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Contents
Section I: The Postanesthesia Care Unit
Chapter 1: S pace Planning and Basic Equipment
Systems, 1
Chapter 2: Perianesthesia Nursing as a Specialty, 9
Chapter 3: Management and Policies, 18
Chapter 4: Crisis Resource Management in the
PACU, 34
Chapter 5: Infection Prevention and Control in the
PACU, 44
Chapter 6: The Changing Health Care System and
Its Implications for the PACU, 59
Chapter 7: Patient Safety and Legal Issues in the
PACU, 73
Chapter 8: Ethics in Perianesthesia Nursing, 86
Chapter 9: Evidence-Based Practice and
Research, 101
Section II: Physiologic Considerations in the
PACU
Chapter 10: he Nervous System, 110
T Chapter 42: Care of the Obstetric and Gynecologic
Chapter 11:The Cardiovascular System, 133
Chapter 12: The Respiratory System, 155
Chapter 13: The Renal System, 189
Chapter 14: Fluid and Electrolytes, 199
Chapter 15: The Endocrine System, 213
Chapter 16: The Hepatobiliary and Gastrointestinal
System, 221
Chapter 17: The Integumentary System, 228
Chapter 18: The Immune System, 234
Section III: Concepts in Anesthetic Agents
Chapter 19: B asic Principles of
Pharmacology, 243
Chapter 20: Inhalation Anesthesia, 260
Chapter 21: Nonopioid Intravenous
Anesthetics, 272
Chapter 22: Opioid Intravenous Anesthetics, 284
Chapter 23: Neuromuscular Blocking Agents, 297
Chapter 24: Local Anesthetics, 316
Chapter 25: Regional Anesthesia, 329
Section IV: Nursing Care in the PACU
Chapter 26: T ransition From the Operating Room
to the PACU, 347
Chapter 27: Assessment and Monitoring of the
Perianesthesia Patient, 357
Chapter 28: Patient Education and Care of the
Perianesthesia Patient, 385
Chapter 29: Postanesthesia Care
Complications, 398
Chapter 30: Assessment and Management of the
Airway, 417
Chapter 31: Pain Management, 431
Chapter 32: C are of the Ear, Nose, Throat, Neck,
and Maxillofacial Surgical Patient, 456
Chapter 33: Care of the Ophthalmic Surgical
Patient, 473
Chapter 34: Care of the Thoracic Surgical
Patient, 482
Chapter 35: Care of the Cardiac Surgical
Patient, 494
Chapter 36: Care of the Vascular Surgical
Patient, 531
Chapter 37: Care of the Orthopedic Surgical
Patient, 549
Chapter 38: Care of the Neurosurgical Patient, 565
Chapter 39: Care of the Thyroid and Parathyroid
Surgical Patient, 589
Chapter 40: Care of the Gastrointestinal,
Abdominal, and Anorectal Surgical
Patient, 594
Chapter 41: Care of the Genitourinary Surgical
Patient, 606
Surgical Patient, 624
Chapter 43: Care of the Breast Surgical
Patient, 637
Chapter 44: Care of the Plastic and Reconstructive
Surgical Patient, 648
Chapter 45: Care of the Patient Undergoing
Bariatric Surgery, 656
Chapter 46: Care of the Ambulatory Surgical
Patient, 664
Chapter 47: Care of the Laser/Laparoscopic
Surgical Patient, 677
Section V: Special Considerations
Chapter 48: C are of the Patient With Chronic
Disorders, 690
Chapter 49: Care of the Pediatric Patient, 707
Chapter 50: Care of the Older Patient, 733
Chapter 51: Care of the Pregnant Patient, 744
Chapter 52: Care of the Patient With Substance
Use Disorder, 753
Chapter 53: Care of the Patient With Thermal
Imbalance, 763
Chapter 54: Care of the Shock Trauma Patient, 774
Chapter 55: Care of the Intensive Care Unit Patient
in the PACU, 798
Chapter 56: Bioterrorism and Its Impact on the
PACU, 821
Chapter 57: Cardiopulmonary Resuscitation in the
PACU, 831
Drain’s
PERIANESTHESIA
NURSING
A Critical Care Approach

Seventh Edition

Jan Odom-Forren, PhD, RN, CPAN, FAAN

Associate Professor, College of Nursing
University of Kentucky
Lexington, Kentucky
Perianesthesia/Perioperative Consultant
Co-editor, Journal of PeriAnesthesia Nursing
Louisville, Kentucky
3251 Riverport Lane
St. Louis, Missouri 63043

DRAIN’S PERIANESTHESIA NURSING A CRITICAL

CARE APPROACH, SEVENTH EDITION ISBN: 978-0-323-39984-5

Copyright © 2018, Elsevier Inc. All Rights Reserved.

Previous editions copyrighted 2013, 2009, 2003, 1994, 1987, 1979.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechani-
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
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contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and
to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liabil-
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or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Names: Odom-Forren, Jan, author.
Title: Drain’s perianesthesia nursing : a critical care approach / Jan
Odom-Forren, PhD, RN, CPAN, FAAN, Associate Professor, College of Nursing,
University of Kentucky, Lexington, Kentucky, Perianesthesia/Perioperative
Consultant, Co-Editor, Journal of PeriAnesthesia Nursing, Louisville,
Kentucky.
Description: Seventh edition. | St Louis, Missouri : Elsevier, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2016053051 | ISBN 9780323399845 (hardback)
Subjects: LCSH: Post anesthesia nursing.
Classification: LCC RD51.3 .D73 2018 | DDC 617.9/19--dc23 LC record available at https://lccn.loc.gov/2016053051

Executive Content Strategist: Tamara Myers

Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Deepthi Unni
Production Manager: Andrea Lynn Villamero
Design Direction: Bridget Hoette

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 This edition of Drain’s Perianesthesia Nursing
is dedicated to all the perianesthesia nurses who work
day in and day out to assure that patients receive quality
care with optimal outcomes. This edition is particularly
dedicated to those perianesthesia nurses from the Center
for Advanced Surgery, University of Kentucky Medical
Center, Lexington, KY, and PACU/Phase II Recovery,
Baptist Hospital, Louisville, KY, who have put up with me,
encouraged me, and supported my research efforts.

Special thanks go to my entire family, who know what

it means when I disappear into the office and who share
me with my perianesthesia nursing colleagues—
Gary, Kelsey, Brittny, Patrick,
Andrew, Amabelle, and London—you keep me grounded,
and I love you.

Jan Odom-Forren
This page intentionally left blank

     
Contributors

Susan M. Andrews, BAN, MA, RN, CAPA Beverly Breyette, MSN, RN, CDE
Senior Staff Nurse, Perioperative Services Home Care Nurse
Augusta University Medical Center Malone Home Care
Augusta, Georgia Louisville, Kentucky
Chapter 2: Perianesthesia Nursing as a Specialty Maxim Healthcare Services
Chapter 3: Management and Policies Jeffersonville, Indiana.
Chapter 48: Care of the Patient With Chronic
Carolyn G. Baddeley, MSN, CRNA Disorders
Nurse Anesthetist, Department of Anesthesia
St. Jude Children’s Research Hospital Kathleen Broglio, DNP, ANP-BC, ACHPN,
Memphis, Tennessee CPE, FPCN
Chapter 33: Care of the Ophthalmic Surgical Patient Nurse Practitioner, Section of Palliative Care
Dartmouth Hitchcock Medical Center
Kay A. Ball, BSN, MSA, PhD, RN, CNOR, FAAN Lebanon, New Hampshire
Associate Professor, Nursing Department Chapter 52: Care of the Patient With Substance
Otterbein University Use Disorder
Westerville, Ohio
Consultant Nancy Burden, MS, RN
K&D Medical Inc. Retired
Lewis Center, Ohio New Port Richey, Florida
Chapter 26: Transition From the Operating Room Chapter 46: Care of the Ambulatory Surgical
to the PACU Patient
Chapter 47: Care of the Laser/Laparoscopic
Surgical Patient Joseph F. Burkard, DNSc, CRNA
Associate Professor
Andrea D. Bianco, BSN, MSN, RN, FNP-BC University of San Diego, School of Nursing
Primary Care San Diego, California
Veteran Administration Chapter 11: The Cardiovascular System
Postanesthesia Care Unit Chapter 15: The Endocrine System
UCSD Medical Center, Hillcrest Chapter 51: Care of the Pregnant Patient
San Diego, California
Chapter 15: The Endocrine System Matthew D. Byrne, PhD, RN, CPAN, CNE
Assistant Professor, Nursing
Elizabeth Boulette, MSN, CRNA Saint Catherine University
Staff CRNA Saint Paul, Minnesota
Paradise Valley Hospital Chapter 39: Care of the Thyroid and Parathyroid
National City, California Surgical Patient
Chapter 51: Care of the Pregnant Patient Chapter 44: Care of the Plastic and Reconstructive
Surgical Patient
Joni M. Brady, DNP, RN, CAPA
Director of Perioperative Innovation Sarah Marie Independence Cartwright, DNP,
North American Partners in Anesthesia BAM, RN-BC, CAPA
Melville, New York Perioperative Informatics Nurse Manager,
Chair, Board of Directors Perioperative Service
International Collaboration of PeriAnaesthesia Augusta University Medical Center
Nurses Augusta, Georgia
PeriAnaesthesia Nurses, Inc. Chapter 2: Perianesthesia Nursing as a Specialty
Chapter 39: Care of the Thyroid and Parathyroid Chapter 3: Management and Policies
Surgical Patient
Chapter 44: Care of the Plastic and Reconstructive
Surgical Patient

v
vi Contributors
Zohn Centimole, PhD, CRNA
Certified Registered Nurse Anesthetist,
Department of Anesthesiology
PhD Candidate, School of Nursing
University of Kentucky
Lexington, Kentucky
Chapter 18: The Immune System
Theresa L. Clifford, MSN, RN, CPAN, CAPA
Manager Perioperative Services, Surgical Services
Mercy Hospital
Portland, Maine
ASPAN Nurse Liaison for Special Projects
American Society of PeriAnesthesia Nurses
Cherry Hill, New Jersey
Chapter 43: Care of the Breast Surgical Patient
Chapter 45: Care of the Patient Undergoing
Bariatric Surgery
Ann Quinlan Colwell, PhD, RN-BC, AHNBC,
DAAPM
Pain Management Clinical Nurse Specialist
Clinical Effectiveness
New Hanover Regional Medical Center
Pain Management Consultant
Wilmington, North Carolina
Chapter 31: Pain Management
Lindsay Cosco-Holt, PhD, RN
Assistant Nurse Manager, Thornton Perioperative
Services
University of California San Diego
San Diego, California
Chapter 11: The Cardiovascular System
Thomas Corey Davis, PhD, CRNA
Vice Chair of Clinical Affairs
School of Allied Health Professions
Department of Nurse Anesthesia
Virginia Commonwealth University
Richmond, Virginia
Chapter 57: Cardiopulmonary Resuscitation
in the PACU
Cecil B. Drain, PhD, RN, CRNA, FAAN, FASAHP
Professor and Dean
School of Allied Health Professions
MCV Campus Virginia Commonwealth
University
Richmond, Virginia
Chapter 12: The Respiratory System
Chapter 20: Inhalation Anesthesia
Chapter 21: Nonopioid Intravenous Anesthetics
Chapter 22: Opioid Intravenous Anesthetics
Chapter 23: Neuromuscular Blocking Agents
Michael D. Fallacaro, DNS, CRNA, FAAN
Professor and Chair, Nurse Anesthesia
Virginia Commonwealth University
Richmond, Virginia
Chapter 4: Crisis Resource Management
in the PACU
Ken Faulkner, MA, MDiv
Assistant Professor, Department of Patient
Counseling
Virginia Commonwealth University
Advance Care Planning Coordinator
Virginia Commonwealth University Health
System
Richmond, Virginia
Chapter 8: Ethics in Perianesthesia Nursing
Susan J. Fetzer, BA, BSN, MSN, MBA, PhD,
CNL
Professor, College of Health and Human Services
University of New Hampshire
Durham, New Hampshire
Director of Research, Patient Care Services
Southern New Hampshire Medical Center
Nashua, New Hampshire
Chapter 13: The Renal System
Tracey Gendron, MSG, PhD
Assistant Professor, Gerontology
Virginia Commonwealth University
Richmond, Virginia
Chapter 50: Care of the Older Patient
Melody Heffline, MSN, RN, APRN, ACNS-BC,
ACNP-BC
Nurse Practitioner, Optum Clinical Services
Elkridge, Maryland
Nurse Practitioner, Southern Surgical Group
Lexington Medical Center
West Columbia, South Carolina
Chapter 36: Care of the Vascular Surgical Patient
Regina Hoefner-Notz, MS, RN, CPAN, CPN
Clinical Manager, Post Anesthesia Care Unit
Perioperative Services
Children’s Hospital Colorado
Aurora, Colorado
Chapter 49: Care of the Pediatric Patient
Vallire D. Hooper, PhD, RN, CPAN, FAAN
Manager, Nursing Research
Nursing Practice, Education, and Research
Mission Health
Asheville, North Carolina
Chapter 9: Evidence-Based Practice and Research
Chapter 53: Care of the Patient With Thermal
Imbalance

