Purpose To evaluate decision support strategies that enhance bedside clinical reasoning among PACU nurses, focusing on feasibility, applicability, and contextual relevance. Design A modified e-Delphi study. Methods The study was conducted in four phases: questionnaire development, pilot testing, iterative expert consensus rounds, and data analysis. Fourteen strategies were evaluated: Journaling, Thinking Aloud, Mentoring, Shared Decision-Making, Gibbs’ Reflective Cycle, NEWS, Integrative Nurse Coach, Multi-Criteria Decision Analysis, NEXUS, Toolkit (4A, 5MP, TAM, and Feedback), Restraint Decision Tree, Team Concept Mapping, Shared Decision-Making with Personal Health Records, and the Universal Form of Treatment Options. Data were collected via Google Forms and analyzed using SPSS and content analysis. Consensus was defined as greater than or equal to 75% agreement. Findings Of 30 invited experts, 20 completed Round 1 and 14 completed Round 2 (67% response rate; 30% dropout). Ten strategies reached consensus in Round 1, with strong support for reflective, collaborative, and evidence-based approaches such as mentoring, shared decision-making, and team concept mapping. Four strategies were refined and re-evaluated in Round 2. Simulation training and structured briefing/debriefing were also noted as beneficial. Barriers included digital literacy, ethical concerns, and contextual fit. Conclusions Adaptable, ethically sound, and interdisciplinary strategies are needed to support clinical reasoning in PACU nursing, informing future education, practice, and policy.
PURPOSE:To develop and evaluate a competency-based training program for novice operating room nurses. DESIGN:A sequential exploratory mixed-methods study. METHODS:The program was developed via literature review, stakeholder interviews (n=30), and a two-round Delphi expert consensus (n=19). A quasi-experimental study assigned 64 new nurses to an intervention group (competency-based training) or a control group (conventional training). Outcomes included knowledge, skills, competency, coordination quality, and surgeon satisfaction. FINDINGS:Strong expert consensus was achieved. Compared with the control group, the intervention group showed significant improvements across all outcomes (p<.01). CONCLUSION:The program effectively enhances novice nurses' competencies and clinical performance, providing an evidence-based framework for standardizing onboarding training in surgical settings.
PURPOSE:Preoperative anxiety contributes to the perioperative stress response and may influence recovery. Midazolam is commonly used for premedication, while dexmedetomidine has emerged as a potential alternative with a different safety profile. This study aimed to compare their effects on perioperative stress and clinically relevant outcomes. DESIGN:Prospective, randomized, double-blind controlled trial. METHODS:Fifty-nine ASA I-II adult patients undergoing elective laparoscopic cholecystectomy were randomized to receive intravenous dexmedetomidine (0.3 µg/kg) or midazolam (0.03 mg/kg) for premedication. Plasma adrenocorticotropic hormone (ACTH) levels were measured at baseline, pre-induction, and 2 hours postoperatively. Secondary outcomes included hemodynamic parameters, postoperative pain scores, neutrophil-to-lymphocyte ratio, and perioperative adverse events, while anxiety was assessed preoperatively. FINDINGS:ACTH concentrations decreased over time in both groups. Preinduction ACTH concentrations were lower in the midazolam group (2.9 [2.1-4.5] vs 4.3 [2.6-7.9] pmol/L; P= .040), whereas no between-group differences were observed at baseline or 2 hours postoperatively. Hemodynamic parameters, anesthetic and opioid requirements, and postoperative pain scores were comparable between groups. Hypotension and bradycardia were more frequent with dexmedetomidine but without statistical significance. No significant associations were observed between anxiety, ACTH levels, and inflammatory markers. CONCLUSIONS:No statistically significant differences were observed between low-dose dexmedetomidine and midazolam in the measured perioperative clinical outcomes. Although midazolam resulted in lower pre-induction ACTH concentrations, this isolated finding was not accompanied by differences in postoperative ACTH concentrations or clinical outcomes. These findings suggest that the measured psychological, neuroendocrine, and inflammatory components of the perioperative stress response may not be directly correlated, and provide one of the first direct comparisons of pre-induction ACTH responses between dexmedetomidine and midazolam.
