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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
administered, to verify the recommended dose or formula, the method and duration of administration, and
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
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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
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This hot-lake district was becoming a great sanatorium, and tourists
flocked to it from all countries, for the warm water was credited with
wonderful healing powers. From this circumstance alone, it was
believed that the district had a great future before it. The Maoris
thought not a little of the natural wonders of which they were the
stewards, and took care to levy blackmail on all their visitors. All this
is now at an end, for the wonders have gone, until possibly new ones
are gradually developed in their stead.
Much has been written on the subject of mysterious noises, which in
most cases, if intelligently inquired into, would be found to have no
mystery at all about them. A Professor at Philadelphia recently
recorded that at a certain hour each day one of the windows in his
house rattled in the most violent manner. On consulting the local
railway time-table, he could find no train running at the hour
specified. But on examining another table, which included a separate
line, he found that a heavy train passed at the time at a distance of
several miles from his house. He then referred to the geological
formation of the ground between the two points, and at once saw
that there was an outcropping ledge of rock which formed a link of
connection between the distant railway line and his home. It was the
vibration carried by this rock from the passing train that rattled the
window.
Dr Marter of Rome has discovered in many of the skulls in the
different Roman and Etruscan tombs, as well as in those deposited
in the various museums, interesting specimens of ancient dentistry
and artificial teeth. These latter are in most cases carved out of the
teeth of some large animal. In many instances, these teeth are
fastened to the natural ones by bands of gold. No cases of stopped
teeth have been discovered, although many cases of decay present
themselves where stopping would have been advantageous. The
skulls examined date as far back as the sixth century b.c., and prove
that the art of dentistry and the pains of toothache are by no means
modern institutions.
The city of Hernosand, in Sweden, can boast of being the first place
in Europe where the streets are lighted entirely by electricity to the
exclusion of gas. It has the advantage of plenty of natural water-
power for driving the electric engines, so that the new lights can
actually be produced at a cheaper rate than the old ones.
Although many investors have burnt their fingers—metaphorically,
we mean—over the electric-lighting question in this country, it seems
to be becoming a profitable form of investment in America. A circular
addressed by the editor of one of the American papers to the general
managers of the lighting Companies has elicited the information that
many of them are earning good dividends—in one case as much as
eighteen per cent. for the year. As we have before had occasion to
remind our readers, the price of gas in this country averages about
half what it does in New York, and this fact alone would account for
the more flourishing state of transatlantic electric lighting Companies.
At a half-demolished Jesuit College at Vienna, a dog lately fell
through a fissure in the pavement. The efforts to rescue the poor
animal led to a curious archæological discovery. The dog had, it was
found, fallen into a large vault containing ninety coffins. The
existence of this underground burial-place had hitherto been quite
unsuspected. The inscriptions on the coffins date back to the reign of
Maria Theresa, and the bodies are of the monks of that period, and
of the nobles who helped to support the monastery.
In an interesting lecture lately delivered before the Royal Institution
on ‘Photography as an Aid to Astronomy,’ Mr A. A. Common, who is
the principal British labourer in this comparatively new field of
research, described his methods of working, and held out sanguine
hopes of future things possible by astronomical photography.
Speaking of modern dry-plate photography, he said: ‘At a bound, it
has gone far beyond anything that was expected of it, and bids fair to
overturn a good deal of the practice that has hitherto existed among
astronomers. I hope soon to see it recognised as the most potent
agent of research and record that has ever been within the reach of
the astronomer; so that the records which the future astronomer will
use will not be the written impression of dead men’s views, but
veritable images of the different objects of the heavens recorded by
themselves as they existed.’
Two remarkable and wonderful cases of recovery from bullet-wounds
have lately taken place in the metropolis. In one case, that of a girl
who was shot by her lover, the bullet is deeply imbedded in the head,
too deep to admit of any operation; yet the patient has been
discharged from the hospital convalescent. The other case was one
of attempted suicide, the sufferer having shot himself in the head
with a revolver. In this case, too, the bullet is still in the brain, and in
such a position as to prevent the operation of extraction. In spite of
this, the patient has been discharged from hospital care, and it is
said that he suffers no inconvenience from the consequences of his
rash act. A curious coincidence in connection with these cases is
that both shots were fired on the same day, the 19th of June, and
that both cases were treated at the London Hospital. ‘The times have
been,’ says Shakspeare, ‘that, when the brains were out, the man
would die.’ The poet puts these words into the mouth of Macbeth,
when that wicked king sees the ghost of the murdered Banquo rise
before him. In the cases just cited, we have a reality which no poet
could equal in romance. People walking about in the flesh with
bullets in their brains are certainly far more wonderful things than
spectres. These marvellous recoveries from what, a few years ago,
would have meant certain death, must be credited to surgical skill
and the modern antiseptic method of treating wounds.
Magistrates are continually deploring the use of the revolver among
the civil community, and hardly a week passes but some terrible
accident or crime is credited to the employment of that weapon. That
it is a most valuable arm when used in legitimate warfare, the paper
lately read before the Royal United Service Institution by Major
Kitchener amply proved. According to this paper, every nation but
our own seems to consider that the revolver is the most important
weapon that cavalry can be armed with. In Russia, for instance, all
officers, sergeant-majors, drummers, buglers, and even clerks, carry