Karen A. Kane, MSN, RN, CPAN
Nurse Manager, Postanesthesia Care Unit/
Children’s Perioperative Unit
Virginia Commonwealth University Medical
Center
Adjunct Faculty, School of Nursing
Virginia Commonwealth University
Richmond, Virginia
Chapter 8: Ethics in Perianesthesia Nursing
Xinliang Liu, PhD
Assistant Professor, Department of Health
Management and Informatics
University of Central Florida
Orlando, Florida
Chapter 6: The Changing Health Care System and
Its Implications for the PACU
Mary Beth Flynn Makic, PhD, RN, CNS,
CCNS, CCRN-K, FAAN, FNAP
Associate Professor
University of Colorado, College of Nursing
Aurora, Colorado
Chapter 55: Care of the Intensive Care Unit Patient
in the PACU
Debra Pecka Malina, DNSc, MBA, CRNA,
FNAP
Self-Employed
Malina Anesthesia and Consulting Services
Temecula, California
Staff Anesthetist
Endoscopy Center of Inland Empire
Murrieta, California
Chapter 14: Fluids and Electrolytes
Chapter 17: The Integumentary System
Myrna Eileen Mamaril, MS, RN, NEA-BC,
CPAN, CAPA, FAAN
Clinical Nurse Specialist, Perioperative Services
Johns Hopkins Hospital
Baltimore, Maryland
Chapter 54: Care of the Shock Trauma Patient
Chapter 55: Care of the Intensive Care Unit Patient
in the PACU
Donna R. McEwen, BSN, RN, CNOR(e)
Instructional Designer Consultant
Optum/United Health Care
San Antonio, Texas
Chapter 32: Care of the Ear, Nose, Throat, Neck,
and Maxillofacial Surgical Patient
Contributors vii
John J. Nagelhout, PhD, CRNA, FAAN
Director
Kaiser Permanente School of Anesthesia
California State University Fullerton
Pasadena, California
Chapter 19: Basic Principles of Pharmacology
Chapter 24: Local Anesthetics
Chapter 25: Regional Anesthesia
Denise O’Brien, DNP, RN, ACNS-BC, CPAN,
CAPA, FAAN
Perianesthesia Clinical Nurse Specialist
Department of Operating Rooms/PACU
University of Michigan Hospitals and Health Centers
Adjunct Clinical Instructor
University of Michigan, School of Nursing
Ann Arbor, Michigan
Chapter 1: Space Planning and Basic Equipment
Systems
Chapter 28: Patient Education and Care of the
Perianesthesia Patient
Chapter 29: Postanesthesia Care Complications
Chapter 40: Care of the Gastrointestinal
Abdominal, and Anorectal Surgical Patient
Captain Lisa Osborne-Smith, PhD, CRNA
Associate Professor, Navy Senior Service Leader
Uniformed Services University of the Health
Sciences
Bethesda, Maryland
Chapter 56: Bioterrorism and Its Impact on the PACU
Corey R. Peterson, DNP, CRNA
Assistant Professor
Augusta University, College of Nursing
Augusta, Georgia
Chapter 10: The Nervous System
Chapter 16: The Hepatobiliary and
Gastrointestinal System
Jacqueline M. Ross, PhD, RN, CPAN
Patient Safety Analyst
Patient Safety
The Doctors Company
Napa, California
Chapter 7: Patient Safety and Legal Issues
in the PACU
Lois Schick, MN, MBA, RN, CPAN, CAPA
Per Diem Staff Nurse II, PACU
Lutheran Medical Center
Wheatridge, Colorado
Entrepreneur
Self-Employed Educator
Lakewood, Colorado
Chapter 27: Assessment and Monitoring of the
Perianesthesia Patient
viii Contributors
Patricia C. Seifert, MSN, RN, CNOR,
CRNFA(e), FAAN
Former Educator, Cardiovascular Operating
Room, Inova Heart and Vascular Institute
Falls Church, Virginia
Former Editor-in-Chief, AORN Journal
Association of periOperative Registered Nurses
Denver, Colorado
Independent Consultant
Falls Church, Virginia
Chapter 35: Care of the Cardiac Surgical Patient
Beverly A. Smith, BSN, RN, CPAN, CAPA
Nurse Manager, UHPACU
University of Michigan Health System
Ann Arbor, Michigan
Chapter 1: Space Planning and Basic Equipment
Systems
Lisa Sturm, MPH, CIC
Director, Infection Prevention and Epidemiology
University of Michigan Health System
Ann Arbor, Michigan
Chapter 5: Infection Prevention and Control
in the PACU
Alexander Tartaglia, MA, MDiv, DMin, BCC,
ACPE Supervisor
Senior Associate Dean
Virginia Commonwealth University, School of
Allied Health Professions
Professor, Patient Counseling
Virginia Commonwealth University
Richmond, Virginia
Chapter 8: Ethics in Perianesthesia Nursing
Melissa L. Thomas, MSN, RN, CAPA
PACU/Phase II Recovery Nurse Manager
Baptist Health Louisville
Louisville, Kentucky
Chapter 37: Care of the Orthopedic Surgical Patient
Chapter 38: Care of the Neurosurgical Patient
V. Doreen Wagner, PhD, RN, CNOR
Associate Professor
Kennesaw State University, WellStar School of
Nursing
Kennesaw, Georgia
Chapter 48: Care of the Patient With Chronic
Disorders
Carolyn A. Watts, PhD
Arthur Graham Glasgow Professor and Chair
Health Administration
Virginia Commonwealth University
Richmond, Virginia
Chapter 6: The Changing Health Care System and
Its Implications for the PACU
E. Ayn Welleford, MSG, PhD, AGHEF
Gerontologist
Chair and Associate Professor
Department of Gerontology
Virginia Commonwealth University
Richmond, Virginia
Chapter 50: Care of the Older Patient
Wendy K. Winer, BSN, RN, CNOR, RNFA
Director of Research and Technology
Development and Endoscopic
Surgery Specialist
Center of Endometriosis Care
Registered Nurse First Assistant, Gynecology and
General Surgery
Northside Hospital
Atlanta, Georgia
Chapter 41: Care of the Genitourinary Surgical
Patient
Chapter 42: Care of the Obstetric and Gynecologic
Surgical Patient
Suzanne M. Wright, PhD, CRNA
Associate Professor, Nurse Anesthesia
Vice Chair for Academic Affairs, Nurse
Anesthesia
Virginia Commonwealth University
Richmond, Virginia
Chapter 4: Crisis Resource Management
in the PACU
Chapter 30: Assessment and Management
of the Airway
Reviewers

Linda Beagley, MS, RN, CPAN
Clinical Nurse Educator/Quality Coordinator
Swedish Covenant Hospital
Chicago, Illinois
Elizabeth Card, MSN, APRN, FNP-BC, CPAN,
CCRP
Nursing Research Consultant
Vanderbilt University Medical Center
Nashville, Tennessee
Melanie Chichester, BSN, RNC-OB, CPLC
Staff Nurse, Clinical Level III, Labor & Delivery
Christiana Care Health System
Newark, Delaware
Denise O’Brien, DNP, RN, ACNS-BC, CPAN,
CAPA, FAAN
Perianesthesia Clinical Nurse Specialist
University of Michigan Health System
Ann Arbor, Michigan
Teresa Passig, BSN, RN, CPAN, CAPA, CCRN
Arnold Palmer Medical Center
Orlando, Florida
Donna DeFazio Quinn, RN, BSN, MBA,
CPAN, CAPA
Director
Orthopaedic Surgery Center
Concord, New Hampshire

Theresa L. Clifford, MSN, RN CPAN, CAPA Wanda Rodriguez, RN, MA, CCRN, CPAN
Nurse Manager Surgical Services Perianesthesia Nurse Educator
Mercy Hospital Memorial Sloan-Kettering Cancer Center
Portland, Maine New York, New York

Rebecca Francis, BSN, RN, CPAN Blake Shrout, PharmD

Registered Nurse Pharmacist
Johns Hopkins Children’s Center Kansas City, Missouri
Baltimore, Maryland
Twilla Shrout, BSN, MBA, RN, CPAN, CAPA
Christopher Patrick Henson, DO Staff Nurse, Ambulatory Procedure Unit
Assistant Professor, Division of Anesthesiology Harry S. Truman Memorial Veterans’ Hospital
Critical Care Medicine Columbia, Missouri
Vanderbilt University Medical Center
Nashville, Tennessee Terri Voepel-Lewis, PhD, RN
Associate Research Scientist
Jan Lopez, BSN, RN, CPAN, CAPA Mott Hospital, University of Michigan
Registered Nurse IV Ann Arbor, Michigan
St. Luke’s Hospital
Kansas City, Missouri V. Doreen Wagner, PhD, RN, CNOR
Associate Professor
Kathleen J. Menard, PhD, RN, CPAN, CAPA Kennesaw State University, WellStar School
Perianesthesia Nurse Education Specialist of Nursing
University of Massachusetts Memorial Medical Kennesaw, Georgia
Center
Worcester, Massachusetts Valerie Watkins, BSN, RN, CAPA
Clinical Nurse IV
Debby Niehaus, BSN, RN, CPAN Denver, Colorado
Clinical Ladder IV
Bethesda North Hospital Susan W. Wesmiller, PhD, RN
Cincinnati, Ohio Assistant Professor
University of Pittsburgh
Pittsburgh, Pennsylvania

ix
x Reviewers

Christol D. Williams, DNAP, CRNA
Assistant Professor, Nurse Anesthesia Program
Midwestern University
Glendale, Arizona
Pamela E. Windle, MS, RN, NE-BC, CPAN,
CAPA, FAAN
Nurse Manager, PACU & CV Preop/PACU
CHI Baylor, St. Luke’s Medical Center
Houston, Texas
Preface
Dr. Cecil Drain wrote the first edition of this book,
then titled The Recovery Room, after working with
“recovery room” nurses who had many questions
about care of the anesthetized patient. He discov-
ered that there were no texts that offered this kind
of information to nurses in this specialty. So after
working all day, Dr. Drain would write until the
wee hours of the morning. First published in 1979,
The Recovery Room has since become known as
the standard textbook for perianesthesia nurses.
Known unofficially as “the blue book,” the title has
evolved as the specialty has progressed, changing
from The Recovery Room to The Postanesthesia
Care Unit: A Critical Care Approach to Postanes-
thesia Nursing to Perianesthesia Nursing: A Criti-
cal Care Approach. This seventh edition continues
the tradition of excellence established originally
by Dr. Drain, providing the perianesthesia nurse
with the most comprehensive knowledge base for
this nursing specialty available under one cover.
The title of the seventh edition, Drain’s Perianes-
thesia Nursing: A Critical Care Approach, contin-
ues to reflect the evolving professionalism of this
advanced nursing practice specialty and to reflect
the time and effort of Dr. Drain in his pursuit to
provide a textbook with comprehensive informa-
tion about the complete nursing care of the patient
who undergoes a surgical procedure.
All the chapters in this seventh edition contain
an opening paragraph introducing the reader to
the topic to be discussed. After the introduction, a
complete section on the definitions of terms par-
ticular to the chapter topic is provided, and then
the chapter topic is presented in detail. The final
portion of the chapter contains a summary of the
material and references the reader can use to facil-
itate further reading about the topic. Evidence-
Based Practice boxes are present in Sections IV
and V that will alert the reader to new evidence
related to the chapter topic.
This book is organized into five major sections.
Section I, “The Postanesthesia Care Unit,” focuses
on the postanesthesia facilities and equipment,
the specialty of perianesthesia nursing, and man-
agement and policy issues. The chapter on crisis
resource management in the postanesthesia care
unit (PACU) covers the newest techniques in the
care of the patient with use of technology such
as anesthesia simulators and provides the most
up-to-date concepts with regard to patient safety.
The health care system continues to change, par-
ticularly in the PACU, so a chapter is devoted to
those changes and their impact on the PACU. The
chapter on research explores the basic concepts of
evidence-based practice (EBP) and their relation-
ship to research and explores the application of
EBP in the perianesthesia setting.
Section II deals with physiologic consid-
erations in the PACU. All chapters have been
revised to reflect current concepts in anatomy and
physiology. Section III, “Concepts in Anesthetic
Agents,” presents the reader with up-to-date phar-
macologic considerations of postanesthesia care.
Section IV addresses nursing care in the PACU
for various surgical specialties. Chapter 31, “Pain
Management in the PACU,” which includes dis-
cussions on related physiology and pharmacology,
has been extensively revised and updated.
Section V, “Special Considerations,” has been
revised and updated in this edition. This section
offers up-to-date information on the special needs
and concerns of perianesthesia nurses. Chapter
48, “Care of the Patient With Chronic Disorders,”
covers a range of chronic disorders experienced
by patients in the perianesthesia setting and has
been updated to reflect best practices. Chapter 52,
“Care of the Substance-Using Patient,” is timely
and has been extensively updated in this edition.
Chapter 53, “Care of the Patient With Thermal
Imbalance,” provides a complete discussion of the
care of patients with hyperthermia and hypother-
mia. Chapter 54 addresses the needs and care of
the shock trauma patient. The chapter focusing on
bioterrorism and its impact on the PACU reflects
the most current thinking in regard to this pub-
lic health concern. The chapter “Cardiopulmo-
nary Resuscitation in the PACU” features current
information based on the 2015 AHA guidelines
for CPR and ECC as they apply to the PACU.
The success of any multi-authored book is in
large part dependent on the expertise and com-
mitment of the contributors. I am grateful to all
past contributors, including Dr. Susan Christoph,
who was enlisted by Dr. Drain to assist with the
first two editions of this book. These contributors
have helped to build this book into the compre-
hensive text that it is. I would like to thank con-
tributors from the sixth edition who, for various
reasons, are not in the seventh edition: Robin
Blixt, Mallorie Croal, William Hartland, Jr.,
Elizabeth Howell, Daniel D. Moos, Chris Pasero,
Audrey R. Roberson, Nancy Saufl, Candace Tay-
lor, and Kenneth White. I am grateful to all the
returning and new contributors who offer their
knowledge and expertise to the reader. The con-
tributors to this book were invited because they
xi
xii Preface
are acknowledged authorities in their fields. With
their help, it is hoped that this book will continue
to inform and guide students, teachers, and clini-
cians in the critical care specialty of perianesthesia
nursing.
It is impossible to produce a book of qual-
ity without an able and expert publisher. I would
like to particularly thank Laura Selkirk, who kept
me on task and reasonably sane during the writ-
ing process, and Andrea Lynn “Drei” Villamero,
whose contributions to the final project resulted
in the book you now see. Thank you both for your
guidance and support.
Jan Odom-Forren
Contents

Section I: The Postanesthesia Care Unit

Chapter 1: Space Planning and Basic Equipment Systems, 1
Chapter 2: Perianesthesia Nursing as a Specialty, 9
Chapter 3: Management and Policies, 18
Chapter 4: Crisis Resource Management in the PACU, 34
Chapter 5: Infection Prevention and Control in the PACU, 44
Chapter 6: The Changing Health Care System and Its Implications for the PACU, 59
Chapter 7: Patient Safety and Legal Issues in the PACU, 73
Chapter 8: Ethics in Perianesthesia Nursing, 86
Chapter 9: Evidence-Based Practice and Research, 101

Section II: Physiologic Considerations in the PACU

Chapter 10: The Nervous System, 110
Chapter 11: The Cardiovascular System, 133
Chapter 12: The Respiratory System, 155
Chapter 13: The Renal System, 189
Chapter 14: Fluid and Electrolytes, 199
Chapter 15: The Endocrine System, 213
Chapter 16: The Hepatobiliary and Gastrointestinal System, 221
Chapter 17: The Integumentary System, 228
Chapter 18: The Immune System, 234

Section III: Concepts in Anesthetic Agents

Chapter 19: Basic Principles of Pharmacology, 243
Chapter 20: Inhalation Anesthesia, 260
Chapter 21: Nonopioid Intravenous Anesthetics, 272
Chapter 22: Opioid Intravenous Anesthetics, 284
Chapter 23: Neuromuscular Blocking Agents, 297
Chapter 24: Local Anesthetics, 316
Chapter 25: Regional Anesthesia, 329

Section IV: Nursing Care in the PACU

Chapter 26: Transition From the Operating Room to the PACU, 347
Chapter 27: A ssessment and Monitoring of the Perianesthesia Patient, 357

xiii
xiv Contents

Chapter 28: Patient Education and Care of the Perianesthesia Patient, 385
Chapter 29: Postanesthesia Care Complications, 398
Chapter 30: Assessment and Management of the Airway, 417
Chapter 31: Pain Management, 431
Chapter 32: Care of the Ear, Nose, Throat, Neck, and Maxillofacial Surgical Patient, 456
Chapter 33: Care of the Ophthalmic Surgical Patient, 473
Chapter 34: Care of the Thoracic Surgical Patient, 482
Chapter 35: Care of the Cardiac Surgical Patient, 494
Chapter 36: Care of the Vascular Surgical Patient, 531
Chapter 37: Care of the Orthopedic Surgical Patient, 549
Chapter 38: Care of the Neurosurgical Patient, 565
Chapter 39: Care of the Thyroid and Parathyroid Surgical Patient, 589
Chapter 40: Care of the Gastrointestinal, Abdominal, and Anorectal Surgical Patient, 594
Chapter 41: Care of the Genitourinary Surgical Patient, 606
Chapter 42: Care of the Obstetric and Gynecologic Surgical Patient, 624
Chapter 43: Care of the Breast Surgical Patient, 637
Chapter 44: Care of the Plastic and Reconstructive Surgical Patient, 648
Chapter 45: Care of the Patient Undergoing Bariatric Surgery, 656
Chapter 46: Care of the Ambulatory Surgical Patient, 664
Chapter 47: Care of the Laser/Laparoscopic Surgical Patient, 677

