantages & Limitations

• Cost issues

• Accessibility & patient acceptance

• Institutional or facility needs or limitations

• Patient outcomes

Evaluation

• Self-report

• Direct Observation

• Return demonstration

• Teaching sheets

• Outcome standards

Documentation

• Always: document teaching!!

• Remember....if it is not documented, it is not done

Success is measured by:

• Patient readiness, compliance

• Patient satisfaction surveys

• Reduction in anxiety

• Controlling feelings of powerlessness

• Early diagnosis and treatment

• Increased patient confidence

=

To offer patients the BEST in preoperative care, nurses need to create an environment in which patients are free to identify their

fears and anxieties

Teaching Characteristics & Domains of Learning

• Knowledge of teaching-learning characteristics • Use Common language • Anxiety & pain impede learning • Adult learning is goal directed • Reinforce learning • Knowledge of teaching tools • Knowledge of content • Domains of Learning

– Cognitive (understanding) – Psychomotor (motor skills) – Affective (attitudes)

Cognitive

• Recall facts, information

• Understand concepts

• Apply learned ideas, facts

• Analyze

• Problem solve

• Intellectual abilities

Psychomotor

• Use muscular action

• Use control

• Demonstrate a skill

• Perform an action

• Manipulate objects

• Ability to perform

Affective

• Change

• Attitudes, beliefs, values

• Develop

• Specific feelings, interests

• Involves emotions & attitudes

The patient receives education and training specific to patient’s needs and as appropriate to care and services provided by the organization.

• The assessment of learning needs addresses

– Cultural and religious beliefs

– Emotional barriers

– Desire and motivation to learn

– Physical or cognitive limitations

– Barriers to communication

– The content is presented in an understandable manner.

– Comprehension is evaluated

“Discharge criteria should be developed in consultation with the anesthesia department…

Discharge criteria must be approved by the department of anesthesiology and the medical staff.”

The RN will adhere to institutional policy for patient reassessment following discharge.”

ASPAN Standards 2012-2014 Practice Recommendation 2

(Components of Assessment for the Perianesthesia patient)

Discharge Assessment Phase I

• Airway & Respiratory/ventilatory status

• Cardiac & hemodynamic status

• Thermoregulation • Level of Consciousness • Pain Level • Sedation level • Comfort level • Sensory/motor function

• Patency of tubes, catheters, drains, IV

• Skin color & condition • Condition of dressing

&/or surgical site • Intake and Output • Medication management • Emotional status • Child-parent/significant

others interaction • Post Anesthesia Scoring

status if used.

Discharge Assessment Phase II (In addition to Phase I DC assessment)

• Ambulation

• Swallowing

• Voiding/urine volume if indicated

• Patient and home care provider knowledge of discharge instructions

• Written discharge instructions given to patient/accompanying responsible adult

• Arrangements for safe transportation from the institution

• Provision of additional resources to contact if any problem arises.

Medications

• Previously prescribed meds

– When to resume

• Newly prescribed meds

– Name, dose, purpose, time ‘Next dose due’ should be written on Discharge Instruction sheet (antibiotics, pain meds)

Newly Prescribed Analgesic Medications

• Drug name, dose, purpose • Proper usage according to onset and

duration of action and physician prescription

• Self medication using pain scale • Acetaminophen warning if appropriate • What to do if pain is not relieved • Driving/alcohol use while taking pain

medications

Activity Restrictions

• Next 24 hours – Light activity/no important decisions/no

driving

• Dizziness/drowsiness expected • Restrictions depend on surgical procedure • Lifting/weight bearing • Be in the care of a responsible adult for first

24 hours • Sexual Activity: Varies according to types of

procedures done.