revolvers. In Germany, again, there is a regular annual course of
instruction in the use of the weapon. In our army, however, the
revolver seems to be in a great measure ignored, excepting by
officers on active foreign service.
A new method of detecting the source of an offensive odour in a
room is given by The Sanitarian newspaper. In the room in question,
the smell had become so unbearable that the carpet was taken up,
and a carpenter was about to rip up the flooring to discover, if
possible, the cause. By a happy inspiration, the services of some
sanitary inspectors in the shape of a couple of bluebottle flies were
first called into requisition. The flies buzzed about in their usual
aggravating manner for some minutes, but eventually they settled
upon the crack between two boards in the floor. The boards were
thereupon taken up, and just underneath them was found the
decomposing body of a rat.
The extent to which the trade in frozen meat from distant countries
has grown since the introduction, only a few years back, of the
system of freezing by the compression and subsequent expansion of
air, is indicated by the constant arrival in this country of vast
shiploads of carcases from the antipodes. The largest cargo of dead-
meat ever received lately arrived in the Thames from the Falkland
Islands on board the steamship Selembria. This consisted of thirty
thousand frozen carcases of sheep. This ship possesses four
engines for preserving and freezing the meat, and the holds are lined
with a non-conducting packing of timber and charcoal.
A new system of coating iron or steel with a covering of lead,
somewhat similar in practice to the so-called galvanising process
with zinc, has been introduced by Messrs Justice & Co. of Chancery
Lane, London, the agents for the Ajax Metal Company of
Philadelphia. Briefly described, the process consists in charging
molten lead with a flux composed of sal ammoniac, arsenic,
phosphorus, and borax; after which, properly cleansed iron or steel
plates will when dipped therein receive a coating of the lead. The
metal so protected will be valuable for roofs, in place of sheet-lead or
zinc, for gutters, and for numberless purposes where far less durable
materials are at present used with very false economy.
It would seem, from the results of some experiments lately
conducted on the Dutch state railroads in order to discover the best
method of protecting iron from the action of the atmosphere, that
red-lead paints are far more durable than those which owe their body
to iron oxide. The test-plates showed also that the paint adhered to
the metal with far greater tenacity if the usual scraping and brushing
were replaced by pickling—that is, treatment with acid. The best
results were obtained when the metal plate was first pickled in spirits
of salts (hydrochloric acid) and water, then washed, and finally
rubbed with oil before applying the paint.
The latest advance in electric lighting is represented by the
introduction of Mr Upward’s primary battery, the novelty in which
consists in its being excited by a gas instead of a liquid. The gas
employed is chlorine, and the battery cells have to be hermetically
sealed, for chlorine is, as every dabbler in chemical experiments
knows, a most suffocating and corrosive gas. In practice, this
primary battery is connected with an accumulator or secondary
battery, so that the electricity generated by it is stored for subsequent
use. The invention represents a convenient means of producing the
electric light on a small scale for domestic use, where gas-engines
and dynamo-machines are not considered desirable additions to the
household arrangements. The battery is made by Messrs
Woodhouse and Rawson, West Kensington.
Mr Fryer’s Refuse Destructor has now been adopted in several of
our large towns. Newcastle is the latest which has taken up the
system, and in that town thirty tons of refuse are consumed in the
furnaces daily. The residue consists of between seven and eight tons
of burnt clinker and dry ashes, which are used for concrete and as a
bedding for pavement. There is no actual profit attached to the
system, but it affords a convenient method of dealing with some of
that unmanageable material which is a necessary product of large
communities, and which might otherwise form an accumulation most
dangerous to health.
After three years of constant work, the signal station on Ailsa Craig,
in the Firth of Clyde, is announced, by the Northern Light
Commissioners, to be ready for action. In foggy or snowy weather,
the fog-horns which have been placed there will utter their warning
blasts to mariners, and will doubtless lead to the prevention of many
a shipwreck. The trumpets are of such a powerful description, that in
calm weather they will be audible at a distance of nearly twenty miles
from the station; and as the blasts are of a distinctive character, the
captain of a ship will be easily able to recognise them, and from
them to learn his whereabouts.
Mr Sinclair, the British consul at Foochow, reports that the
manufacture of brick tea of varieties of tea-dust by Russian
merchants, for export to Siberia, is acquiring considerable
importance at Foochow. The cheapness of the tea-dust, the
cheapness of manufacture, the low export duties upon it, together
with the low import duties in Russia, help to make this trade
successful and profitable. The brick is said to be beautifully made,
and very portable. Mr Sinclair wonders that the British government
does not get its supplies from the port of Foochow, as they would
find it less expensive and more wholesome than what is now given
the army and the navy. He suggests that a government agent should
be employed on the spot to manufacture the brick tea in the same
way as adopted by the Russians there and at Hankow.
 CYCLING AS A HEALTH-PRODUCT.
The advantages of a fine physical form are under-estimated by a
large class of people, who have a half-defined impression that any
considerable addition to the muscles and general physique must be
at the expense of the mental qualities. This mistaken impression is
so prevalent, that many professional literary people avoid any
vigorous exercise for fear that it will be a drain upon their whole
system, and thus upon their capacity for brain-work. The truth is that
such complete physical inertness has the effect of clogging the
action of the blood, of retaining the impurities of the system, and of
eventually bringing about a host of small nervous disorders that
induce in turn mental anxiety—the worst possible drain upon the
nervous organisation. When one of these people, after a year of
sick-headache and dyspepsia, comes to realise that healthy nerves
cannot exist without general physical health and activity, he joins a
gymnasium, strains his long-unused muscles on bars and ropes, or
by lifting heavy weights. The result usually is that the muscles, so
long unaccustomed to use, cannot withstand the sudden strain
imposed upon them, and the would-be athlete retires with some