Section V: Special Considerations

Chapter 48: Care of the Patient With Chronic Disorders, 690
Chapter 49: Care of the Pediatric Patient, 707
Chapter 50: Care of the Older Patient, 733
Chapter 51: Care of the Pregnant Patient, 744
Chapter 52: Care of the Patient With Substance Use Disorder, 753
Chapter 53: Care of the Patient With Thermal Imbalance, 763
Chapter 54: Care of the Shock Trauma Patient, 774
Chapter 55: Care of the Intensive Care Unit Patient in the PACU, 798
Chapter 56: Bioterrorism and Its Impact on the PACU, 821
Chapter 57: Cardiopulmonary Resuscitation in the PACU, 831
 SECTION I - THE POSTANESTHESIA CARE UNIT
F rom the birth of the recovery room in the 1940s
to the postanesthesia care unit (PACU) of the
twenty-first century, the look and function of this
room (or unit) have been in a state of continual evo­
lution. 1 Throughout the past six decades, surgical
procedures have become more extensive and com­
plex and thus require more nursing staff and equip­
ment specially prepared for care of the patients.
The first recovery rooms were established for
centralization of patients and personnel. The
PACUs of today have evolved from general care to
intensive care specialty units that provide a spec­
trum of nursing care, from neonatal to geriatric
and from outpatient or same-day surgery to inpa­
tient surgery. The modern PACU must be flexible
to serve all perianesthesia phases and patient acu­
ities. The design of the space is critical to the abil­
ity of the staff to safely and efficiently care for �'­
variety of patients.2 , status classification)?
SPACE
Many factors are considered in/the design of a
PACU. Before the architect or design firm is con­
sulted, the users of the space (1.e., perianesthesia
nurses, anesthesia providers, cleriqil staff, patient/
family representative) should meet to answer the
following questions regarding the function of the
space:
• Is this a new construction, or is the current
space to be remodeled?
• How will the space be used?
• Will a separate preoperative holding area be
created, or will preoperative functions be car­
ried out in this space?
• Is this space used for PACU Phase I level of
care, PACU Phase II level of care, or both?
• What patient population will be served (i.e.,
outpatient, same-day admission, inpatient)?
• What patient age groups will be served (i.e.,
neonatal, pediatric, adult only, combined age
groups)?
• What is the institution's goal for family pres­
ence in each phase of care?
Current and future programs in the depart­
ment of surgery and the institutional demo­
graphics are also important considerations. The
following questions should be answered:
• How many operating rooms (ORs) will this
area serve?
• How many surgeries will be performed per
day?
• How many different surgical services will be
served?
• What types of procedures will be performed?
• Will some patients need prolonged monitor­
ing or observation?
• What types of anesthesia practices will impact
th·s area (i.e., regional anesthesia program,
acute or chronic pain service)?
• What is the average patient acuity (i.e., Ameri­
can Society of Anesthesiologists' physical
• Will nonsurgical or procedural patients who
need anesthesia undergo recovery in this same
space?
Purpose of the Space
Flexibility is an important consideration. One
of the first factors for consideration is how the
space will be used. Will the bays be used strictly
for postoperative care, or will the unit need the
flexibility of preoperative use? Many institutions
have a separate area dedicated to preadmission
testing or screening. This area is best located near
the surgical clinics and testing areas (i.e., blood
draw station, radiology and cardiology [ electro­
cardiography] departments). However, consid­
eration should be given to how the preoperative
holding area will be designed and used. Because
of the cost of construction and the limited hours
of use, many administrators are reluctant to
build a space with only a single function and that
does not lend itself to change as the users or pro­
grams evolve. Therefore, all disciplines that use
or expect to use the area need to engage in the
space usage discussion so future needs can be
anticipated.
2 Section I - The Postanesthesia Care Unit
Perianesthesia nurses have knowledge of the
entire process from preadmission testing to dis-
charge the day of surgery. The staff members
in the surgery department need to have input
regarding types of operations, new surgical tech-
niques, and the need for prolonged observation
before discharge. The anesthesiology department
medical staff members will have input regarding
preoperative needs (e.g., a preadmission test-
ing or screening area, day-of-surgery preopera-
tive procedures area). Clerical services personnel
should have input related to the flow of patients
and record and paperwork systems. Input from
environmental services personnel is related to
janitorial space needs and housecleaning supplies
and equipment. Central supply personnel should
be consulted regarding the space needed for stor-
age of disposable supplies and linen for ready
availability on the unit. Patient equipment per-
sonnel should give input regarding space needed
to deliver and store reusable equipment, such as
stretchers, beds, wheelchairs, infusion pumps,
intermittent or sequential pneumatic compres-
sion devices, patient-controlled analgesia pumps
(intravenous [IV] or epidural), and implantable
cardioverter defibrillators.
Adequate time for consultation with all poten-
tial users and ancillary personnel who will use or
provide services in the space is wise. One needs
only a brief conversation with staff who have had
to work in a poorly designed space to understand
the importance of this first step in the design
process.
Determine the Location
The same factors influencing the building of a
housing development or retail shops in one place
versus another can be applied to this discussion
of perianesthesia space needs. A new construction
design typically offers greater probability of design
optimization than remodeling does. The first con-
sideration before construction should be ease
of access for the patients and families. Parking
should be easily accessible and plentiful, and the
entrance should be located adjacent to the park-
ing garage or lot. The patient reception and wait-
ing area should be near the entrance to decrease
the patient anxiety and frustration that result from
searching for an area.
The second consideration should be egress.
A logical patient flow—with adjacent areas that
naturally follow the patients’ transit through the
unit—should be established for maximization of
staff efficiency and decreased steps between areas.
The waiting area should be adjacent to the pre-
operative holding area. PACU Phase I and PACU
Phase II should be adjacent but with separate
entrances from the ORs for safety and efficiency.
In an inpatient setting, a separate elevator is ideal
for patients of the OR to be transported to general
care and intensive care units (ICUs). This separate
elevator is a matter of safety for patients going
to an ICU, and it maximizes staff efficiency for
patients going to general care. With remodeling,
great care should be taken to determine that the
design shows consideration of these factors and
incorporation whenever possible.
Components of the Space
Several key components must be incorporated
into the design of the space. The first element to
determine is the number of patient bays. Before
this number can be calculated, consideration must
be given to several key factors that influence that
number2, 3:
• How are the bays to be used? Will they be
used for preoperative care only, PACU only,
or PACU Phase II only? Or will they be used
interchangeably for all levels of care?
• Are they to be used for preoperative care, or is
a separate space available for that function?
• How many ORs use the preoperative area and
PACU, and how many cases are performed per
day?
• Does the PACU service other procedure areas
of the hospital (i.e., cardiac catheterization,
electrophysiology laboratory, electroconvul-
sive therapy treatments, medical procedures
[endoscopy, bronchoscopy], radiology and
angiography, anesthesia pain service [chronic
and acute])? If so, how many cases do they see
per day and at what time of day?
• Are the patients adults, children, or both?
• What is the scheduling method used by the
department of surgery? How many different
surgical services are served?
• What is the hospital bed capacity and usual
census?
• Do patients wait long periods for inpatient
beds?
• Is the PACU used for ICU, telemetry, or gen-
eral care overflow? If so, how often is it used
and for how many patients at one time?
• Does the department of anesthesia have a re-
gional anesthesia program? Does it need space
for these services?
• What is the average patient acuity (i.e., Ameri-
can Society of Anesthesiologists’ physical
status classification)?
• What is the average length of surgical proce-
dures?
• What is the average length of stay for different
patient types (i.e., outpatient, inpatient, same-
day admission)?
 Chapter 1 - Space Planning and Basic Equipment Systems
For an inpatient hospital PACU that services
a combined patient population of inpatients and
same-day admission patients, a ratio of 1.5 to
2 PACU bays per OR is necessary to safely care
for the patients and not back up the OR. For an
ambulatory surgery center with a limited number
of surgical services and types of procedures, 2.5 to
3 PACU Phase I and PACU Phase II (combined)
bays are necessary. The shorter surgical proce-
dures necessitate an increased number of PACU
slots because the recovery time may be two to
three times the length of the procedure. If pedi-
atric patients receive care in either setting, the
number of bays may need to be increased because
this patient population necessitates 1:1 nursing
care for a longer time than does a solely adult
population.
Cases of multidrug-resistant organisms and
tuberculosis infections have been on the rise
over the past several years. As a result, the need
for negative pressure isolation or body substance
isolation should be considered in the design. Geo-
graphic location and patient population demo-
graphics should be reviewed to determine the
number of isolation rooms needed. Every PACU
should have at least one negative pressure room.
However, more rooms may be necessary if the
institution services a more susceptible popula-
tion. Consultation with the institution’s infectious
diseases department is advisable to ensure that the
design meets institutional policy and is prepared
to serve the patient population.4
Family presence in the PACU is a concern.
American Society of PeriAnesthesia Nurses
(ASPAN) Practice Recommendation 9, Visitation in
the Perianesthesia Care Unit, endorses family pres-
ence in all phases of perianesthesia care.4 Space
constraints may make family presence difficult to
achieve as the family and nurse will compete for
the same space around the patient’s bed/stretcher.
Understanding the institution’s goals related to
family presence will help guide planning of the
space. In a new construction, dedicated space for
family should be part of the individual slot design,
similar to how space is planned for equipment,
including bed/stretcher, monitor, computer, and
additional patient equipment (IV pole, IV pumps,
ventilator, etc.). In a remodel project, the space for
family becomes more challenging. PACU nurses,
other caregivers (including assistive personnel,
anesthesia personnel, surgeons, etc.), and family
representatives should mock up a slot to visu-
alize placement of family, equipment, and the
workflow. Dedicating space for particular activi-
ties can be a solution for the competing needs
of family and caregivers in the same space. One
way to achieve this is to dedicate one side of the
3
THE POSTANESTHESIA CARE UNIT
bed/stretcher for the family and one side for the
caregivers. There may still be times, due to patient
care needs, that the nurse will need to negotiate
space with the family. However, having a standard
practice, known to both families and caregivers,
will help lessen the frustration when a change is
necessary.
Another consideration in the design of patient
bays is size and means of separation. Most states
have building codes that define the minimum
square footage of each bay (e.g., Minimum Design
Standards for Health Care Facilities in Michigan
requirement is 80 square feet).5 However, consid-
eration should be given to how the bays are to be
used. If they are strictly for patients requiring a
PACU Phase I level of care, the minimum required
square footage may be adequate. If the bays are to
be used for anesthesia preoperative procedures
or anesthesia pain procedures that necessitate
equipment such as fluoroscopy or bronchoscopy,
the size may need to be increased (to as much as
150 square feet). Also, if the bays are to be used
alternatively as PACU Phase I or PACU Phase II
levels of care and then as observation for 23-hour
admissions, they may need to be large enough to
accommodate a patient bed, table, lounge chair, or
other equipment. Building some of the bays larger
to accommodate these future needs may also be
wise, but it is important to realize that the size of
the bays affects the configuration of the space.
Patient privacy needs to be considered when
determining the means of separation between
patient bays. Typically, PACU bays are open
spaces defined only by a curtain that can be
pulled for privacy. The open floor plan maximizes
patient safety and staff efficiency in the higher
acuity PACU Phase I setting. With preoperative
and PACU Phase II care, patient acuity is typi-
cally lower, and continual observation of patients
is usually not necessary. Patients are more alert
and families are generally present; therefore the
need for privacy is increased. Half-walls may be
considered in these spaces. A half-wall (i.e., floor-
to-ceiling wall one third to half the depth of the
bay) gives more privacy to the patient and family
from the sights and sounds of the adjacent bays.
However, this configuration still allows clinicians
to observe patients and be readily available for
acute needs.
The bays should be carefully arranged for max-
imized staffing efficiency within the constraints
of the ASPAN staffing resource guidelines.4 The
PACU Phase I staffing recommendation is a
maximum of two patients per registered nurse
(RN)—less for an unstable condition or a pediat-
ric patient. For PACU Phase II staffing, the rec-
ommendation is a maximum of three patients to
4 Section I - The Postanesthesia Care Unit
one RN—less for a patient with an unstable con-
dition who needs transfer or a pediatric patient
without family or staff support. Grouping of slots
in multiples of two or three allows the most effi-
cient, safe staffing. Careful consideration should
be given to how the space will be used (i.e., as pre-
operative care, PACU Phase I or PACU Phase II,
or interchangeably).
The ASPAN Perianesthesia Nursing Standards
and Practice Recommendations do not define staff-
ing ratios for preoperative cases.4 Ideal safe staffing
ratios are determined by individual institutions on
the basis of the particular patient population, the
number of ORs, the OR turnover time, and the
number of preoperative procedures performed
with anesthesia. The amount of nursing time
necessary to prepare for surgery depends on the
patient’s age, the amount of preparation done in
the surgery clinic, the institution’s established ele-
ments of the perianesthesia nursing assessment,
and the patient’s knowledge and anxiety level.
Patients who are well prepared when they arrive
for surgery may require less preoperative nursing
time. The number of ORs, the average length of
procedures, and turnover time affect how many
patients are in the preoperative area at one time
and how much time they wait before going into
the OR. In a small ambulatory surgery center, one
or more rooms may be used for quick procedures
that necessitate little equipment or cleaning to
ready the OR for the next patient. In this case, two
patients for that same OR may need to be in the
preoperative area at the same time. Other factors
that affect preoperative staffing are the numbers
and types of anesthesia preoperative procedures.
Again, in a small ambulatory surgery center, most
procedures can be performed with a general anes-
thetic or sedation; therefore, preparation time is
shorter. Conversely, a teaching institution may
have a patient population with significant comor-
bid conditions that necessitate monitoring lines
(e.g., pulmonary artery catheters, arterial lines,
central lines). In addition, many institutions have
a pain management service that offers patients
epidural catheters or extremity blocks for postop-
erative pain. These patients occupy the preopera-
tive holding area bay for a longer period and may
need nursing assistance for sedation or monitor-
ing during and after the procedure until they go
into the OR. In these situations, a ratio of three to
five patients to one RN is safe and efficient. How-
ever, staffing should be flexible to decrease the
number of patients per RN as the patient acuity
rises or the need for nursing care and monitoring
increases.
For space that is flexible for any need, pre-
operative or postoperative care, all headwalls
should be designed uniformly to allow flexibility
day-to-day or in the future as institutional needs
change. During a new construction, when the
walls are open, the addition of piped-in medical
gases and vacuum for suction at each bay is sim-
ple and cost-effective. For the care of critically ill
patients in PACU Phase I, each bay should have
a minimum of two oxygen outlets, one air outlet,
and three vacuum outlets for suction. In a free-
standing ambulatory surgery center that never
serves a critically ill inpatient population, it may
be more prudent to decrease the number of oxy-
gen and vacuum outlets. However, consideration
should be given to the possibility of a patient with
a surgical or anesthesia complication that neces-
sitates more intensive care. The other elements of
the headwall design include electrical outlets and
data and telephone jacks. Again, whether the unit
is a new construction or renovation, a plan for
maximum care and future needs is wise. Each bay
should have adequate electrical outlets to service a
variety of pieces of equipment, including a patient
bed, a forced air warming and cooling device,
multiple infusion pumps, a ventilator, a physi-
ologic monitor, a computer, a compression device,
and a patient-controlled analgesia machine. Tele-
phone and data jacks should be installed to service
the current standard of practice and future needs.
Most physiologic monitors are computers that
need a data jack. Technology development has
brought online data entry to the bedside. Planning
for adequate data jacks to support this need is wise
and necessary. In addition, wireless networking
capability should be considered when designing
the space to allow for the use of smartphones,
wireless local area network–enabled computers,
and other technology in the unit.
Another important component of the design
of the patient care bay is lighting. Adequate light
needs to be available for admission assessment
and emergency situations. Large overhead lights
provide the best source of light to meet this safety
need. Consideration should be given to the patient
in stable condition for whom bright lighting is not
a safety concern. Wall-mounted lights, overhead
canned lights on a dimmer, or low-wattage light-
ing provides appropriate ambience for the patient
and still allows the nurse to provide safe care.
Storage in the patient bay is also essential.
Some emergency equipment must be stored at
each bay for ready availability to the practitio-
ners. However, careful planning should occur to
avoid clutter that would hamper the nurses’ abil-
ity to quickly access equipment. Many different
systems are available to service this need. Before
any system is purchased, the items to be stored
and the space needed must be assessed. Another
 Chapter 1 - Space Planning and Basic Equipment Systems
point for consideration is what constitutes emer-
gent equipment and what is at the bedside for
convenience.4 Fig. 1.1 shows one example of a
bedside cart storage system. The carts are mobile,
are stocked with essential bedside supplies, and
contain an interior locked space. A larger storage
cart complements this system; it contains items
that need to be readily available for efficiency but
are not needed emergently. The ability to safely
and efficiently care for patients in the PACU
depends on the layout of the room. Beyond the
confines of the patient bay and its components,
immediate access to supplies, equipment, and
service areas is essential. Box 1.1 contains a list of
the space and service areas needed for the func-
tion of the preoperative holding area and PACU.
Many of the supplies, pieces of equipment, and
service areas overlap, which should be consid-
ered in the design. If service areas are strategi-
cally placed, they can service two units and thus
increase staff efficiency while decreasing the cost
of building and maintenance.
The amount of duplication can be decreased
with determination of the components that may
be shared. These spaces should be placed between
two units or in close proximity to one another.
This thoughtful, careful planning allows for safe,
FIG. 1.1 Example of perianesthesia bedside supply
carts with exterior open storage and interior locked
storage capacity.
5
THE POSTANESTHESIA CARE UNIT
efficient care and minimization of duplication and
cost.
Staff needs are an important consideration in the
design. Staff lounge and toilets adjacent to the unit
are essential and allow staff members the opportu-
nity to take breaks consistent with the workflow.
Because of the dynamic nature of the preoperative
holding area and PACU, scheduling of breaks con-
sistent with staff members’ requests is sometimes
difficult. Facilities immediately adjacent to the unit
allow flexibility of scheduling and ensure the avail-
ability of staff members in an emergency.
Ergonomics and efficiency are important ele-
ments in the design of the space and the equip-
ment. For patient safety, the nurse must be
able to visualize the patient from every point
in the room. Essential equipment should be in
the room so the nurse can constantly moni-
tor the patient while obtaining and using the
equipment. A bedside table and chair should
be available for every staff member for sitting
at the patient’s bedside and documenting dur-
ing observation. Tables, chairs, and computer
monitors and keyboards should be adjustable to
fit multiple users. With an aging workforce, the
lack of adequate adjustable furnishings could
lead to increased injury and exacerbate the
growing nursing shortage.
Another component of the space is the recep-
tion and waiting area, which varies depending
on the location (i.e., inpatient hospital-based
versus freestanding ambulatory surgery cen-
ter). In either location, several items need to be
incorporated. If possible, preoperative patients
and their families should wait in a separate loca-
tion from the families of patients in the OR or
PACU. Preoperative patient anxiety can increase
when a physician is seen with another family
or a family is visibly upset. Also, the sight and
smell of food and drink are inconsiderate to a
patient who has been fasting. Conversely, fami-
lies of patients in the OR or PACU want to stay
in close proximity to their loved ones and need
to be readily available to clinical staff; therefore,
they need to be able to eat and drink in the wait-
ing area. In addition, the waiting areas should
accommodate a variety of needs so waiting
patients and families can work or be entertained
or distracted, if necessary. Some considerations
are an area dedicated to Internet access with
computer workstations and data connections for
laptops, a television area, a quiet area for read-
ing, a children’s play area with toys, and furni-
ture appropriate to the patient population being
served. Consultation rooms should be avail-
able for private consultation with physicians,
patients, and families.
6 Section I - The Postanesthesia Care Unit
••BOX 1.1  Support Areas and Equipment*
PREOPERATIVE HOLDING AREA
• Clean storage
• Dirty or soiled utility
• Patient toilet
• Equipment storage (e.g., stretchers, beds, wheelchairs,
infusion pumps, transducer setups)
• Procedure cart
• Blanket warmer
• Emergency cart
• Automated medication dispensing unit (e.g., Pyxis, Omnicell)
• Point-of-care testing (blood gas laboratory)
• Medical records storage
• Radiograph view box
• Bulletin board for patient education material
• Patient locator board (electronic or write-on)
• Dry erase boards for staff lists, locations
• Computers (stationery and mobile)
• Nursing station
PACU Phase I
• Clean storage
• Dirty or soiled utility
• Automated medication dispensing unit (e.g., Pyxis,
Omnicell)
• Blanket warmer
• Emergency cart, defibrillator
• Equipment storage (e.g., stretchers, beds, wheelchairs,
infusion pumps, patient warming devices, patient-
controlled analgesia pumps)
• Point-of-care testing (blood gas laboratory)
• Radiographic view box
*This list is not meant to be all-inclusive. It should serve as a guide to help determine the needs of the institution.
STANDARD EQUIPMENT
The type and amount of equipment needed for
the safe care of preoperative and postanesthesia
patients vary to some extent on the basis of envi-
ronment and patient population. However, some
basic items are essential in any setting.
Types of equipment can be divided into three
categories: emergent, readily available, and neces-
sary. Emergency cases in the PACU typically start
as a result of airway compromise; therefore, the
availability of supplies (e.g., resuscitation bag, oral
and nasal airways, suction catheters, lubricant)
at the bedside is prudent. Intubation equipment
should be readily available as part of the emer-
gency cart or as a separate container or bag of
anesthesia supplies. Box 1.2 provides a list of sug-
gested items to be stocked in an anesthesia PACU
emergency bag. In addition, the ASPAN 2015–
2017 Perianesthesia Nursing Standards, Practice
Recommendations and Interpretive Statements,
Practice Recommendation 3 provides a list of sug-
gested equipment for a preoperative holding area,
PACU Phase I, and PACU Phase II.4
• Patient toilet
• Patient nourishment
• Medical records storage
• Computers (stationery and mobile)
• Procedure cart
• Patient education bulletin board
• Patient locator board (electronic or write-on)
• Dry erase boards for staff lists, locations
• Physician dictation area
• Staff toilet
• Staff lounge
• Staff locker room
PACU Phase II
• Clean storage
• Dirty or soiled utility
• Automated medication dispensing unit (e.g., Pyxis, Omnicell)
• Patient toilet
• Emergency cart
• Equipment storage (e.g., stretchers, beds, wheelchairs)
• Blanket warmer
• Patient nourishment
• Patient education bulletin board
• Patient locator board (electronic or write-on)
• Dry erase boards for staff lists, locations
• Computers (stationary and mobile)
• Nursing station
• Physician dictation area
• Staff toilet
• Staff lounge
• Staff locker room
Malignant hyperthermia (MH) is a rare but
potentially fatal complication of anesthesia. An
MH box or cart or equivalent supplies in the
PACU Phase I is essential. The Malignant Hyper-
thermia Association of the United States has a
recommended list of supplies for MH emergency
cases (Box 1.3; see also Chapter 53).6
Institutions where intensive care patients
recover in the PACU should have an emergency or
“travel box” of medications and supplies available
for use in transportation. Each institution may
choose to have a dedicated travel box or use the stan-
dard emergency drug box, which can be secured
in a medication room or automated ­medication-
dispensing cabinet.
Readily available bedside supplies may vary
among institutions depending on the types of
patients and volume. However, some essential
supplies should be at every patient bedside. In
addition to the aforementioned airway supplies,
several means of oxygen delivery (see Chapter 28),
suction catheters and tubing, gloves, emesis basins,
and tissues should be immediately available at the
 Chapter 1 - Space Planning and Basic Equipment Systems 7