Diet/Elimination

• Any restrictions ordered by MD

• Foods to avoid

– May cause PONV (spicy/greasy)

• Laxatives/stool softeners

– Due to opioids or procedure

– Diet alterations to minimize constipation

• Voiding

– By when and what to do if unable

Anesthesia Side Effects

General Anesthesia/Sedation

• Dizziness/drowsiness – Rise slowly, limit activity

• PONV, myalgia

• Sore throat

• Impaired psychomotor and cognitive skills

• General malaise

Anesthesia Side Effects

Regional / Blocks

• Motor function may return before sensory – Protect limb

• Careful positioning and protection

• Signs and symptoms that should be reported and who to contact

Hygiene

• When patient can bathe and shower

• How to protect dressings or incision

• What to do with drains while bathing

Possible Complications

• Signs and symptoms indicative of postop complications

– Fever > 38.3°C (101°F)

– Breathing problems

– Bleeding – dressing saturated with continually increasing amount of blood

– Pain unrelieved by medication

Possible Complications

• Urinary retention or inability to void within defined time frame

• Persistent PDNV

• Extreme swelling/redness around surgical wound

• Drainage change to yellow or green

• Change in pain: increase in or change in location or characteristic

Treatments or Tests

• Procedures – Dressing changes, ice/heat treatment

• List supplies needed

• Follow-up tests if ordered

• Postop follow-up with surgeon

• Teaching about – Use of crutches, incentive spirometer,

antiembolic stockings, drain/catheter care

Operative Site/Wound Care

• Instructions for care – Dressing changes

• Prevention of infection – Including hand washing & dressing disposal

• Sexual activity – Clarify physician’s instructions if appropriate

• Extremity care – Swelling, numbness or tingling

• Ice/elevation as ordered

Emergency Care

• When to seek treatment

• Whom to contact

• Where to go

Documentation of Discharge Teaching

• Specific information taught

• Specific instruction sheets provided to patient

• Method of instruction: verbal, written, return demonstration

• Patient’s response to instructions provided

• Nurse’s assessment of patient/family/significant other’s understanding of instructions

Documentation of Discharge Teaching

• Instructions should be signed by the nurse and person to whom they were given (family/accompanying responsible adult) according to facility policy

PACU Discharge Criteria

• Awake with muscle strength

• Patent airway / good respiratory function

• Stable vital signs

• Patency of tubes, catheters, IV’s

• Condition of surgical site

• Comfort / anxiety

Vital Signs

Within 20% of preoperative value

Within 20-40% preoperative value

40% of preoperative value

Ambulation & Mental Status

Oriented X3 and has a steady gait

Oriented X3 or has a steady gait

Neither

Pain, or Nausea/vomiting

Minimal

Moderate

Severe

Surgical Bleeding

Minimal

Moderate

Severe

Intake and output

Has had PO fluids and voided

Has had PO fluids OR voided

Neither

Chung’s Postanesthesia Discharge System (PADSS)

The total score is 10, with patients scoring ≥9 fit for discharge home

Modified Postanesthesia Discharge Scoring System (MPADSS)

The total score is 10, with patients scoring ≥9 fit for discharge home

Vital Signs

Within 20% of preoperative value

Within 20-40% preoperative value

40% of preoperative value

Ambulation

Steady gait/No dizziness

With assistance

None/Dizziness

Pain

Minimal

Moderate

Severe

Nausea/ vomiting

Minimal

Moderate

Severe

Surgical Bleeding

Minimal

Moderate

Severe

Aldrete’s Modified Postanesthesia Scoring System A minimum score of 9/10 (and/or return to similar preop status) is

achieved prior to transferring the patient to a Phase II recovery area

Category Score =2

Score = 1

Score = 0

Respirations

Breathes and coughs freely

Dyspnea

Apnea

O2 Saturation

SpO2 > 92% on Room air

Supplemental O2

SpO2 < 92% on O2

Circulation

BP +/- 20 mm Hg preop value

BP +/- 20-50 mm Hg preop value

BP +/- 50 mm Hg preop value

Level Of Consciousness

Awake and oriented

Wakens with stimulation

Non-responsive

Movement

Moves 4 limbs spontaneously

Moves 2 limbs spontaneously

Moves 0 limbs spontaneously

Post Procedure Follow-Up

• Telephone call

• Written survey

Purpose of Phone Call

• Evaluate patient’s general condition • Assess patient satisfaction • Provide positive marketing for facility • Provides nurse with completion; adds to

nurse satisfaction • Legally

– Potential liabilities addressed ASAP, may avoid lawsuit if problem identified/corrected early

• Performance Improvement

Postop Phone Calls

• Ideally should be done 24 to 48 hours after visit - follow facility policy

• Should be done by Perianesthesia nurse (to address patient teaching needs)

• Facility policy addresses how many attempts should be made to contact patient

Patient Privacy

• Do not call patient at work unless patient requests

• Do not divulge to family members who is calling

• In Preop ask patient: for an accurate phone number to call and best time to call

Questions to Ask

• Do you have any problems related to your procedure or anesthesia?