PURPOSE:Postoperative pain is a multidimensional experience that may be difficult to express using conventional pain descriptors. Metaphorical expressions can reveal the physiological, psychological, social, and spiritual meanings embedded in patients' pain experiences and provide additional insight into postoperative pain. The purpose of this study was explore how surgical patients express postoperative pain through metaphors and to identify the underlying meaning domains reflected in these expressions. DESIGN:A descriptive phenomenological study. METHODS:The study included 88 patients who underwent surgery in the general surgery and urology clinics of a university hospital. Data were collected through face-to-face semi-structured interviews conducted approximately 24 hours after surgery between August 1 and December 1, 2023. Participants completed a demographic information form and responded to a metaphor-elicitation prompt ("Pain is like… because…"), followed by probing questions. Data were analyzed using Giorgi's descriptive phenomenological approach. Coding and categorization techniques derived from qualitative content analysis were used solely to facilitate the systematic organization of participants' metaphorical expressions. FINDINGS:Participants' mean age was 46.93 ± 16.35 years; 83.0% had previous surgical experience, and 73.9% reported prior negative pain experiences. Participants generated 91 metaphor statements representing 14 distinct metaphors. Analysis revealed four overarching meaning domains of postoperative pain: psychological, physiological, social, and spiritual. Psychological meanings emerged most prominently, reflecting fear, stress, anger, restlessness, and loss of control. Physiological meanings emphasized bodily threat and functional restriction, whereas social and spiritual meanings illustrated burden, helplessness, endurance, transformation, and existential meaning-making. Collectively, participants described postoperative pain as extending beyond physical discomfort to encompass emotional, social, and spiritual dimensions. CONCLUSIONS:Metaphorical expressions provide an additional perspective on how patients make sense of postoperative pain that extends beyond physical discomfort. The findings suggest that brief metaphor-based questions may complement conventional pain assessment by offering an additional perspective on how patients make sense of postoperative pain. Further research is needed to determine their feasibility and potential value for supporting patient-centered communication in perianesthesia nursing care.
PURPOSE:This study aimed to determine the risk and contributing factors of pressure injuries related to surgical positioning and medical devices in older adults in the postanesthetic care unit (PACU). DESIGN:A descriptive cross-sectional design guided this project. The study was based on the clinical question: What are the risk levels and contributing factors for positioning- and device-related pressure injuries in older PACU patients? METHODS:The study was conducted between November 2024 and May 2025 with 150 patients aged 60 years and older who underwent general anesthesia for surgeries lasting longer than 60 min. Risk levels were assessed using the Braden Scale, the Risk Assessment Scale for Surgical Positioning, and the Medical Device-Related Pressure Injury Risk Scale (ELPO). Assessments were performed at admission to PACU, post-extubation, and before discharge. Demographic, clinical, and perioperative data were also analyzed to identify contributing risk factors. FINDINGS:Sixty-one percent of patients were at high risk for positioning-related pressure injuries, especially those aged 65-84 and smokers. Abdominal and orthopedic surgeries were the most common procedures. Additionally, 28% of patients were at high risk for medical device-related pressure injuries. Although risk levels decreased after extubation, they remained high in patients who required prolonged mechanical ventilation or inotropic support. Advanced age, smoking status, duration of ventilator use, and the need for inotropic therapy were identified as significant contributors to increased risk. CONCLUSIONS:Older PACU patients are at substantial risk for positioning- and device-related pressure injuries, especially when additional clinical factors are present. Early identification and proactive prevention strategies are essential to reduce risk in this population. Future studies should evaluate the effectiveness of targeted preventive interventions and integrate standardized risk assessment tools into routine PACU practice.
PURPOSE:This study was conducted to determine the impact of preoperative anxiety on postoperative pain and comfort levels in patients following ureteroscopy. DESIGN:Descriptive cross-sectional study. METHODS:The sample population of the study consisted of 212 patients who were planned to undergo ureteroscopy because of urinary system stones at a Urology Clinic. Descriptive Information Form, Early Perioperative Comfort Scale, Visual Analog Scale, State Anxiety Scale, and Surgical Anxiety Scale were used to collect study data. RESULTS:In the study, it was determined that the average score of the Surgical Anxiety Scale was 21.75±3.46, the average score of State Anxiety Scale was 35.94±6.43, the pain intensity of the patients at the 4th postoperative hour was 5.75±1.84, the pain intensity at the 8th hour was 2.53±1.86, mean total score of the Perianesthesia Comfort Scale was 4.48±0.6, and 41.0% of the patients experienced moderate-to-high levels of preoperative anxiety. In this study, it was found that as the preoperative anxiety scores of the patients increased, the severity of postoperative pain increased, and the comfort level decreased. Preoperative anxiety was observed to be a significant predictor of pain severity and comfort level at the 4th and 8th hours postoperatively. CONCLUSION:It was demonstrated in this study that nearly half of the patients experienced moderate-to-severe preoperative anxiety, and preoperative anxiety was a crucial factor affecting postoperative pain and comfort levels.