THE POSTANESTHESIA CARE UNIT

••BOX 1.2  Contents of Anesthesia PACU Emergency Bag
MAIN COMPARTMENT FRONT COMPARTMENT
• ET tubes with stylet and syringe (6.0, 7.0, 8.0) • Guedel airway (red, green, yellow)
• Extra ET tubes (5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0) • Soft suction catheter
• Bougie • Yankauer suction
• Laryngoscope with blades (MacIntosh 3 and 4, Miller 2 and 3) • Jackson Reese circuit
• Face mask, clear (2) • Nasopharyngeal airway (6.5, 7.5, 8.5)
• Pediatric ET tubes (2.5, 3.0, 3.5, 4.0)
• Medications (sealed Code Pack) SIDE POCKET
• Syringes
Atropine 0.4 mg/mL–3-mL syringe × 2
• Alcohol pads
Epinephrine 1:1000–1 mL × 2
Etomidate 2 mg/mL–10 mL × 1 BACK POCKET EMERGENCY KIT
Phenylephrine 100 mcg/mL–10-mL syringe × 2 • Cricothyrotomy kit
Propofol 20 mL × 2 • Nasal cannula oxygen tubing
Rocuronium 10 mg/mL–5 mL × 2 (or 10 mL × 1) • Laryngeal mask airways 3, 4, 5 (1 each)
• 60-mL syringes (2)
Succinylcholine 20 mg/mL–10 mL × 1
• Saline flush 10-mL syringe (2)
ET, Endotracheal; PACU, postanesthesia care unit.

••BOX 1.3  Malignant Hyperthermia Cart or Kit Supplies

An MH cart or kit that contains the following drugs, equip- DRIP SUPPLIES
ment, supplies, and forms should be immediately accessible • D5W, 250 mL (1)
to ORs and the PACU. • Microdrip IV set (1)

DRUGS NURSING SUPPLIES

• Dantrolene sodium IV, (Dantrium/Revonto: 36 vials, each
diluted with 60-mL sterile water; Ryanodex: 3 vials, each
diluted with 5-mL sterile water)
• Sterile water for injection USP (without a bacteriostatic
agent) to reconstitute dantrolene, 1000 mL (2)
• Sodium bicarbonate (8.4%), 50 mL (5)
• D50%, 50-mL vials (2)
• Calcium chloride (10%; 2)
• Regular insulin, 100 units/mL (1; refrigerated)
• Lidocaine HCl (2%), 1 box (2 g) or 20-mL vials (5)
• Refrigerated cold saline solution (minimum 3000 mL for
IV cooling)
GENERAL EQUIPMENT
• Syringes (60 mL; 5) to dilute dantrolene; 5 mL, 3 for
Ryanodex
• Mini spike IV additive pins (2) and Multi-Ad fluid transfer
sets (2; to reconstitute dantrolene)
• IV catheters: 16-gauge, 18-gauge, 20-gauge, 2-inch;
22-gauge, 1-inch; 24-gauge, ¾-inch (4 each; for IV
access and arterial line)
• NG tubes: sizes appropriate for the patient population
• Irrigation tray with piston syringe (1) for NG irrigation
• Toomey irrigation syringes (60 mL; 2) for NG irrigation
• Bucket for ice
• Disposable cold packs (4)
MONITORING EQUIPMENT
• Esophageal, temperature-sensing balloon-tipped urinary
catheter or other core temperature probes
• Central venous pressure kits (sizes appropriate to the
patient population)
• Transducer kit
• Large sterile Steri-Drape (for rapid drape of wound)
• Three-way irrigating urinary catheters: sizes appropriate
for the patient population
• Urine meter (1)
• Toomey irrigation syringe (60 mL; 2)
• Rectal tubes: sizes (Malecot drain) 14F, 16F, 32F, 34F
• Large clear plastic bags for ice (4)
• Small plastic bags for ice (4)
• Tray for ice
LABORATORY TESTING SUPPLIES
• Syringes (3 mL) or arterial blood gas kits (6)
• Blood specimen tubes (each test should have two pediat-
ric and two large tubes): (A) creatine kinase, myoglobin,
sequential multiple analysis (SMA 19 [lactate dehydro-
genase, electrolytes, thyroid studies]); (B) prothrombin
time/partial thromboplastin time, fibrinogen, fibrin split
products, lactate; (C) complete blood cell count, platelets
• Blood culture specimen containers should be available if
needed
• Urine cup (2), myoglobin level
• Urine test strips for hemoglobin
FORMS (OR ORDER SETS IN COMPUTERIZED PROVIDER ORDER
ENTRY APPLICATION)
• Laboratory request forms: arterial blood gas form (6),
hematology form (2), chemistry form (2), coagulation
form (2), urinalysis form (2), physician order form (2)
• Adverse Metabolic or Muscular Reaction to Anesthesia
report form (obtained from the Malignant Hyperthermia
Association of the United States at http://www.mhaus.
org/public/registry/amra.pdf)
• Consult form

IV, Intravenous; MH, malignant hyperthermia; NG, nasogastric; OR, operating room; PACU, postanesthesia care unit; USP, United States
Pharmacopeia.
8 Section I - The Postanesthesia Care Unit
bedside. Bedside supplies should be limited to
only essential items to ensure that they are stocked
and easily retrieved by all personnel.
Other supplies that need to be readily available
can be stored in a variety of ways. If the clean stor-
age room is in close proximity to all patient bays
and has a user-friendly system, equipment can be
left there and retrieved when needed. If the room
design does not allow for quick retrieval of sup-
plies from the clean storage room, consideration
should be given to a storage system located in the
immediate proximity of patient bays. This sys-
tem could be a cart that moves from bay to bay
or built-in cupboards that service several bays. It
is essential that staff members are involved in the
choice of a storage system so their needs are met.
Institutions that have a 24-hour equipment
delivery service, which allows for just-in-time
delivery, may not need to store such items as IV
pumps, pneumatic compression devices, forced
air warming devices, and IV poles for transport.
However, if these items are not readily available,
they should be stored on the unit.
Pain management is an essential part of the
patient care delivered in the PACU. If the institu-
tion uses IV patient-controlled analgesia pumps
and epidural pumps for patient-controlled anal-
gesia, a supply of this equipment should be kept
in the PACU for ready availability. The PACU is a
critical care unit and should therefore have a venti-
lator available at all times. Individual institutional
policy governs which department is responsible
for setting up and maintaining any ventilators.
SUMMARY
Many changes in the care of perianesthesia
patients have occurred in the past 60-plus years,
and continued change is inevitable. Thoughtful
planning and interdisciplinary communication
are essential for space and equipment to continue
to meet the patient care needs in PACUs.
REFERENCES
1. American Society of PeriAnesthesia Nurses: ASPAN’s
history timeline (website). www.aspan.org/About-
Us/History/History-Timeline#1923. Accessed
November 10, 2015.
2. Israel JS, DeKornfeld TJ: Recovery room care, ed 2,
Chicago, IL, 1987, Year Book Medical Publishers.
3. Nicholau TK: The postanesthesia care unit. In
Miller RD, editor: Miller’s anesthesia, ed 8, Philadel-
phia, PA, 2015, Elsevier Saunders.
4. American Society of PeriAnesthesia Nurses:
2015–2017 Perianesthesia nursing standards, prac-
tice recommendations, and interpretive statements,
Cherry Hill, NJ, 2014, ASPAN.
5. Michigan Department of Community Health: The
2007 minimum design standards for health care
facilities in Michigan (website). www.michigan.gov/
documents/mdch/bhs_2007_Minimum_Design_St
andards_Final_PDF_Doc._198958_7.pdf. Accessed
November 10, 2015.
6. Malignant Hyperthermia Association of the United
States: FAQs (website). www.mhaus.org/faqs/stocking-
an-mh-cart. Accessed November 10, 2015.