• Are you – Eating, drinking, voiding without difficulty?

• Is your pain controlled?

• What level of discomfort/pain are you experiencing? (0 – 10)

• Is there anything we could have done to make your stay better?

Documentation

• In patient’s record

–Problems identified or statement of patient’s well being

–Any issues related to compliance with DC Instructions

–Any referrals made to patient

One Last Word About Postop Phone Calls…

Share any positive comments from patients to the staff responsible

Questions??

References

• Drain, Cecil & Jan Odom-Forren. Perianesthesia Nursing: A Critical Care Approach. 5th edition St. Louis: Saunders Elsevier. 2009.

• Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care. 2009. Philadelphia: F.A. Davis Company.

• Nagelhout, John & Karen Plaus. Handbook of Nurse Anesthesia. 4th Edition. St. Louis: Saunders Elsevier. 2010

• Schick, Lois & Pam Windle (Editors) Perianesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU nursing. 2nd Edition . St. Louis: Mosby Elsevier. 2010.

• Skidmore-Roth, Linda. Herbs & Natural supplements. 4th edition. St. Louis: Mosby Elsevier. 2010.

• Ziolkowski, Linda. “Herbal Agens and the Perianesthesia Patient” Presentation April 21, 2009 at 28th ASPAN National Conference in Washington, D.C.

References • ASPAN Perianesthesia Nursing Standards and Practice

Recommendations 2010-2012. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses, 2010

• Atlee, John. Complications in Anesthesia. 2nd Edition. Philadelphia:

Saunders Elsevier. 2007 • Chung, F: Discharge criteria- a new trend. Can J. Anaesth 42(11): 1056

• Cole, Daniel and Michelle Schlunt. Adult Perioperative Anesthesia: The

Requisites in Anesthesiology. Philadelphia: Mosby Elsevier. 2004

• Odom-Forren, Jan. Drain’s Perianesthesia Nursing: A Critical Care

Approach. 6th edition. St. Louis, MO: Saunders Elsevier. 2013

• Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care.

Philadelphia: F.A. Davis Company. 2009

• Pasero, Chris & Margo McCaffery. Pain Assessment and

Pharmacologic Management. St. Louis: Elsevier Mosby. 2012

• Putrycus, Barbara & Jacqueline Ross. ASPAN’s Certification Review

for Perianesthesia Nursing. St. Louis: Elsevier Saunders 2013

• Reed, Alan. Clinical Cases in Anesthesia. 2nd Edition. New York:

Churchill Livingstone.1995

• Schick, Lois and Pamela Windle (Editors) PeriAnesthesia Nursing

Core Curriculum: Preprocedure, Phase I and Phase II PACU

Nursing. 2nd Edition. St. Louis, MO: Saunders Elsevier, 2010.

• Stannard, Daphne and Dina Krenzischek. PeriAnesthesia Nursing

Care: A Bedside guide for safe recovery. Sulbery MA: Jones &

Bartlett Learning. 2012

References

• His and hers heart disease accessed at

http://www.health.harvard.edu/fhg/updates/his-and-hers-heart-

disease.shtml

• Obstructive Sleep Apnea. Accessed at www.CritCareMD.com

• Pulmonary Disorders accessed at

http://dynamicnursingeducation.com/class.php?class_id=55&pid=1

8

• Sutherland, Sara. “Pulmonary Embolism: Treatment and

Medication” at http://emedicine.medscape.com/article/759765-

treatment

• What is Obstructive Sleep Apnea (OSA)? Accessed at

http://www.medicalnewstoday.com/articles/178633.php

ON Line References