severe or perhaps fatal injury.
But occasionally he finds some especial gymnastic exercise suited to
him, and weathers the first ordeal. He persists bravely, and is
astonished to find that his digestion improves, his weight increases,
and his mind becomes clear and brighter. He exercises
systematically, and cultivates a few special muscles, perhaps those
of the shoulder, to the hindrance of the complex muscles of the neck
and throat; or perhaps those of the back and groin, as in rowing, to
the detriment of chest, muscle, and development; and although his
condition is greatly improved, he is apt to become wearied from a
lack of physical exhilaration, or a lack of that sweetening of mental
enjoyment which gives cycling such a lasting charm. If a man has no
heart in his exercise, he will not persist in it long enough to get its
finest benefits.
In the gentle swinging motion above the wheel, there is nothing to
disturb the muscular or nervous system once accustomed to it;
indeed, it is the experience of most cyclists that the motion is at first
tranquillising to the nerves, and eventually becomes a refreshing
stimulus. The man who goes through ten hours’ daily mental fret and
worry, will in an hour of pleasant road-riding, in the fresh sweet-
scented country, throw off all its ill effects, and prepare himself for
the effectual accomplishment of another day’s brain-work. The
steady and active employment of all the muscles, until they are well
heated and healthily tired, clears the blood from the brain, sharpens
the appetite, and insures a night’s refreshing sleep.
In propelling the wheel, all the flexor and extensor muscles of the
legs are in active motion; while in balancing, the smaller muscles of
the legs and feet and the prominent ones of the groin and thighs are
brought into play. The wrist and arms are employed in steering; while
the whole of the back, neck, and throat muscles are used in pulling
up on the handles in a spurt. Thus the exertion is distributed more
thoroughly over the whole body than in any other exercise. A tired
feeling in any one part of the body is generally occasioned by a
weakness caused by former disuse of the muscles located there,
and this disappears as the rider becomes habituated to the new
motions of the wheel. With an experienced cyclist, the sensation of
fatigue does not develop itself prominently in any one part of the
body, but is so evenly adjusted as to be hardly noticeable.
The wretched habit of cyclists riding with the body inclined forward
has produced an habitual bent attitude with several riders, and gives
rise to a prejudice against the sport as producing a ‘bicycle back.’
Nearly all oarsmen have this form of back; it has not proved
detrimental, but it is ungainly, and the methods by which it is
acquired on a bicycle are entirely unnecessary. Erect riding is more
graceful, it develops the chest, and adds an exercise to the muscles
of the throat and chest that rowing does not.
The exposure to out-of-door air, the constant employment of the
mind by the delight of changing scenery or agreeable
companionship, add their contribution, and make cycling, to those
who have tried practically every other sport, the most enjoyable,
healthful, useful exercise ever known. Most cyclers become sound,
well-made, evenly balanced, healthy men, and bid fair to leave to
their descendants some such heritage of health and vigour as
descended from the hardy old Fathers to the men who have made
this country what it is.
 OCCASIONAL NOTES.
FLAX-CULTURE.
The depressed condition of agriculture, consequent on the low
prices obtainable for all kinds of produce, has led the British farmer
to turn his attention to the growth of crops hitherto neglected or
unthought of. This is exemplified by the interest now taken in the
cultivation of tobacco and the inquiries being made regarding it, with
a view to its wholesale production in England. It is doubtful, however,
if in this case the British farmer will be able to compete successfully
with his American rival, the latter being favoured by nature with soil
and climate specially suited for the growth of the ‘weed.’
There are other plants, however, which claim our attention, and
amongst these the flax plant. This is perfectly hardy and easily
cultivated, and is free from the bugbear of American competition. It is
grown largely in Ireland, especially in the north, and at the present
time is the best paying crop grown in the island. The following figures
show the quantity of fibre produced during the year 1885: Ireland,
20,909 tons; Great Britain, 444 tons. As far as the British Islands are
concerned, Ireland has practically a monopoly in the production of
this valuable article of commerce. It was formerly grown to a large
extent in Yorkshire and in some parts of Scotland; but of late years,
was given up in favour of other crops. It can now be produced to
show much better results than formerly, flax not having fallen in price
so much in proportion as other farm produce. Compared with the
requirements of the linen manufacturers, the quantity grown in the
British Isles is very small, and had to be supplemented by the import
from foreign countries, during 1885, of over eighty-three thousand
tons, value for three million and a half sterling. Two-thirds of this
quantity is imported from Russia, the remainder principally from
Holland and Belgium.
The manufacturer will give the preference to home-grown fibre
provided that it is equal in all respects to the foreign. We can
scarcely hope to compete successfully with Holland and Belgium, as
flax-culture has been brought to great perfection there; but we can
produce a fibre much superior to Russian, and if we can produce it
cheap enough, can beat Russia out of the market. The average price
of Irish flax in 1885 was about fifty-two pounds per ton; the yield per
acre, where properly treated, would be from five to six
hundredweight on an average. In many cases the yield rose far
above these figures, reaching ten to twelve hundredweight, and in
one instance which came under the writer’s personal observation, to
eighteen hundredweight. A new scutching-machine—a French
patent—is now being tested in Belfast, and it is stated that by its use
the yield of fibre is increased by thirty per cent. Should this
apparatus come into general use, it will add greatly to the value of
the flax plant as a crop. In continental countries, the seed is saved,
and its value contributes largely to the profit of flax-culture there. Any
difficulty that might exist in this country with regard to the preparation
of the fibre for market might be met by farmers in a district banding
together to provide the requisite machines, which can now be had
cheaper and better than before.
If flax-culture is profitable in Ireland, it can be made so in Britain; and
if only half of the eighty-three thousand tons annually imported could
be grown at home, a large sum would be kept in the country which
now goes to enrich the foreigner.