Perianesthesia Nursing as a Specialty
Sarah Marie Independence Cartwright, DNP, BAM, RN-BC, CAPA, and
Susan M. Andrews, BAN, MA, RN, CAPA
P erianesthesia nursing is a diverse field that
encompasses patient care in a variety of set-
tings. Recognition of perianesthesia nursing as
a critical care specialty is well established.1 The
main goal of the perianesthesia nurse is to pro-
vide competent, efficient care to patients and their
families who are experiencing an anesthetic event.
This care can be given in a traditional care setting,
such as a hospital setting, or in a nontraditional
care environment, such as a physician’s office.
When there is an opportunity for a patient to
experience anesthesia—from moderate sedation
to general anesthesia—there is an opportunity for
a perianesthesia nurse to provide care.
Recent history has been witness to a number
of significant factors that have influenced the
practice of perianesthesia nursing. Among these
factors are the emphasis on cost containment in
health care, declining reimbursement for medical
services, the aging and increased acuity level of
the population, advances in technology and phar-
maceutical therapy, and fast-tracking of patients
through the postanesthesia process.
The American Society of PeriAnesthesia
Nurses (ASPAN) is the professional organization
representing the interests of perianesthesia nurses
and sets the clinical standards of care in this spe-
cialty in the United States and its territories. In
an effort to define the role of the perianesthesia
nurse, ASPAN has published a formal Scope of
Perianesthesia Nurse Practice document (Box 2.1)
that addresses the core, dimensions, boundaries,
and intersections of the perianesthesia nursing
practice.2 The members and governing bodies
partner to establish practice standards, guidelines,
and evidence-based practices to promote safe
patient care. These standards encourage compe-
tent practice through their use as vetted through
peer review processes and member representa-
tion. The guidelines define practice issues such
as evaluation of patient condition, practice state-
ments for staffing patterns, use of unlicensed care
personnel, and overflow of intensive care patients.
ASPAN also partners with other nursing profes-
sional organizations to establish professional
nursing standards advocating for safe conditions
for both the patient and the caregiver.2
Perianesthesia nursing is practiced in multiple
settings, both inpatient and outpatient, within the
2
hospital setting and in free-standing practice set-
tings (Box 2.1). The continued emphasis on cost
containment has stimulated the regionalization of
health care and the development of tertiary care
centers in major cities, while primary care has
increasingly moved to ambulatory settings.3 As a
consequence, perianesthesia nursing is practiced
in a variety of traditional and nontraditional set-
tings, from the physician’s office to recovery care
centers to highly specialized postanesthesia care
units (PACUs) in dedicated medical centers, such
as eye institutes and surgical hospitals, as well as
practice sites including dental clinics, ambula-
tory surgery centers, office-based procedure areas,
endoscopy suites, and pain management centers.
The traditional hospital-based approach is
most prevalent with perianesthesia nurses prac-
ticing in areas from preoperative evaluation and
pretesting to the PACU and beyond. As patient
care evolves, the nontraditional perianesthesia
environments are becoming more frequently used
and in demand. The care provided by the perianes-
thesia nurse is similar in fashion regardless of the
location. The use of outstanding assessment skills,
monitoring, and application of specific specialized
knowledge is needed regardless of the physical site
and setting. The patient initially experiences this
care in the pretesting and evaluation area followed
by the immediate preprocedure evaluation, moni-
toring of the patient during and immediately after
anesthesia, during Phase II, and through extended
care as necessary. The detail and care required
during each one of these phases depends on the
patient, procedure, anesthetic agent, and care
environment.
The perianesthesia environment is delineated
by the following phases: preanesthesia phase
(preadmission and day of surgery/­procedure),
postanesthesia Phase I, postanesthesia Phase
II, and extended care.2 Care during all levels
assists the patient with transition through the
perianesthetic event. The care provided to the
perianesthesia patient by the perianesthesia
nurse must be delivered with the understanding
that it is critical care requiring critical thinking.
The perianesthesia patient is most vulnerable
during and immediately after anesthesia when
most basic functions are controlled by the pro-
viders (nurses and physicians).4 Perianesthesia
9
10 Section I - The Postanesthesia Care Unit
••BOX 2.1  Scope of Practice: Perianesthesia Nursing
The American Society of PeriAnesthesia Nurses (ASPAN), the
professional organization for the specialty of perianesthesia
nursing, is responsible for the defining and establishing of
the scope of perianesthesia nursing. In doing so, ASPAN rec-
ognizes the role of the American Nurses Association (ANA) in
defining the scope of practice for the nursing profession as
a whole.
ASPAN supports the Nursing’s Social Policy Statement:
2010 Edition.1, 2 This statement charges specialty nursing
organizations with defining their individual scope of practice
and identifying the characteristics within their unique spe-
cialty area.
Evolving professional and societal demands have neces-
sitated a statement clarifying the scope of perianesthesia
nursing practice. Given rapid changes in health care delivery,
trends, and technologies, the task of defining this scope is
complex. This document allows for flexibility in response to
emerging issues and technologies in health care delivery and
the practice of perianesthesia nursing.
The scope of perianesthesia nursing practice involves the
cultural, developmental, and age-specific assessment, diag-
nosis, intervention, and evaluation of individuals within the
perianesthesia continuum. Those individuals across the age
continuum will or have had sedation/analgesia and/or anes-
thesia for surgical, diagnostic, or therapeutic procedures. Our
practice is systematic, integrative, and holistic and involves
critical thinking, clinical decision making, and inquiry. ASPAN
strives to promote an environment in which the perianesthe-
sia nurse can deliver quality care among a diverse population
within a multidisciplinary health care team.
This scope of practice includes, but is not limited to:
• Preanesthesia level of care
• Preadmission
• Day of surgery/procedure
• Postanesthesia levels of care
• Phase I
• Phase II
• Extended care
The delivery of care includes, but is not limited to, the
following environments:
• Hospitals
• Ambulatory surgery units/centers
• Procedural areas (e.g., cardiology, ECT, GI/endoscopy,
interventional and diagnostic radiology, oncology, pain
management, etc.)
• Obstetric units
• Office-based settings
This specialty of perianesthesia nursing encompasses
the care of the patient and family/significant other along the
perianesthesia continuum of care—preanesthesia, postan-
esthesia Phase I, Phase II, and extended care. Characteristics
unique to perianesthesia practice are:
1. Preanesthesia phase
a. Preadmission—The nursing roles in this phase focus
on physical, psychological, sociocultural, and spir-
itual preparation for the experience. Interview and
assessment techniques are used to identify potential
or actual problems. Education and interventions are
initiated to optimize positive outcomes.
b. Day of surgery/procedure—The nursing roles in this
phase focus on validating existing information, rein-
forcing preoperative teaching, reviewing discharge
instructions, and providing nursing care to complete
preparation for the experience.
2. Postanesthesia Phase I—The nursing roles in this phase
focus on providing postanesthesia nursing in the immedi-
ate postanesthesia period, transitioning to Phase II, the in-
patient setting, or to an intensive care setting for continued
care. Basic life-sustaining needs are of the highest priority.
Constant vigilance is required during this phase.3
3. Postanesthesia Phase II—The nursing roles in this phase
focus on preparation for care in the home or an extended
care environment.
4. Extended care—The nursing roles in this phase focus on
providing care when extended observation/intervention
after discharge from Phase I or Phase II is required.
Perianesthesia nursing roles include those of patient care,
research, administration, management, education, consulta-
tion, and advocacy. The specialty practice of perianesthesia
nursing is defined through the implementation of specific role
functions delineated in documents including ASPAN’s Perian-
esthesia Nursing Core Curriculum: Preprocedure, Phase I and
Phase II PACU Nursing 4 and the 2012–2014 Perianesthesia
Nursing Standards, Practice Recommendations, and Inter-
pretive Statements.5 The scope of perianesthesia nursing
practice is also regulated by policies and procedures dictated
by the hospital/institution, state and federal regulatory agen-
cies, and national accreditation bodies.
Professional behaviors inherent in perianesthesia prac-
tice are the acquisition and application of a specialized body
of knowledge and skills, accountability and responsibility,
communication, autonomy, and collaborative relationships
with others. Resources to support this defined body of knowl-
edge and nursing practice include ASPAN’s Perianesthesia
Nursing Core Curriculum: Preprocedure, Phase I and Phase
II PACU Nursing,4 2012–2014 Perianesthesia Nursing Stand-
ards, Practice Recommendations, and Interpretive State-
ments,5 and Competency Based Orientation and Credential-
ing Program for the Registered Nurse in the Perianesthesia
Setting.6 Certification in perianesthesia nursing (Certified
Post Anesthesia Nurse: CPAN and Certified Ambulatory Peri-
anesthesia Nurse: CAPA) is recognized by ASPAN as it vali-
dates the defined body of knowledge for perianesthesia nurs-
ing practice.
ASPAN interacts with other professional groups to ad-
vance the delivery of quality care. These include but may not
be limited to:
• American Academy of Ambulatory Care Nursing (AAACN)
• American Nursing Informatics Association (ANIA)

••BOX 2.1  Scope of Practice: Perianesthesia Nursing—cont’d
• Ambulatory Surgery Center Association (ASCA)
• American Academy of Anesthesiologists Assistants (AAAA)
• Association of Anesthesia Clinical Directors (AACD)
• American Association of Colleges of Nursing (AACN)
• American Association of Critical Care Nurses (AACN)
• American Association of Nurse Anesthetists (AANA)
• American Board of Perianesthesia Nursing Certification
(ABPANC)
• American Nurses Association (ANA)
• American Society for Pain Management Nurses (ASPSN)
• American Society for Plastic Surgical Nurses (ASPSN)
• Americans for Nursing Shortage Relief (ANSR)
• Anesthesia Patient Safety Foundation (APSF)
• Association for Vascular Access (AVA)
• Association of periOperative Registered Nurses (AORN)
• Association for Radiologic & Imaging Nursing (ARIN)
• Association of Women’s Health, Obstetric, and Neonatal
Nurses (AWHONN)
• British Anesthetic & Recovery Nurses Association (BARNA)
• Council of Surgical and Perioperative Safety (CSPS)
• Irish Anesthetic and Recovery Nurses Association (IARNA)
• National Association for Clinical Nurse Specialists
(NACNS)
• National Association of PeriAnesthesia Nurses of Canada
(NAPANc)
• National League of Nursing (NLN)
• National Student Nurses’ Association (NSNA)
• Nursing Community Forum
• Nursing Organizations Alliance (NOA)
• Society for Ambulatory Anesthesia (SAMBA)
• Society for Anesthesia and Sleep Medicine (SASM)
ECT, Electroconvulsive therapy; GI, gastrointestinal.
From The American Society of PeriAnesthesia Nurses: 2015–2017 Perianesthesia nursing standards, practice recommendations, and
interpretive statements, Cherry Hill, NJ, 2014, ASPAN. Reprinted with permission.
nurses advocate for their patients during this
most vulnerable time. This advocacy begins
with the preanesthetic evaluation, in which
system reviews identify potential complica-
tions, and continues through the postanesthesia
experience with specific and individualized dis-
charge teaching.4
ROLES OF PERIANESTHESIA
NURSES THROUGH
THE CONTINUUM OF CARE
Role of the Perianesthesia Nurse in the
Preoperative Evaluation, Preadmission
Testing, and Preanesthesia
Evaluation Setting
The preanesthesia evaluation establishes the
initial contact of the perianesthesia nurse
with the patient and the patient’s support per-
sons. This initial contact is crucial because it
Chapter 2 - Perianesthesia Nursing as a Specialty 11
THE POSTANESTHESIA CARE UNIT
• Society of Gastroenterology Nurses and Associates
(SGNA)
• Society for Perioperative Assessment and Quality Im-
provement (SPAQI)
• Society for Office Based Anesthesia (SOBA)
• Surgical Care Improvement Project (SCIP)
This scope of perianesthesia nursing practice document
defines the specialty practice of perianesthesia nursing. The
intent of this document is to conceptualize practice and pro-
vide education to practitioners, educators, researchers, and
administrators and to inform other health professions, legis-
lators, and the public about perianesthesia nursing’s partici-
pation in and contribution to health care.
REFERENCES
1. American Nurses Association: Nursing’s social policy statement:
2010 Edition, Washington, DC, 2010, Nursesbooks.org.
2. American Nurses Association: Nursing scope and standards of
practice, ed 2, Washington, DC, 2010, Nursesbooks.org.
3. Laidlaw et al v. Lions Gate Hospital et al: 1969;70 WWR 727(BC
SC):735.
4. Schick L, Windle P, editors: Perianesthesia nursing core cur-
riculum: preprocedural, phase I, and phase II PACU nursing, St.
Louis, MO, 2010, Saunders.
5. American Society of PeriAnesthesia Nurses: 2010–2012 Perian-
esthesia standards, practice recommendations, and interpretive
statements, Cherry Hill, NJ, 2014, ASPAN.
6. American Society of PeriAnesthesia Nurses: A competency based
orientation and credentialing program for the registered nurse in
the perianesthesia setting, Cherry Hill, NJ, 2009, ASPAN.
establishes the baseline trust the patient will have
in the care provided to him or her during this
vulnerable time.5 The purpose of this preopera-
tive evaluation is to identify potential complica-
tions that can arise during the scheduled event,
provide an opportunity for patient education,
and establish guidelines in preparation for the
procedure. The goal of the preoperative phase
is to provide a complete picture of the patient
relevant to the procedure while providing edu-
cation that will decrease the patient’s anxiety
regarding the perianesthesia care.2, 5 This is
accomplished through the focus on physical,
psychological, sociocultural, and spiritual prep-
aration for the experience.2
The preanesthesia evaluation can occur in sev-
eral ways depending on the clinical enterprise
from which the patient receives care. The his-
torical assessment can be conducted in person,
by telephone interview, or via a computer-based
patient questionnaire application. This historical
12 Section I - The Postanesthesia Care Unit
assessment is a full system review, psychosocial
assessment, and functional assessment, as well
as medication reconciliation and learning needs
assessment. A brief physical examination of heart
and lung sounds as well as airway evaluation can
also occur if the interview is conducted in person.
Preanesthetic testing to include laboratory stud-
ies, cardiac studies, radiology examinations, and
other tests can also be completed at this time as
deemed necessary per patient condition and phy-
sician orders.
The perianesthesia nurse, in the preanesthe-
sia evaluation period, acts as a liaison between
multiple providers to obtain data that provides a
complete picture of the patient’s clinical presen-
tation. The nurse can work with offsite physician
offices to obtain referral records and test results.
Competency-based orientation programs provide
the perianesthesia nurse with the judgment neces-
sary to complete the initial review of documenta-
tion and to send for further review or recommend
additional testing as necessary. Partnering with
other providers allows for the optimization of
the risk stratification of the preanesthetic patient
while reducing costs associated with redundant
testing.
The patient population that the perianesthesia
nurse encounters during this phase depends on
the area of practice. Each specialty patient popula-
tion brings challenges to the perianesthesia nurse,
allowing for further specialization within the field
of perianesthesia nursing. The patient popula-
tion can vary from pediatric to geriatric. Pediatric
perianesthesia nurses face challenges with their
patient populations that are different from, but
just as challenging as, the geriatric population.
Perianesthesia nurses in the nontraditional care
areas also face challenges of limited resources and
specialized assessments. For example, perianes-
thesia nurses in the pain management clinic area
may be more aware of patient coping mechanisms
related to chronic pain conditions not expressed
in the general population.
The effects of the preanesthesia evaluation
are multifaceted. The patient who is adequately
prepared for the procedure has a better postpro-
cedure outcome.6 Information gathered during
this phase is communicated forward to the next
phase of care, which allows each subsequent peri-
anesthesia care provider to follow the established
plan of care while adapting the plan to meet each
patient’s individual circumstance or concern.6
For example, patients identified in the preanes-
thesia evaluation as having a family history of
malignant hyperthermia will have their anesthe-
sia plans altered to reflect that information. Like-
wise, patients identified as having risk factors for
postoperative nausea and vomiting will be given
appropriate premedication to prevent postpro-
cedural nausea. The effects of the preanesthesia
evaluation are evidenced by patient readiness for
the operative experience and further evidenced
by limited incidences of patient complications
during subsequent phases of perianesthesia care.
Verifying historical assessment information with
current physical status potentiates patient safety
by addressing needs such as medication reconcili-
ation, fall risk assessments and interventions, side
or site verification of planned procedure, poten-
tial for compliance of instructions, and discharge
planning assessments.2
Role of the Perianesthesia Nurse in
Ambulatory Surgery and
Preoperative Holding
The ambulatory surgery unit and preoperative
holding areas provide the perianesthesia nurse
the opportunity to interact with the patient and
the patient’s family or other support persons
before the procedure. This time period of height-
ened anxiety may be surreal for the patient and
the family as the level of vulnerability increases.4
The perianesthesia nurse in this phase provides
competent care including an assessment to iden-
tify any changes from the preanesthetic evalu-
ation, pain and anxiety control, advocacy, and
clinical skills, such as intravenous line insertion
and medication management. The perianesthesia
nurse uses therapeutic communication skills with
the patients and their families to ensure a calming
environment and patient readiness for the sched-
uled procedure.
This phase of perianesthesia care can occur
in any clinical practice site before the procedure.
­Hospital-based ambulatory settings can provide
care for patients from same-day outpatient proce-
dures to complex cases requiring lengthy postoper-
ative admissions. The preprocedure perianesthesia
nurse can promote the safety of the patient by
verifying patient compliance and identifying any
alteration from preanesthetic instructions, such
as validation of NPO status. The perianesthesia
nurse also reviews relevant preoperative testing
results, current orders, completion of medication
reconciliation to include last dose date and time
verification, comfort and safety needs, and verifi-
cation of discharge planning, such as validation of
the postprocedure driver and care provider.2
The patient population under the care of the
perianesthesia nurse depends on the provider’s
scope of care. In addition to the patient, this care
period will include the patient’s support structure
of family members, friends, clergy, and other sup-
port providers. These additional support persons