PURPOSE:To evaluate the impact of a nurse-led, multifaceted quality improvement initiative on reducing post-anesthesia care unit (PACU) length of stay (LOS) and patient boarding in a governmental hospital. DESIGN:Quality improvement study using a Root Cause Analysis (RCA) framework and pre-post intervention evaluation. METHODS:A multidisciplinary team conducted a retrospective review of PACU data over a 12-month baseline period to identify clinical and operational contributors to prolonged PACU stays among boarded patients. Targeted, evidence-based interventions were implemented, including symptom-inclusive discharge criteria, adoption of the Bromage Score for patients receiving spinal anesthesia, enforcement of documentation timelines through a service-level agreement, optimization of staffing mix and rotation, improved communication with bed management, streamlined transfer processes during shift changes, and revision of blood transfusion practices. Outcomes were assessed by comparing PACU LOS, boarding rates, and safety indicators before and after implementation. FINDINGS:Following implementation, substantial improvements in patient flow were observed. The mean number of boarded patients decreased from 716.6 per month at baseline to 129.6 per month three months postintervention. Mean cumulative PACU LOS was reduced from 745.3 h/mon to 215.5 h/mon. Standardized discharge assessment and operational workflow improvements contributed to more timely transfers without increases in postoperative adverse events, unplanned PACU readmissions, or escalation of care. CONCLUSIONS:A nurse-led, system-based quality improvement approach can significantly reduce PACU length of stay and boarding while maintaining patient safety. These findings highlight the critical role of nursing leadership in optimizing perioperative care and strengthening health system efficiency in public hospital settings.
PURPOSE:To evaluate the efficacy of remifentanil in maintaining hemodynamic stability along with postoperative recovery in cerebral palsy (CP) children following tourniquet use during orthopedic surgery (OS). DESIGN:A retrospective cohort study. METHODS:In this retrospective cohort study, we included CP children received remifentanil infusion at 40 minutes after tourniquet application before OS surgery. In the adjustment group, remifentanil dose increased to 0.5 µg/kg/min at 40 post-tourniquet application, and then gradually reduced to 0.25 µg/kg/min at 60 minutes. The control group maintained a constant dose of 0.25 µg/kg/min over the same period. Then we compared the blood pressure (BP), heart rate (HR), intraoperative blood loss, recovery after anesthesia, inpatients' length-of-stay (LOS), mobilization out of bed after OS, incidence of adverse events (AEs), and sedation and pain scores between the groups. FINDINGS:The adjustment group showed significantly lower BP and HR during surgery. Additionally, they experienced shorter anesthesia recovery time, LOS, and earlier mobilization. Sedation and pain scores, as well as the incidence of AEs, were also significantly lower in adjustment group compared to controls. CONCLUSIONS:Dose modulation of remifentanil infusion in children reduced BP and HR, and shorten recovery time after anesthesia, LOS, and time to mobilization out of bed after OS, with less AEs.
PURPOSE:This article describes methods of reducing emergence delirium, and subsequently narcotic administration, in the post-anesthesia care unit (PACU) using an intraoperative dexmedetomidine bolus and evidence-based education bundles. DESIGN:Quality improvement (QI) project including retrospective data analysis and evidence-based education bundle intervention. METHODS:Compared the administration of narcotics to pediatric dental patients pre- and post-intervention of intraoperative dexmedetomidine bolus and presentation of evidence-based education bundles to PACU nurses and certified registered nurse anesthetists (CRNAs). FINDINGS:The intervention of evidence-based education bundles and intraoperative dexmedetomidine bolus resulted in significant decrease (p < 0.001) in narcotic administration in the PACU. CONCLUSIONS:Implementation of intraoperative dexmedetomidine and perioperative staff education to prevent and identify emergence delirium for pediatric dental patients resulted in decreased postoperative narcotics administration in the PACU, although no significant change in length of stay.