THE RIGHTS OF DESERTED WIVES.

A legal correspondent writes to us on this subject as follows:
‘It has long been felt to be a defect in the English law that if a man
deserted his wife without any cause or otherwise, she had no direct
remedy against him in respect of the expense of her maintenance
and the bringing up of the children (if any) of the marriage. In case
the wife so deserted could carry on any business, or in any other
way acquire the means of livelihood, she could obtain a protection
order so early as the year 1858, long before the passing of the first
Married Women’s Property Act. But if she were not so fortunately
situated, and had no near relatives to whom she could look for
assistance, she must go into the workhouse, and leave the poor-law
officers to look after her husband. This has often been productive of
great hardship, for it is no light thing for a woman delicately nurtured
to become an inmate of the refuge for the destitute. But by an Act
passed in the recent session, this defect has been remedied to a
considerable extent in an easy and practical way. Thus, if an
innocent woman has been deserted by her husband, she may have
him summoned before any two justices of the peace in petty
sessions or any stipendiary magistrate; and thereupon, if the justices
or magistrate should be satisfied that the husband, being able wholly
or in part to maintain his wife, or his wife and family, as the case may
be, has wilfully refused or neglected so to do, and that he has
deserted his wife, they or he may order that the husband pay to his
wife such weekly sum not exceeding two pounds as may be
considered to be in accordance with his means, taking also into
account any means which the wife may have for the support of
herself and family, if any. Power is given for the alteration of the
order whenever it should appear to be necessary or just, in case of
any alteration in the circumstances of the husband or of the wife.
And any such order may be discharged on the application of the
husband, if it should appear just to do so. Writers in some of the
legal journals have expressed the opinion that this change in the law
goes too far; but the present writer has long advocated such a
change, and it appears to be altogether an improvement upon the
previous state of the law in this respect.’