(e.g., family or friends) can provide anxiety relief
for the patient and may be able to provide the
perianesthesia nurse with additional information
the patient is unable to share because of height-
ened anxiety. It is important to note that, during
all interactions with the patient and the patient’s
support system, the perianesthesia nurse’s inter-
action must maintain patient confidentiality, pri-
vacy, and respect.
After obtaining the day-of-procedure assess-
ment update and initiating patient care prepa-
ration orders, the perianesthesia nurse hands
off care. The critical thinking and interpretation
of the assessment by the perianesthesia nurse is
essential, as is the communication of this assess-
ment along with any changes or concerns, to
the procedure nurse who will be involved with
the immediate care of the patient during the
procedure. This vital communication provides
the patient with the best opportunity for a safe,
successful anesthetic event. While the patient
receives care, the perianesthesia nurse continues
to support the patient’s family.
Role of the Perianesthesia Nurse in the
Postanesthesia Care Unit Phase I
The perianesthesia nurse in Phase I cares for
patients in the PACU and provides care for
patients who have completed their anesthetic
event. The PACU is a critical care environment;
therefore, it is designed to provide active line-
of-sight monitoring of patients who have under-
gone a general anesthetic. Phase I is available in
all areas for care after a general anesthetic, such as
hospital-based surgery units, ambulatory surgery
clinics, and office-based procedure areas. Because
these patients have had their basic life-sustaining
reflexes suppressed during their anesthetics, it is
imperative for the perianesthesia nurse in this set-
ting to be acutely aware of changes in the patient’s
status, such as a sudden oxygen desaturation, pos-
sibly indicating a loss of airway. Phase I status is
determined by the patient condition, in which
constant vigilance to the patient is provided and
priority given to basic life-sustaining needs.2
During this critical care period, the patient
is acutely monitored and evaluated for subtle
changes indicating a change in homeostasis.
As the patient recovers from the anesthetic, the
patient is vulnerable, uncertain of location, and
often in pain. The perianesthesia nurse offers reas-
surance; assesses for pain and other physical indi-
cators; and provides medication, monitoring, and
additional comfort measures. Using therapeutic
communication techniques, the perianesthesia
nurse guides the patient through the experience,
allowing the patient to express any needs. The
Chapter 2 - Perianesthesia Nursing as a Specialty 13
THE POSTANESTHESIA CARE UNIT
perianesthesia nurse communicates frequently
with the patient’s support members, providing
condition updates. The perianesthesia nurse also
communicates frequently with the physician or
anesthesia care provider to ensure an optimal con-
tinuum of care.
The perianesthesia nursing assessment includes
integration of relevant preoperative information,
such as patient comorbidities. Understanding
the patient’s anesthetic technique and potential
consequences, such as airway management or
resedation potential, is critical to the patient’s
safe recovery. The perianesthesia nurse obtains
information from the anesthesia provider regard-
ing technique, length, and drugs administered
including reversal agents. Cardiovascular, pulmo-
nary, and neurologic assessments are completed
to validate return to baseline values after the
administration of anesthetic agents. The critical
aspect of this assessment cannot be understated.
The PACU nurse is the primary care provider
who uses critical care skills and training to detect
early subtle changes that could become cata-
strophic without intervention. The PACU nurse
assesses the patient for pain and discomfort using
a variety of pain scales, from an observational
scale for sedated patients to the numeric scale
for those who are more alert and able to answer
questions. The patient’s procedure will dictate
additional assessments for wound assessment,
potential for hypovolemia owing to hemorrhage,
alteration in maintenance of normothermia, as
well as additional physical assessments, such as
peripheral pulse verification. A thorough skin
integrity assessment should also be performed
to verify continued integrity of skin structures or
to identify concerns with skin integrity from the
operative procedure or positioning.2
As in any critical care nursing unit, the PACU
nurse may care for patients who need a ventilator
or require hemodynamic intravenous medication
administration and intensive cardiac monitor-
ing. If the requirements of the institution’s Phase I
includes care and management of these most criti-
cal patients, appropriate competencies—to include
patient assessment and intervention, advanced
cardiac monitoring skills, advanced hemody-
namic medication administration, and advanced
pulmonary care, such as ventilator manage-
ment skills—must be included in the competency-
based orientation program for the Phase I PACU
nurse.
Communication with the anesthesia care team
to understand the patient’s preprocedure emo-
tional status will allow the perianesthesia nurse to
provide the appropriate emotional support to the
emerging patient who will have anxiety because of
Another random document with
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every summer without a single drowning. Parents may feel perfectly safe in
allowing their boys to spend a term at such well protected camps.”
“I shall never hear three blasts from a whistle again,” said Mr. Holwell,
“but that I shall think of this time up here.”
“Indeed, sir,” continued Mr. Rowland, “I understand that some of the
young volunteer life-savers on returning to the city after a summer in the
woods, confess to having a shock whenever they hear a whistle. When the
emergency call sounds, no matter whether in the midst of the swimming
hour or at dead of night, the rule is to drop everything and run.”
Dick had noticed that Asa Gardner seemed to be enjoying himself
greatly when in the water. He was turning out to be a clever swimmer.
Evidently, the boy had included this in his programme when he decided to
take all the open air exercise he could. Dick mentioned the fact to Peg while
they were dressing as fast as they could, urged on to speed by the odor of
breakfast that was in the air.
“Why, yes,” the other boy remarked, immediately, “that fellow acts as if
he had sprung from a fish family.”
“What makes you say that?” demanded Dick, smiling at the same time
on account of the queer way Peg had of describing things.
“Oh! only that he seems to go fairly wild when he gets in the lake,” was
the reply. “Eddie Grant says he really believes Asa can stay under water
longer than any fellow he ever knew. And did you see him dive off that high
tree stump overhanging the edge of the deep hole? He turned a complete
somersault in the air, and struck the water as clean as a knife. Mr. Rowland
complimented him on his feat, though he also cautioned Asa to be careful
not to overdo it.”
“Yes, Asa is improving right along,” confessed Dick. At the same time
he could not help wondering deep down in his mind whether the strange
boy could be as successful in overcoming his one terrible fault as he seemed
to be in regaining his health. For somehow Dick could not quite forget
about the shadowy figure that had vanished from his sight on the preceding
night, not far from the tent where he knew Asa had been quartered.
“I never thought he had it in him,” admitted Peg; “but I’m ready to say
Asa is beginning to pick up considerably, and show the stuff he’s made of.”
 It was kind of Peg to say that, for, truth to tell, as Dick well knew, the
other had had good reasons in the past for looking on the lonely boy with
anything but friendly feelings. But then Peg could never hold anything
against another who showed signs of being sorry for faults. Peg believed in
giving every one a second, yes, even a third, chance to make amends.
After finishing his dressing and coming outside again, Dick looked
toward the tent which Mr. Holwell occupied. He knew the minister must be
dressing, for he had seen him peer out once. Perhaps he was shaving, for he
had laughingly said on the previous night that he hoped they did not have
any iron-bound rules in the camp prohibiting brushing the hair, or using a
razor during the whole stay, such as he had heard was the case with some
outing parties.
Just then Dan came along, and stopped to exchange a few words with
Dick.
“To-morrow being Sunday, I expect we’ll be pretty quiet up here,” he
observed; “so we ought to do all we can to-day. The fellows who go fishing
will have to try to get a double quantity, if we think to have a course dinner
to-morrow. I’m one of the six selected by Mr. Bartlett to go over to that
farm we heard about. If we can buy a few chickens or ducks or anything in
that line, don’t you think we’d better go prepared to dicker?”
“Not a bad scheme, Dan,” Dick told him. “And don’t forget that while
there are just twenty-one of us all told, besides Mr. Holwell, Mr. Bartlett
and our physical director, we’ve got the storage capacity of twice that
number.”
“Oh! we’ll take on all the supplies we can stagger under, make up your
mind to that, Dick. But here comes Mr. Holwell straight this way, and, tell
me, doesn’t he look kind of queer? I wonder if anything could have
happened to him in the night.”
Dick almost held his breath as the minister hurriedly drew near them.
“A ridiculous thing has happened to me, Dick,” remarked the minister,
as he reached them. “The very first night I’m in camp I have been guilty of
the fault of carelessness. To tell you the truth, I am unable to find my gold
watch this morning, though Harry Bartlett thinks I wound it up as usual, and
hung my vest upon a nail driven part way into the tent pole.”
 Dick felt as though a cold hand had clutched his heart. He and Peg
exchanged anxious looks, but before either of them could say a word Mr.
Holwell went on.
“I wouldn’t care so much, you understand, boys, only it was presented
to me years ago by my people in a church of which I formerly had charge,
and consequently I value it many times over its intrinsic worth. But, of
course, I have mislaid it. I’ll go back once more and turn things over. The
chances are I’ll find it where I placed it. On account of my strange quarters
and having no regular spot for it, I must have dropped it down at random
and don’t know just where.”
 CHAPTER XIV
TRYING TO FIGURE IT OUT

Dick knew it would not come out that way. He seemed to “feel it in his
bones” as he told Leslie afterwards, that the terrible mystery with which
they had been confronted on their first night in camp, was closing around
them with even a tighter grip.
When Mr. Holwell had left them to hasten back to his tent Dick and Dan
looked at one another with blank expressions on their faces.
“Whew!” gasped the latter. “Say, Dick, this is what I call piling it on
thick.”
“It begins to look like a bad business I must admit,” returned the other,
trying to grasp the situation fully.
“All these things couldn’t just happen by accident, you see,” continued
Dan, as if arguing with himself. “Mr. Holwell is a careful man, and
wouldn’t be guilty of leaving so valuable a watch around loose, so it could
be mixed up with the bed clothes in his tent. I tell you we’re up against a
real old-fashioned mystery, and no mistake.”
“There’s something queer going on around this camp, for a fact,” said
Dick, and taking advantage of the fact that they were alone for a brief time
he confided to Dan what he had seen during the night on coming suddenly
out of his tent.
The other was deeply impressed by the story. His eyes grew round with
wonder and curiosity.
“Let’s go over to Mr. Holwell’s tent and see if we can help him hunt,”
he proposed presently. “I used to be a master-hand at finding lost things,
and mebbe my luck may hold good in this case.”
“I certainly hope it will, Dan. Nothing would tickle me more than to
have you unearth that watch somewhere in his tent. All the same I don’t
believe it can be done.”
 “Well, there’s no use crying over spilt milk, anyhow,” said Dan with
philosophy.
When the two boys reached the minister’s tent they met Mr. Holwell,
accompanied by Mr. Bartlett and Mr. Rowland, coming out. The minister
looked a little grave and deeply puzzled, though on seeing the expression of
anxiety on the faces of the two lads he smiled encouragingly.
“We haven’t been able to find it so far, boys,” he remarked. “Suppose
you step in and root around a bit. Young eyes are sharper than older ones. I
hope it turns up, because I should very much dislike to lose anything that
was endeared to me by so many precious memories.”
Although Dick and Dan turned everything upside-down, they failed to
discover any sign of the lost watch. Breakfast was soon announced and they
were forced to abandon the search.
Some of the other boys had noticed that something unusual had
happened. The doings of Dick and Dan had struck them as suspicious,
especially after their previous experience.
Accordingly, Harry Bartlett, knowing that there was no use of trying to
keep things secret, announced the new catastrophe that had befallen
Russabaga Camp. It came like a thunderbolt upon the assembled boys, who
exchanged puzzled and anxious looks, as though a great fear had fallen
upon them.
Conversation languished after that. It was as though a wet blanket had
been suddenly cast upon them. Every one was busy with his own thoughts,
wondering if it could be possible that the dreadful finger of suspicion
pointed anywhere in his direction.
Mr. Holwell it was after all who, laughing as though he did not have a
care in the world, started to raise their spirits.
“Come, this will never do,” he told them. “You look as if you had lost
all interest in life. We mustn’t let a thing like this spoil the whole outing.
Doubtless in good time the mystery will be cleared up. And now let’s talk
of all our good friends here, Mr. Bartlett and Mr. Rowland, have planned to
do to-day.”
 By degrees he had the boys looking much more cheerful, though when
they got together in clumps after the meal, the conversation was naturally
almost wholly of the last strange happening.
Nat and his two cronies were seen talking earnestly. Some of the others
could hazard a pretty good guess as to what must be troubling the trio. This
was a time when a person’s past reputation was going to come back to
haunt him. Nat, aided and abetted by Dit and Alonzo, had engineered
numerous dubious enterprises in times that were gone, some of them of a
questionable nature. And now being reproached by their consciences, they
felt that the others must of a certainty be eyeing them with suspicion.
Alonzo showed signs of wanting to desert the camp at once, being only
restrained from doing so by the stronger wills of his companions, who
realized that this action would look too much like guilt.
Altogether it was not a very happy lot that proceeded to take up the
various duties laid out for that morning, and in doing which they had
expected to enjoy themselves hugely.
After the excitement had died down the six who had been selected to
visit the farm went off in one of the two boats. And while the chosen
fishermen were making deft use of the mosquito-net seine in order to secure
minnows for bait, Dick found an opportunity to have a little talk with Mr.
Holwell.
Eddie Grant, Ban Jansen and Cub Mannis, with tin pails in their hands,
hurried past, looking as though they meant business.
“We have found where the blueberries are as thick as clover in a field,”
called Ban. “It’ll be an easy job filling these pails by noon. Never saw such
big berries as there are on this island. It’ll be a picnic getting stacks and
stacks of ’em, and we can pay our way easily as we go.”
Mr. Holwell looked at Dick on hearing this, as though he did not quite
understand. Accordingly, the boy hastened to explain that Mr. Nocker had
proposed that boys belonging to the association who wanted to go on the
camping trip and could not spare the ready money to pay for their share of
the expenses should earn enough while on the island by picking the
blueberries that found a ready market in Cliffwood.
 “That’s a very good scheme,” declared the minister, smiling. “And it
shows that our friend, Mr. Nocker, knows more about boys than some of us
gave him credit for. Of course he could have offered to pay the way of
Eddie and the rest, but after all it’s the wise thing to do to make boys feel
that they have earned things, and are not objects of charity.”
“Of course,” Dick went on to explain, “that sort of thing is unusual, and
will break in on some of the customary rules that govern all Y. M. C. A.
camps. But Mr. Bartlett says that after all this is only a beginning, and on
that account we can’t expect to do everything with perfect regularity.”
“Another year,” said Mr. Holwell, “it may perhaps be different. We will
find some way whereby a score or two of the mill hands can spend a week
or two up at a regularly organized camp. And when we get things to
working smoothly, such an outing is bound to be of great benefit to
everybody concerned. I’m in it heart and soul, and so is Mr. Nocker.”
“I want to talk with you a little more, sir,” said Dick, boldly, “about this
queer disappearance of your watch. I wish now I had gone to Mr. Nocker
and asked him to explain what he meant when just before leaving the
meeting that night he warned us to beware of the thief up here in Bass
Island.”
“Did he say that?” demanded Mr. Holwell, quickly. “Then there must
have been a reason for it. Others who have camped here, fishing parties,
perhaps, have lost things. And Dick, what you have told me actually raises
my spirits considerably, even if it does not promise to bring back my
missing property.”
Dick could understand. The kind-hearted minister must have been
oppressed by some of the same dreadful thoughts that ever since the first
raid had been tugging at his own heart-strings. He feared that one of the
boys might be guilty, and the very suspicion caused him unhappiness. It
would be so much easier to bear if in the end the culprit proved to be some
outside person, possibly a crazy man who had escaped from his keepers, as
Peg had suggested.
Long and earnestly did the minister and Dick converse while sitting
there. Dick found much encouragement from what the gentleman told him.
He even took occasion to mention the suspicions that had oppressed him
concerning Asa Gardner; but Mr. Holwell shook his head as though
determined not to harbor such himself.
“I have studied boy-nature for many years, Dick,” he said, with feeling;
“and I know how hard a fight poor Asa is doubtless putting up against the
strange weakness that used to dominate him. The memory of his dead
mother will cause him to be victorious in the struggle, I fully believe; and
just now he needs all the encouragement he can get. And you are the one
best fitted to stand by him as a faithful friend.”
“I’ll willingly do everything I can to help him along,” said Dick, with a
look of determination on his young face. “I’ve known times myself when I
needed a friendly hand to help me along, but never one half so much as he
does. There go Nat and his two chums into the woods. Mr. Bartlett must
have given them permission to explore the island.”
“I wonder if they are thinking of hunting up Eddie’s crowd, and helping
pick berries,” remarked Mr. Holwell. “It would be a kindly thing if some of
the other boys would lend a helping hand. The berry pickers will find it no
easy task to collect enough at a few cents a quart to pay their expenses.”
Although Dick did not say so, he was of the opinion that Nat and his
cronies were hardly the kind of boys to be anxious about anything
excepting their own welfare.
 CHAPTER XV
DAN TELLS SOME WHOLESOME TRUTHS