PURPOSE:This study aimed to evaluate the effect of acupressure applied before gastrointestinal endoscopy on patients' pain, anxiety, and nausea levels, with implications for perianesthesia nursing care. DESIGN:A single-center, randomized, sham-controlled experimental study. METHODS:Sixty patients scheduled for gastrointestinal endoscopy who met the inclusion criteria were enrolled. Patients were randomly assigned to either the acupressure group or the sham acupressure group, with 30 patients in each group. In the acupressure group, patients received 15 minutes of acupressure at the HT7, LI4, and PC6 points before the procedure, while the sham group received 10 minutes of sham acupressure. Data were collected using a Personal Information Form, visual analog scale (VAS) for pain and nausea, and the Spielberger State Anxiety Scale. Statistical analyses included independent and paired t-tests, Mann-Whitney U test, Friedman and Pearson χ² tests, and repeated measures ANOVA with Bonferroni correction. FINDINGS:Following the interventions, the acupressure group experienced a significant reduction in VAS pain and nausea scores compared to the sham group (P<.001). Furthermore, the third measurement of State Anxiety scores was significantly lower in the acupressure group (P=.035). CONCLUSIONS:Acupressure before endoscopy effectively reduces anxiety and alleviates pain and nausea after the procedure. However, the limitations of these findings should be acknowledged. Further validation with larger sample sizes and multicenter studies is recommended before considering routine clinical application.
PURPOSE:This study aimed to (1) identify modifiable preoperative risk factors for postoperative delirium (POD) in elderly patients undergoing hip surgery under general anesthesia, and (2) evaluate the feasibility and potential effectiveness of a nurse-led, home-based physical and cognitive intervention to prevent POD. DESIGN:A two-phase mixed-method study was conducted, consisting of a retrospective cohort analysis (Phase 1) and a prospective non-randomized interventional study with historical controls (Phase 2). Phase 1 analyzed 42 patients aged ≥70 years to identify preoperative risk factors. Phase 2 evaluated a 14-day home-based exercise and cognitive training program (59 intervention; 79 controls). FINDINGS:Phase 1 identified preoperative bed rest (OR = 6.66, P =.03) and inadequate comprehension of orientation materials (OR = 18.17, P =.02) as significant POD risk factors. In Phase 2, POD occurred in 5.1% of the intervention group versus 12.7% of controls (P =.153). Adherence was high: 69.5% completed exercise training, 76.3% completed cognitive training, and 64.4% achieved full completion of both intervention components. No adverse events were reported. Although statistical significance was not reached, a trend toward reduced POD incidence was observed. CONCLUSIONS:A nurse-led, dual-component preoperative intervention combining physical and cognitive training demonstrated high feasibility, strong adherence, and potential clinical applicability in elderly hip surgery patients. These findings support further investigation of scalable non-pharmacological perioperative strategies for POD prevention.
PURPOSE:Postoperative nausea and vomiting (PONV) is commonly seen after laparoscopic gynecological surgery despite standard prophylaxis. Dexamethasone-ondansetron is widely used but may be undesirable due to metabolic and wound-related effects. We evaluated whether haloperidol-ondansetron is non-inferior for PONV prevention. DESIGN:Randomized, double-blind, non-inferiority trial. METHODS:120 women (ASA I-II, aged 18 to 60 years) undergoing laparoscopic gynecological surgery were randomly assigned to receive intravenous haloperidol 1 mg plus intravenous ondansetron 4 mg (HO, n = 62) or intravenous dexamethasone 8 mg plus intravenous ondansetron 4 mg (DO, n = 58). The primary outcome was the incidence of PONV within 24 hours. Secondary outcomes included nausea severity, vomiting episodes, rescue antiemetic requirement, time to first rescue antiemetic, postoperative pain scores, sedation, delirium, and QTc interval. FINDINGS:PONV occurred in 45.2% (HO) and 50.0% (DO) (risk difference: -4.8%, 95% CI: -23% to 13%; risk ratio 0.90, 95% CI: 0.62 to 1.31). As the upper bound of the confidence interval (13%) was below the pre-specified non-inferiority margin of 15%, non-inferiority was established. HO was associated with lower early postoperative nausea and pain scores during the first two hours. Rescue antiemetic use, sedation, delirium, and QTc interval were comparable between groups. No patient developed QTc less than 500 milliseconds or arrhythmia. CONCLUSIONS:Haloperidol-ondansetron is non-inferior to dexamethasone-ondansetron for PONV prophylaxis after laparoscopic gynecological surgery. Lower early postoperative pain scores were observed with haloperidol-ondansetron, although this exploratory finding should be interpreted cautiously. The regimen may be considered an alternative in patients for whom corticosteroid use is undesirable.