THE GREAT SPHINX.

An interesting work has been going on, under the direction of M.
Maspéro, at the great Sphinx of Gizeh, which has been buried, all
but the head, for centuries. M. Maspéro, while we write, had got
down as far as the paws, on the right of which are a number of
Greek inscriptions. The paws appear to be cut out of the solid stone,
and afterwards built round with masonry, the surface of which is
painted red with yellow additions. Bryant is of opinion that the Sphinx
was originally a vast rock of different strata, which, from a shapeless
mass, the Egyptians fashioned into an object of beauty and
veneration. Although the excavators have now reached a lower level
than Carglia and others, yet much remains to be done before the
whole of this wondrous specimen of ancient art is entirely uncovered;
for, if we are to believe Pliny’s statements, the head of the Sphinx
was one hundred and two feet in circumference, and sixty-two feet
high from the belly; whilst the body was one hundred and forty-three
feet long, and was, moreover, supposed to be the sepulchre of King
Amasis, who died 525 b.c. But, according to Herodotus, the body of
this monarch was buried in the Temple of Sais; and on the defeat
and death of his son by the Persians, it was taken from its tomb,
brutally mangled, and then publicly burnt, to the horror of the
Egyptian people. If the Sphinx is really found to be a solid rock,
Pliny’s story of its having been a tomb falls to the ground. M.
Maspéro has been working in layers of hard sand which has lain
undisturbed for probably eighteen hundred years. This is found to be
so close and hard, that it is more like solid stone than sand, and
requires a great amount of labour to cut through. The work is,
however, progressing with energy and determination, and it is to be
hoped that it will not be suffered to stop abruptly for want of funds.

NOVEL USE OF ELECTRICITY.

Electric power has been applied in a very novel manner of late on
the estate of the Marquis of Salisbury at Hatfield, where it has been
in operation for some time past in various ways and works; but the
last is perhaps the most peculiar of all. On one of the farms, ensilage
has been stored in large quantities, a farm-building being turned into
a silo for this purpose; and it being decided that the green food shall
be ‘chaffed’ before placing it in the silo, a chaff-cutter has been
erected about twenty feet above the ground. This machine is not
only driven by electric power, but the same motor is employed to
elevate the grass to the level of the chaff-cutter. This is done so
effectually that about four tons of rough grass are raised and cut per
hour. A sixteen-light ‘Brush’ machine is the generator, driven by a
huge water-wheel, and both are on the banks of the river Lea, a mile
and a half distant. The power is transmitted to one of Siemens’ type,
specially constructed to work as a motor with the ‘Brush’ machine.
Nor is this all, for the same electric power is ingeniously applied to
work the ‘lifts’ in use at the many haystacks on the estate.
 PICCIOLA.
[Count de Charney, when in prison, was led into a
philosophical train of reflections by the sight of a flower
which grew up between the flagstones of the prison court.]

Of all the flowers that deck the verdant knoll,

And lift their snowy petals to the air,
One spray has risen in my dungeon bare
That breaks the sceptic chain that bound my soul,
And makes me feel the might of God’s control.
O flower of sweetness! thy frail form so fair
Swept from my brow the cankering lines of care,
And safe will lead me to the eternal goal.
What hand but One could guard thy tender leaves
From the fierce fury of the summer sun,
When noonday hovers o’er my prison dun?
’Tis He that for my hapless fortune grieves!
Blest flower! that drew me to the arms of God,
With grateful tears I bathe thy dewy sod.

Robert W. Cryan.

The Conductor of Chambers’s Journal begs to direct the attention

of Contributors to the following notice:
1st. All communications should be addressed to the ‘Editor, 339 High
Street, Edinburgh.’
2d. For its return in case of ineligibility, postage-stamps should
accompany every manuscript.
3d. To secure their safe return if ineligible, All Manuscripts,
whether accompanied by a letter of advice or otherwise, should
have the writer’s Name and Address written upon them in full.
4th. Offerings of Verse should invariably be accompanied by a
stamped and directed envelope.
If the above rules are complied with, the Editor will do his best to
insure the safe return of ineligible papers.

Printed and Published by W. & R. Chambers, 47 Paternoster Row,

London, and 339 High Street, Edinburgh.

All Rights Reserved.

*** END OF THE PROJECT GUTENBERG EBOOK CHAMBERS'S
JOURNAL OF POPULAR LITERATURE, SCIENCE, AND ART,
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