“How is Humbert Loft getting on with the rest of the boys?” asked Mr.
Holwell, glancing over to where the lad in question was talking earnestly
with Dan, who had changed his mind about going with the “foraging party,”
on account of a bruised heel, caused by a shoe that chafed him.
Dick shook his head as though he rather despaired of weaning the
nephew of the town librarian from his stilted and unpleasant ways.
“He’s been well drilled at his home, sir, I’m afraid,” he went on to say,
“by that uncle of his who knows about as much about real boys as he does
of Egyptian mummies, and perhaps a good deal less. I’ve talked with him a
number of times, but everything he says is just an echo of what Mr. Loft has
been telling us right along.”
“Then you don’t really believe these lofty ideas are his own, but
acquired from association with older people?” asked the minister, looking
amused, for he personally had no sympathy with the principles of the
pedantic librarian.
“Why, Mr. Holwell, it’s impossible for a boy to think as he claims to do,
unless he was brought up among a lot of stuffy people who filled him with
their ideas. A boy to be natural is just bound to want to read stories that are
full of action. We all think that the writer who can give us healthy
adventure, and perhaps put some good, strong traits into his characters, is
doing us all the good we’ll stand for.”
“My opinion exactly,” said the minister, heartily.
“Still,” went on Dick, “Humbert has waked up some and is taking to the
water and to swimming like a fish; so, you see, there may be hope for him
in other things as well.”
“Let us hope so,” the minister said with a smile.
“I hope you have told Mr. Loft how we boys feel about our reading, sir,”
ventured Dick, boldly.
 “Oh! many times when we have been warmly discussing these same
matters,” came the reply. “But it seems as useless as water dropping on a
stone. In the course of ages it may wear the stone away, but neither of us is
likely to live to see the day. Mr. Loft is very bigoted, and has a false idea
concerning boys and what they ought to read.”
“Still, he seems to be more civil to us nowadays,” observed Dick, with a
gleam of amusement in his eye as he spoke.
“H’m! for a very good reason,” laughed Mr. Holwell. “Since you and
your comrades started the Boys’ Library, with a select list of books, all
approved by myself, Mr. Henry Fenwick, and several other gentlemen who
love boys, Mr. Loft has been reading the handwriting on the wall. He begins
to fear that if he keeps on thrusting his classical ideas of boys’ literature
upon the patrons of the town library he may lose his job. So he believes it
good policy to quiet down.”
“Let’s wander over a little closer to where Dan and Humbert are sitting,
sir,” suggested Dick. “I’d just like to hear what they are saying, because
from the way Dan is laying the law down I expect it’s about books and Mr.
Loft’s ideas for boys. Dan, you know, is head and heels interested in that
library of ours; and he fairly despises Mr. Loft. I’ve heard him call him a
‘human icicle’ many a time.”
“Just as you say, Dick,” consented Mr. Holwell, smiling at the apt
designation given by Dan, for, regardless of the librarian’s intellectual gifts,
it seemed to fit him.
When the two sauntered near the place where the boys were talking,
Dan was getting up as though to leave. He did not notice the presence of
Mr. Holwell, but was shaking his forefinger in Humbert’s face. That
individual looked worried, as though he felt the crushing force of the
arguments Dan had been heaping up before him.
“I tell you, Humbert Loft,” they heard Dan say with emphasis, “boys
can’t be treated as if they were machines. Boys have feelings, and they
know what kind of reading they want every time. Their books have got to
have a certain amount of good, lively, healthy adventure in ’em, or else
nobody’s going to bother spending his time over ’em.”
 “But my uncle says——” began Humbert feebly, when Dan interrupted
him.
“Oh! what does your uncle know about boys, tell me? I guess when he
was a baby they must have fed him on Latin verbs and Greek nouns. All he
thinks of is stuffing us boys with ‘standard literature,’ as he calls it, when
we’re just shouting for things that appeal to our boy natures.”
“But what he wants boys to read are the books that all cultivated people
consider the finest fruits of human endeavor!” urged Humbert, desperately.
“Who says they ain’t?” demanded Dan, with a reckless disregard for all
rules of grammar that must have chilled the other boy’s heart. “But they
never were meant for boys’ consumption. When we get older we’ll
gradually drop reading boys’ stories, and some of us may take up the
classics, while others will get out in the busy world and go to work.”
“I don’t know—I’m only telling you what my uncle thinks about it,”
pleaded Humbert, weakly.
“Stop and think for a minute, will you?” continued Dan, still waving
that threatening forefinger back and forth. “If every boy in Cliffwood were
built on the same model as you, Humbert Loft, what a terrible desolation
there would be in that poor town. Why, with not a single boy playing ball,
or giving a shout when he felt real good, the people would think the end of
the world had come. Isn’t that so, Humbert?”
Humbert smiled in a sickly fashion.
“Why, I guess it would seem pretty queer,” he admitted, slowly.
“And another thing, Humbert,” finished Dan as a clincher, “since
you’ve been up here with us I’ve noticed that you begin to show some
interest in our doings. I really believe you’re beginning to find your real
self, and that when we go back to Cliffwood you’ll be a different sort of
fellow. Think it over, won’t you, and just join in with the rest of us in our
fun? Forget your uncle, and remember that you’re a living, breathing boy,
not a mummified classic.”
With that Dan tore away to do something he had in mind. Mr. Holwell
touched Dick on the arm, and the two of them retreated without Humbert’s
being aware that his heart-to-heart talk with Dan had been overheard.
 “See him shaking his head, and then smiling, sir,” said Dick, with
considerable interest. “I really do believe those sledge-hammer blows Dan
gave him have made an impression on Humbert. Given a week or ten days
up here, and he may throw off the heavy load he’s been carrying so long,
and act like a regular boy for once.”
“We’ll hope so, Dick,” returned Mr. Holwell. “But while Humbert is
growing less pedantic and dropping some of his foolish pose, I trust the rest
of you will pick up a genuine love of books. The love of good books is
always a joy and sometimes a solace when other things fail one.”
The morning passed away, and those in the camp found many things to
do under the supervision of Mr. Bartlett and the athletic instructor.
It must have been all of half-past eleven when Dick heard the sound of
hasty footsteps in the woods near by. Then several figures burst into sight,
hurrying toward the camp, and making extravagant gestures as they
stumbled along. At the same time they cast frightened looks over their
shoulders, and Dick heard Nat Silmore cry:
“This here island’s no place for our camp, fellers. There’s a terrible wild
man loose on the same, and he roared at us something fierce. We’d better
get away from here while the going’s good, I tell you! Wow! I’m nearly all
in.”
 CHAPTER XVI
WAS IT A WILD MAN OF THE WOODS?

“What’s all this you are telling us, Nat?” asked Mr. Bartlett, with a show
of interest, while the boys of the camp crowded around the trio of
newcomers, and Mr. Holwell and Mr. Rowland stood listening not far to
one side.
Dit and Alonzo seemed pretty well exhausted. They sank down on a
log, panting as if they could hardly catch their breath. Despite the color in
their flushed faces they looked alarmed, as well as sheepish on account of
having given way to their fears.
“Why, we certain sure did see something, Mr. Bartlett!” urged Nat, with
emphasis. “The woods happened to be kind o’ gloomy right there, so we
couldn’t be dead sure what it was, but he made a horrible drumming sound,
and waved his arms above his head. Ugh! did we run? Well, to say we tore
along’d be hitting it closer.”
“And I reckon the wild man chased after us for a little, too,” Dit
Hennesy managed to say between his gasps. “Leastwise I could hear
something comin’ back of us, and it made me smash into a tree, I was that
worried.”
He put a hand up to his forehead, where they could see that a lump had
made its appearance. This at least was evidence that the boys were not
trying to play one of Nat’s customary practical jokes. Bumps like that have
a way of telling a story of their own. Bumps seldom lie.
“What makes you think it was a wild man?” asked Harry Bartlett, trying
to get all the information possible from the boys.
“Oh! well,” replied Nat, slowly, “he just seemed to act wild, I reckon.
When we glimpsed him he was squatting down, and as soon as Dit here let
out a whoop he commenced growling at us something fierce.”
“Yes, sir,” said Alonzo, thinking he ought to add the weight of his
testimony to that given by his two companions, “it was a wild man as sure
as anything. And right away, sir, there were three wild boys tearing through
the woods like fun. As luck would have it we came in the right direction,
and didn’t get lost. Whew! I’d hate to spend a night alone on this island
with that thing roaming around loose!”
The camp director and Mr. Holwell walked aside, Dick going with
them.
“What do you think about it, Mr. Holwell?” asked the boy.
“They evidently did see something that frightened them,” admitted the
gentleman. “But whether it was an animal or a crazy human being remains
to be found out later. When boys are suddenly thrown into a bad scare they
can easily mistake a hog, or even a harmless calf, for a monster.”
“But if there is some sort of strange creature loose on Bass Island,”
pursued Dick, eagerly, “mightn’t that explain the thefts that have been
taking place?”
“True enough, Dick,” answered Harry Bartlett, “and for one I earnestly
hope that may turn out to be the case. It gives me a heartache to think of
suspecting any boy among us of being a thief.”
Several other boys joined them just then. They were all trying to figure
out how much dependence could be placed on the story told by Nat and his
cronies. In times past they had cried “wolf” so often that now no one felt
like believing them, though, in fact, there might be real cause for alarm.
“Huh!” said Dan, skeptically, “like as not they were looking to see what
the chances were to leave the island when they could hook one of the boats,
and then got scared at their own shadows. It’s nearly always the way with
bullies like Nat.”
“But why should they want to desert us, Dan?” asked Mr. Holwell.
The other shrugged his shoulders in a way that stood for a great deal.
“Oh! well, sir,” he went on to say, “I don’t want to accuse any one, you
understand, and right now I’m not hinting that Nat had a hand in those
thefts; but you see they think we suspect them, and that makes it
disagreeable here for them.”
“To tell the truth,” said Elmer Jones, “I never thought they’d tag along
with us up here, in a regularly organized Y. M. C. A. camp, because they’re
always in fear of being lectured on account of their ways. But they came,
and now they feel uneasy when this queer mystery is afoot.”
“We mustn’t make them feel that they are suspected,” said the minister.
“So far they seem to have behaved themselves fairly well, and I have been
allowing myself to hope that by degrees those boys may see that it pays to
be decent. I would like to show them that there’s more genuine fun to be
gotten out of the clean method of living than in the way they’ve usually
carried on. Besides, we mustn’t forget that none of those boys has the best
of home influences back of him.”
“There comes the boat with the bass fishermen!” called Dan just then,
as a shout was heard from the water.
“They act as if they had met with at least fair success,” said Mr.
Holwell, who could read boys like the printed page of a book, though for all
that he confessed that he found something new every day to study in their
make-up.
“And unless my eyes are deceiving me,” remarked Harry Bartlett,
“there’s the other boat pushing out from the shore across the lake.”
“Just what it is,” added Clint Babbett, who possessed keen vision. “And
say! let me tell you they’ve got a load of stuff along with them. Must have
about cleaned that farmer out of eatables.”
There was more or less excitement as the boats came in, one after the
other. The fishermen had succeeded beyond their most ardent expectations,
and showed a splendid catch of bass, several of which exceeded in weight
the largest taken on the preceding day.
When those from the second boat landed they proudly exhibited the
results of their visit to the farm. There was butter, beautiful golden in color,
and many dozens of eggs, some of them from ducks, though it was pretty
late in the summer for these fowls to be laying, Mr. Holwell observed.
“And here’s six of the finest spring chickens you ever saw,” said Phil
Harkness, one of the foragers, exultantly. “They had just fixed them for
market, and were only too glad to sell them to us.”
“The farmer’s wife treated us to all the buttermilk we could swallow,”
observed Fred Bonnicastle, another of the returned pilgrims. “She said we
could have gallons of it if only we had some way of carrying it back with
us, which we didn’t—only in us.”
Lunch was prepared with the customary breezy accessories in the way
of directions called back and forth. Mr. Holwell seemed just the same as
usual. If he felt his late loss keenly he knew how to hide his feelings, so that
he might not cause the spirits of his boys to droop.
One lad, however, said nothing. This was Asa Gardner. Dick could not
help noticing that the boy heaved a deep sigh every little while, when he
thought no one was noticing him.
“He certainly looks unhappy,” Dick told himself, as once more
suspicions began to force themselves into his mind, though he hurriedly put
them aside, remembering the promise he had made to Mr. Holwell to
believe in Asa and help him all he possibly could.
The three berry pickers had returned with full buckets. They reported
the supply of berries as literally inexhaustible. Still it could be seen that
they were beginning to wonder where the fun of their outing was to come in
if they had to spend most of their time in doing this sort of work.
“On Monday,” Dick told Mr. Holwell and Mr. Bartlett, “I’ll give some
of the fellows a tip, and see if many hands won’t make light work. We’d all
like to pick berries for a while, I expect, and every quart will count so much
to their score. And I’ve an idea Mr. Nocker means to see that they get a
price for those berries that no one ever had before.”
“That’s the right spirit to show,” Mr. Holwell remarked as he placed a
hand affectionately on Dick’s shoulder.
It happened that a little while after lunch Dick wandered down to the
landing to take a look at one of the boats which had been reported as
leaking again. He believed he knew of a way in which it could be mended
so as to stay dry and serviceable.
He turned the boat upside-down; and, while stooping over examining
the bottom of the flat craft, he heard some one coming. Turning his head he
saw it was Asa Gardner. Like a flash it struck Dick that the other wanted to
say something to him in secret, and was taking this chance when no one
else was near.
 A chill gripped Dick’s heart. He seemed to feel that something dreadful
was coming, though he could not guess its nature as yet.
Asa drew alongside.
“Dick,” he said, and the other boy noticed how his voice trembled.
“Yes, what is it, Asa?”
“I’ve been waiting to catch you alone, because I’ve got something to
say to you that I wouldn’t like anybody else to hear, especially Mr.
Holwell.”
Dick felt the chilly sensation again; but he looked up smilingly.
“All right, Asa,” he said, cheerily, “here’s your chance to tell me what’s
bothering you. If I can do anything to make you feel easier just make up
your mind I want to help you. Now, what’s gone wrong?”
Asa’s eyes were growing wet, and evidently he labored under great
emotion.
“It’s just this, Dick,” he said, weakly, “I never should have dared come
along with a bunch of decent fellows like your crowd. I ought to have
known I just couldn’t keep from falling back into my old ways, that have
got such a terrible grip on me. And Dick, there’s only one thing to be done
—send me home right away!”
 CHAPTER XVII
DICK’S PROMISE

