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    Post Anesthesia Care Unit Record

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    Damien Marwein
    This document is a recovery room record for a patient in the post-anesthesia care unit (PACU). It includes sections to record the patient's procedure, type of anesthesia, vital signs, oxygen support, ventilation, breathing sounds, cardiac status, abdomen assessment, drains, dressings, IVs, pain level, and interventions provided. The record is designed for the healthcare team to monitor and document the patient's status as they recover from their procedure or surgery in the PACU.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Post Anesthesia Care Unit Record

    Uploaded by

    Damien Marwein
    720 views1 page
    This document is a recovery room record for a patient in the post-anesthesia care unit (PACU). It includes sections to record the patient's procedure, type of anesthesia, vital signs, oxygen support, ventilation, breathing sounds, cardiac status, abdomen assessment, drains, dressings, IVs, pain level, and interventions provided. The record is designed for the healthcare team to monitor and document the patient's status as they recover from their procedure or surgery in the PACU.

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    Post Anesthesia Care Unit Record

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    This document is a recovery room record for a patient in the post-anesthesia care unit (PACU). It includes sections to record the patient's procedure, type of anesthesia, vital signs, oxygen support, ventilation, breathing sounds, cardiac status, abdomen assessment, drains, dressings, IVs, pain level, and interventions provided. The record is designed for the healthcare team to monitor and document the patient's status as they recover from their procedure or surgery in the PACU.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    720 views1 page

    Post Anesthesia Care Unit Record

    Uploaded by

    Damien Marwein
    This document is a recovery room record for a patient in the post-anesthesia care unit (PACU). It includes sections to record the patient's procedure, type of anesthesia, vital signs, oxygen support, ventilation, breathing sounds, cardiac status, abdomen assessment, drains, dressings, IVs, pain level, and interventions provided. The record is designed for the healthcare team to monitor and document the patient's status as they recover from their procedure or surgery in the PACU.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Name Post-Anesthesia Care Unit Record Page 1 Date

    Recovery Room Record one per patient


    Date: Type of Anesthesia:
    Procedure:
    PACU Adm. Time: General Local Epidural
    Allergies: Regional Spinal
    TED Hose: Y N SCDs: Y N Local w/Sedation
    PHASE I ASSESSMENT
    Arrived Via: Stretcher Bed Infant Carried By Anesthetist
    L.O.C. Drowsy Reacting Alert Disoriented Unresponsive
    Skin Pink Warm Cool Mottled Cyanotic
    Extremities Pink Warm Cool Mottled Cyanotic
    Airway Support: None Oral Nasal Chin Lift Jaw Thrust ET Tube Trach
    Oxygen: None 40% ______ % Cannula Tent Mask T-Bar
    Ventilation: Adequate Exchange Ambu Ventilator Other
    Resp. Quality: Deep Shallow Snoring Stridor Labored
    Regular Irregular B Chest Exp Free of ext. sounds Tachypnea
    Breath Sounds: Clear all fields Equal Bil.. Rales Rhonchi Wheezing
    Cardiac: Regular Rhythm Irregular Rhythm ____________________________________
    Abdomen: Soft Firm Distended

    DRAINS
    Type Site Patent Color of Drainage Type Site Patent Color of Drainage
    Foley JP
    Hemovac NG
    Chest tube Penrose
    Other Other
    DRESSINGS
    Site Dressing Type Dry/Intact Other (explain)
    Y N
    Y N
    Y N
    Y N
    I.V.s
    Site Type Gauge IVF Type Amount Infused Patent, dressing dry & intact, no redness or edema
    Y N If no, explain:
    Y N If no, explain:
    Y N If no, explain:
    Y N If no, explain:

    PAIN
    Time Score (1-10) Intervention Rescore N/V Intervention Relief
    Y N Y N
    Y N Y N
    Y N Y N
    Y N Y N

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