PURPOSE:Pediatric patients are vulnerable to perioperative anxiety, while pharmacological and routine nursing approaches may be constrained by adverse effects and insufficient developmental support. Child Life Service (CLS) offers structured, developmentally appropriate psychosocial care, but its overall effectiveness and optimal application remain unclear. This systematic review and meta-analysis synthesized the effects of CLS compared with traditional nursing care and examined variations across study characteristics. DESIGN:Systematic review and meta-analysis. METHODS:This study was conducted in accordance with PRISMA guidelines. CNKI, Wanfang, PubMed, Embase, Scopus, and Web of Science were searched from inception to December 1, 2025, for Chinese- and English-language randomized or quasi--randomized controlled trials. Risk of bias was assessed using the Cochrane RoB Tool. Standardized mean differences with 95% confidence intervals were pooled using a random-effects model. FINDINGS:Eighteen studies involving 1863 pediatric patients were included. Across 25 post-intervention measurement time points, CLS was associated with significantly lower anxiety in the preoperative phase (SMD = -1.06, 95% CI [-1.53, -0.60]), during anesthesia induction (SMD = -1.87, 95% CI [-2.88, -0.86]), and in the postoperative phase (SMD = -1.38, 95% CI [-1.84, -0.92]). Substantial heterogeneity was observed across all phase-specific analyses. Subgroup analyses by types of surgery, anxiety assessment tools, and age groups supported a greater effect of CLS, but did not explain the heterogeneity. According to the GRADE framework, the certainty of evidence was low. CONCLUSIONS:This review suggests that CLS may reduce perioperative anxiety across different perioperative time points, surgical contexts, and age groups, supporting its integration into multidisciplinary perioperative care for pediatric patients and their caregivers.
PURPOSE:This study aimed to investigate the prevalence and characteristics of perioperative sleep disturbances in children undergoing elective surgery, to identify associated risk factors, and to develop and validate a predictive nomogram for the early identification of high-risk patients. DESIGN:This was a prospective cross-sectional study. METHODS:Between June and December 2024, 361 children aged 3 to 12 years scheduled for elective surgery under general anesthesia were enrolled using a two-stage mixed sampling method. Sleep was assessed using the Children's Sleep Habits Questionnaire (CSHQ) and caregiver sleep via the Pittsburgh Sleep Quality Index (PSQI). Univariate analysis was first performed to identify potential predictors, followed by least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation for data-driven variable selection. Multivariable logistic regression was then conducted to determine independent risk factors, and statistically significant predictors were incorporated into the final nomogram. Model evaluation included assessment of discrimination (Area Under the Curve, AUC; concordance index, C-index), calibration (Hosmer-Lemeshow test, calibration curve), and clinical utility (Decision Curve Analysis, DCA). Internal validation was conducted using a 70%/30% stratified split (training/test set) and bootstrap resampling (1000 repetitions). Sensitivity analyses were conducted using alternative CSHQ cutoffs ( ≥48 and ≥54) to assess the stability of prevalence estimates and model performance. FINDINGS:The perioperative sleep disturbance detection rate was 90.0% (325/361) using the standard CSHQ cutoff of ≥41, with core symptoms of sleep resistance (56.0%), sleep anxiety (42.4%), and abnormal sleep duration (36.0%). Sensitivity analyses revealed that raising the CSHQ cutoff to ≥48 reduced prevalence to 67.3% (AUC = 0.684) and to ≥54 reduced prevalence to 36.8% (AUC = 0.606), indicating that the original cutoff provided optimal discriminative performance (AUC = 0.800). Using the standard cutoff, independent risk factors included preschool age (OR = 0.196, 95% CI: 0.045 to 0.850), female sex (OR = 0.470, 95% CI: 0.221 to 0.997), caregiver college education or higher (OR = 1.359, 95% CI: 1.001 to 1.844), and caregiver sleep disturbance (OR = 2.552, 95% CI: 1.031 to 6.320) (all P < .05). Caregiver sleep disturbance remained the only consistently significant predictor across all CSHQ thresholds (OR range: 2.143 to 2.552, all P ≤ .043). The nomogram demonstrated good discrimination (training set AUC = 0.800, 95% CI: 0.711 to 0.888; test set AUC = .771, 95% CI: 0.644 to 0.898; bootstrap-corrected C-index = 0.800) and calibration (mean absolute error = 0.014). DCA confirmed clinical utility within a 25% to 75% threshold probability range. CONCLUSIONS:Perioperative sleep disturbances are highly prevalent in pediatric surgical patients, influenced by both child and caregiver factors. The prevalence is threshold-dependent (range: 36.8% to 90.0%), and caregiver sleep disturbance emerged as the most robust predictor. The validated nomogram provides a clinically useful tool for preoperative risk stratification, enabling early identification and targeted intervention for high-risk children. Multicenter external validation and establishment of perioperative-specific CSHQ thresholds are recommended.