Dick could hardly believe his own ears when he heard Asa make this
terrible confession. He gripped the other boy by the shoulder almost
fiercely.
“Look here, Asa Gardner, do you mean to tell me that it was you who
took those things in the night—Dan’s watch, the aluminum frying-pan, and
last of all the gold watch which your best friend Mr. Holwell thinks so
much of?”
Asa groaned, and drooped pitifully in his grasp.
“I don’t know for sure, Dick, but I’m awfully afraid I did,” he said,
huskily.
“That’s a queer way to put it,” Dick told him, sternly. “Anybody ought
to know if he were guilty of doing such a mean thing as that. You’ll have to
explain yourself, Asa. Do you remember taking those things?”
“No, no, that’s the strangest part of it, you see, Dick,” pleaded the boy.
“But they disappeared, and I was in the camp both nights.”
Dick began to breathe a little easier.
“But that isn’t any proof at all, Asa, that I can see,” he hurriedly
remarked. “How could you take them, and not know it, tell me?”
“I wish I could, Dick, but then nobody else here would be low enough
to steal except me, and so I’ve figured it out that I must have done it in my
sleep, just because the old habit was so strong. While I was awake I could
fight it off, but you see once I lost my senses my grip was broken, and I
must have done it. Oh, I must!”
“Well, that’s a funny thing to tell me, I must say,” Dick replied. “You
haven’t the least remembrance of doing it, yet you’re ready to take all the
blame on your shoulders because once on a time you had a weakness that
way. Brace up, Asa; you never took Mr. Holwell’s watch, I tell you.”
 It was wonderful to see how new hope seemed to come immediately
into the heart of the erring boy. The look of misery began to die out of his
face, and through the tears gathering in his eyes Dick could see a new
sparkle—that of hope.
“Oh! it’s kind of you to say that to me, Dick!” he exclaimed between his
sobs, for he was completely aroused and could not control himself, though
he tried hard to do so. “Tell me who did take the watch, then, that Mr.
Holwell, the finest man on this whole earth, thought so much of?”
Dick laughed breezily, more to cheer the poor fellow up than because he
considered it a joke.
“I wish I could tell you, Asa,” he said, quickly. “But so far it’s a mystery
that has yet to be solved. But I’m dead sure you hadn’t a thing to do with
the robbery, if that’s what you mean.”
“There was one favor I meant to ask you, Dick, if you thought I hadn’t
better leave the camp,” continued Asa, presently, when he could master his
emotion.
“All right, let’s hear it,” he was told encouragingly.
“To-night, and every night after this I want you to let me sleep next to
you in your tent. Yes, and Dick, if only you’d fix it with a cord of some
kind so that I couldn’t move about without your knowing it I’d feel easier.
Then if another robbery was committed I’d begin to understand that I
couldn’t be doing these terrible things in my sleep.”
“I’ll think it over, Asa,” the other told him. “Though I’m sure nothing
like that is going to be needed to prove your innocence. Besides, since
we’ve heard of Nat and the other fellows meeting with some sort of strange
man in the woods, Mr. Holwell, Mr. Bartlett and Mr. Rowland begin to
believe the secret of the robberies will be solved when we run across the
wild man.”
Asa winked hard to clear his eyes from the tears.
“You’ve made me feel a whole lot easier, I tell you, Dick,” he said, and
he persisted in squeezing the other’s unwilling hand with boyish fervor. “I
hope and pray that it may come out that way. I’m trying as hard as I can to
keep my promise to my mother, and she knows that it would nearly kill me
if I found that I was going back to those old ways in my sleep.”
“Cheer up, Asa, and don’t let any of the other fellows see you looking
as if you had lost your last friend. Mr. Holwell believes in you, and so does
Harry Bartlett, and so do I. You’re going to be all right and as good as the
next one. Sure! you can sleep alongside of me if you feel like it. But about
that cord you mentioned, I hardly think it’ll be necessary.”
Asa wandered off until such time as he could recover from his emotion
and Dick continued his examination of the boat’s bottom. After all, he was
glad the other had spoken as he had, because somehow it seemed to clear
the air.
“And,” he told himself, humorously, “I’m beginning to get a hunch that
before a great while we’ll find some way of explaining this mystery. If that
was a wild man Nat and the others saw, surely he must be a lunatic who’s
escaped from some asylum. We may be the means of capturing him, and
restoring him to his quarters. He’ll be frozen to death if he has to stay on
Bass Island all winter.”
The idea pleased Dick exceedingly, and when he once more joined the
others by the fire some of the boys wondered what could have happened to
make him appear so cheerful again.
He took the first favorable opportunity that arose to get Mr. Holwell
aside. Asa had not yet returned to the camp, though they could see him
sitting on the end of a fallen tree that jutted out over the water, possibly a
hundred yards further along the shore of the island.
“I had a pretty bad scare a short time ago, sir,” was what Dick started to
say, which caused the gentleman to start, and look at him strangely.
“Have you been seeing things too, Dick?” he asked. “Would the wild
man become so bold as to approach our camp in broad daylight?”
“No, but I’ve been hearing things that gave me a bad turn at first,
though it came around all right pretty soon,” and with that Dick repeated
what Asa had said to him near the boat landing when they were alone.
Mr. Holwell was of course stunned at first, but as Dick went on with his
story his eyes grew moist, and he shook his head as though he felt
exceedingly sorry for the boy whose past haunted him so persistently.
“Poor Asa,” he said, later on, when he had heard all, “it must be terrible
to feel as he does, and be compelled to fight so desperately to keep from
doing things that other boys have no fear they will be tempted to do. I give
him all credit for his gallant fight, and if he wins, as I firmly believe will be
the case, I shall be proud of him. You must continue to help him in every
way you can, my boy.”
“I certainly will, sir,” declared Dick, with a strong remembrance of the
moist eyes Asa had turned on him when he made that humiliating
confession that after all had proved to be only a dreadful suspicion, and not
a reality.
That was a busy afternoon, all things considered. Some of those who
had been out fishing in the morning decided they had had enough angling
for one day. Besides, they knew very well that others were desirous of
testing their skill against the game qualities of the black bass of Lake
Russabaga.
So it came about that Dick Horner had a chance to be a member of the
quartette that left camp with dark designs against the finny inhabitants of
the inland sea. They carried a goodly number of live bait in a pail
constructed for that purpose, and also some artificial minnows, as well as
trolling spoons to fall back on in case the other supplies were exhausted.
Mr. Holwell had entered into the work with almost as much enthusiasm
as any of the boys.
“To-morrow being Sunday,” he explained as he worked, “we will do
just as little manual labor as possible. My flock in town will have a supply
in the pulpit, for they have given me a little holiday. And if you boys care to
hear it I expect to give you a sermon I wrote for some lads of my
acquaintance many years ago, though it touches on truths that are just as
pertinent to-day as when it was first delivered.”
Dan had not gone off with any of the others, but at the same time he
failed to mingle with those in the camp. They could hear him pottering
away close by, now hammering, and again coming back for bits of stout
twine or rope. Nobody but Mr. Bartlett knew what Dan was about.
 All this naturally aroused something akin to curiosity among the boys,
and as the afternoon wore on many guesses were indulged in as to what
Dan Fenwick could be doing. Finally, one of his companions, more daring
than the rest, sauntered over his way to ask him pointblank what it was he
kept working on so industriously. Andy Hale, for it was he who had
approached Dan, presently came hurrying back, with a half grin on his face,
at the same time laboring under partly repressed excitement.
“Hey! would you believe it?” he announced as he arrived near the fire.
“Dan up and told me he was building a cage to trap that wild man Nat saw
in the woods.”
 CHAPTER XVIII
SETTING THE TRAP

Of course when Andy made this surprising report the rest of the boys
were of a mind to rush over in a body to joke Dan, and perhaps make fun of
his labors. Mr. Holwell, however, dissuaded them.
“Better leave Dan to finish his trap, boys,” he told them. “He’s a busy
fellow these days it seems, and deserves success if anybody does. If he
needs any help you’ll hear him call for it. In the meanwhile don’t thrust
yourselves where evidently you’re not wanted.”
Accordingly, all dropped back into their comfortable seats, and took it
out in speculating as to what the worker could have in mind when his
ambition led him to want to trap a real wild man of the woods.
Dan did not show up in time to take part in the customary preparations
for dinner. There were plenty of recruits, however, for with hunger urging
them on the campers showed an eagerness to hasten the getting of the
evening meal. Sunny Jim grinned more broadly than ever when he found
his tasks so cheerfully lightened.
They managed to hold themselves in check until Mr. Holwell had asked
the customary blessing. Somehow this influence for good was felt even by
those lads who had never known such a custom in their own homes. It
seemed especially well suited to the leafy canopy overhead, the gurgling
waters lapping the shore near by, and the sense of freedom around that
brought them closer to nature and to God.
Dan made his appearance about the time they were half through, and the
twilight shadows were stealing timidly out of the recesses of the mysterious
woods.
Many curious looks were cast in his direction, but somewhat to his
surprise no one ventured to joke him about his ambitious labors. Dan
himself, when the edge had been taken from his appetite, introduced the
topic voluntarily.
 “Course you fellows are wondering what I’m up to,” he said, with a
grin. “Well, I got a little idea into my cranium, and have been working the
same out, with the aid of a hatchet, a hammer and some nails. In fact, I’ve
set a trap hoping to coax the escaped lunatic to go in, after which it’ll drop
and hold him for us.”
“But what will you bait it with, Dan?” demanded Peg, with seeming
innocence, “because you know my aluminum frying-pan is gone, and we
haven’t got another shiny watch in the camp nowadays.”
“Oh! that’s easy,” said Dan, carelessly. “I reckon now that even a crazy
man is liable to get hungry right along. I’m going to bait the trap with some
sort of food that I think ought to draw him on. Just wait and see, that’s all.”
The evening passed in the usual occupations. Some of the boys busied
themselves in one way and some in another. Some had writing to do; some
worked with pictures they had taken during the day, and which were to be
developed at night time.
Already the keen spirit of rivalry had taken complete possession of the
campers. The prizes that had been offered to those coming in with the best
flashlight photograph, the cleanest score in nature study, the highest marks
in knowledge of woodcraft, and numerous other courses laid out by Mr.
Rowland, may have had something to do with their perseverance.
There was more, however, than this desire for gain urging the boys on.
Most of them really yearned to improve themselves along certain lines, and
to be adjudged first in their class would be considered proof that they had
met with success.
So there was hardly a boy in the camp aside from Nat and his two
sombre cronies, Dit Hennesy and Alonzo Crane, but found himself entering
into the spirited rivalry that would act as a spur to achievement.
When finally “taps” was sounded on Mr. Bartlett’s cornet, Asa was
given a place next to Dick, Andy Hale being transferred to another tent,
though no one thought to ask why this was done. If the boys talked it over
at all they must have reached the conclusion that Asa was growing nervous
about sleeping in a tent further removed from the fire at a time when there
was a creature of an unknown species prowling about on Bass Island.
 By degrees the camp fell into an utter silence, though occasionally some
one, who may have been lying on his back, would begin to breathe louder
than his mates liked, whereupon he was punched in the ribs, and made to
roll over.
It must have been well on toward midnight when the sleepers were
suddenly aroused by a tremendous crash not far away; and immediately an
exodus from the several shelters began. Boys, clad in various patterns of
pajamas, all looking a bit frightened, gathered about in groups.
 CHAPTER XIX
A DAY OF REST

“It’s a terrible storm coming, like as not!” Elmer Jones was exclaiming,
as he started to unwrap a rainproof coat he had been thoughtful enough to
provide for such occasions.
“Sounded more like a house falling down to me!” called Clint Babbett.
“I was dreaming of two railroad trains coming together, just when that
smash came,” announced Leslie Capes.
“And I was heading straight for the falls of Niagara, and could hear the
water roaring like everything,” confessed Nat Silmore.
Dan had not said a word up to then, and Dick, glancing toward him,
could see a proud look beginning to take possession of the other’s face.
“You’re all wrong, fellows!” exclaimed Dan, unable to hold in any
longer. “You’ve got another guess coming, I tell you. Don’t you remember
that it was over there that I set my trap? Well, she worked all right, and
mebbe I’ve got our wild man safely caged at this very minute!”
The announcement created great excitement.
“Hey! let’s hurry and get some duds on, so we can go and see!” called
Peg, who was hopping about on one foot, as he had stubbed a toe in the
haste with which he rushed forth from his sleeping quarters.
“How about that, Mr. Bartlett?” asked Dick, seeing the camp director
among them, he having hurriedly slipped on a bath robe before making his
appearance.
“We ought to get there with as little waste of time as possible,” replied
Harry Bartlett, looking interested. “If it should turn out that the trap has
done what Dan intended, the poor fellow may be hurt in some way, and it
would be cruel for us to wait until morning to investigate.”
“Whew! from the racket I should say something fierce had happened!”
declared Phil Harkness, as he hastened back to where his clothes hung
suspended from nails driven into the pole of sleeping tent Number Three.
There was some hurried work done about that time, as every lad wanted
to get himself in readiness as quickly as possible. Many hands quivered
with excitement, and buttons were much more difficult to fasten than
ordinarily.
One by one the boys assembled by the resurrected fire, some still
hurriedly fastening their garments. It was an excited group that collected
around Mr. Holwell, Mr. Bartlett, the physical director and Dick, as camp
leaders.
“Hadn’t we better take something along with us, to defend ourselves in
case he turns out to be ugly?” asked Dick.
“Yes, I suppose that would be only a wise provision,” returned Mr.
Holwell, “for one never knows what a crazy person may do. They are also
possessed of enormous strength as a usual thing. Get any sort of club you
can find, boys.”
There was an immediate hustling around on the part of the half-dressed
campers. Some managed to find suitable cudgels. Others picked up
anything they could see that promised to prove useful in an emergency. Peg
appropriated the camp hatchet, Ban Jansen the axe, while Andy Hale, in lieu
of anything better, armed himself with the stout iron rod which they used
across the fire when hanging a pot over the blaze.
Mr. Rowland had lighted the lantern. Others found blazing brands from
the fire, which they made into serviceable torches by whirling them swiftly
around their heads.
“Now come along,” said the camp director, smiling as he glanced
around and noted the unique character of the procession ready to trail after
him.
“I’d give a dollar, sure I would, to have a snap-shot of this bunch right
now,” declared Clint Babbett, who was becoming quite an expert
photographer, and aspired to win a prize by taking flashlight pictures at
night time of little wild animals in their native haunts.
Indeed, they certainly did look comical as they passed from the camp
and headed toward the spot where Dan had set his great trap. He bravely
acted as pilot of the expedition, since none but he knew just where they
were going.
Presently, from his cautious actions, the rest understood that they were
very close to their destination.
“Can you glimpse the trap yet, Dan?” asked Peg, eagerly, lowering his
voice as if afraid lest he start the prisoner into making new and desperate
efforts to escape from the toils.
“And is he inside?” inquired Fred Bonnicastle, with a gasp that told of
his interest.
“I can just begin to see the thing,” announced Dan, slowly, and Dick
thought he could detect the first shade of growing disappointment in the
other’s voice.
A few more steps, and then Dan spoke again.
“Hey! what does this mean?” he grumbled.
“Didn’t the trap work after all, Dan?” asked Peg, in a grieved tone.
“Work!” snorted Dan, huskily. “I should say it did. Only the maniac was
too much for me after all. He’s gone and busted my trap to flinders.”
Groans of disappointment welled up from numerous throats, and there
was a quickening of footsteps as all drew closer to the spot where the wreck
of the clumsy contrivance lay scattered around.
They stood and stared at the ruin. Dan shook his head, and drew in his
breath with a faint whistle that expressed intense astonishment.
“Say, he must have been a buster of a man!” he finally exclaimed,
bending down to examine some stout limbs that had been actually broken in
two as though by a mighty force. “He just got as mad as hops when it
dropped around him, and smashed things right and left. But, fellows, he
carried off the bait all right, I notice.”
“That shows he has an appetite after all,” remarked Mr. Holwell,
considerably amused at the happening, though at the same time feeling that
the situation bordered on a grave one, with such a terrible denizen of the
woods visiting their camp so frequently.
 “After this he’ll be feeling kind of peeved at us for hurting him, I
guess,” ventured Peg.
“Well, if it comes to the worst,” Phil remarked, “we can some of us sit
up each night, and stand our turn on guard.”
“That sounds pleasant, I must say,” observed Elmer, with a half laugh.
The party once more returned to camp, and Mr. Bartlett told them not to
sit around talking matters over, but to get back to their blankets. Indeed, the
night air felt rather chilly, and the boys were not loath to take this advice.
“Plenty of time to talk it all over in the morning,” the camp director told
them. “Perhaps by that time we may run across some sort of clue that will
put us on the track of the poor fellow. It strikes me we ought to do our best
to make him a prisoner while up here. If, as we suspect, he turns out to be a
lunatic, it would be little short of a crime to leave him here to freeze in the
winter time.”
One thing Dick noticed, and this was that while most of the boys
thought the visit from the wild man almost a tragedy one of their number
seemed to be particularly pleased over it.
This was Asa Gardner, who, from the time they first gathered after the
alarm was given, had been smiling contentedly. Dick could give a pretty
good guess why.
“Asa knows now,” Dick told himself, “that it couldn’t have been his
fault those things disappeared from our camp. He was lying beside me
sound asleep when the alarm came. So he figures that after all it must have
been this strange being who crept into our camp and stole the bright things
that caught his attention. Well, I’m glad for Asa’s sake, that’s all.”
Some of the boys were nervous as they lay down. They half anticipated
a further visit from the unknown. The remainder of the night passed,
however, without further annoyance.
Sunday morning found the boys up early, and taking their cold plunge.
Mr. Holwell joined them, for from boyhood days a dip in the water on a fine
summer morning had always been a delicious treat for the minister. The
usual morning exercises were dispensed with, for Sunday is always
conducted on strictly religious lines in every genuine Y. M. C. A. camp.
 After breakfast had been eaten and everything cleaned up about the
camp, the campers assembled to enjoy a little song service, after which Mr.
Holwell had promised to deliver his famous “boys’ sermon.”
Asa Gardner sought out Dick. Plainly the sensitive boy was feeling
much better than when he had had his last interview with his friend, Dick, a
fact the latter was pleased to note.
“You’re coming around to my way of thinking, I guess, Asa?” he
remarked.
Asa turned his eyes up toward Dick.
“Yes,” he said, softly, “I believe it’s going to come out all right now,
Dick, for my dear mother came to me in my dreams last night, and she told
me I would win the fight! Oh! I’m so glad, so glad, and I owe a heap to you,
that’s right!”