PACUCare

PACU (POST ANESTHESIA CARE UNIT)

TRANSFERRING TO PACU

ARRIVING AT PACU

NURSING RESPONSIBILITIES:

1.MAINTENANCE OF PULMONARY VENTILATION – to prevent hypoxemia and hypercapnea

NURSING RESPONSIBILITIES:

2.PROTECTION AND

PREVENTION OF INJURY

NURSING RESPONSIBILITIES:

3. PROMOTION OF COMFORT

ALDRETE POST ANESTHESIA RECOVERY SCORING SYSTEM

AREA OF ASSESSMENT:1. Muscle activity2. Respiration3. Circulation4. Consciousness level5. Color*Required for discharge

from PACU = 7 to 8 points

ALDRETE Scoring in PACU: (ARCCC)

Activity 2 able to move 4 extremities

1 able to move 2 extremities

0 not able to move

Respiration 2 able to cough & deep breath

1 dyspnea or limited breathing

0 apneic

Circulation 2 20% pre anesthesia

1 20-50% pre anesthesia

0 above 50% pre anesthesia

Consciousness 2 fully awake1 rousable on

calling0 not responding

Color 2 pink1 pale, dusky,

blotchy0 cyanotic

Parameters for discharge from RRActivity – score of 2; able to obey

commands.Respiration – score of 2; easy,

noiseless breathing.Circulation – 20 of pre anesthesia;

BP is within +/-20 mmHg of the pre op level.

Consciousness – score of 2; responsive.

Color – score of 2; pinkish skin and mucus membrane.

Criteria for PACU C discharged

ASSESSMENTA – AIRWAY Maintain patent airway

Head turned to side

SuctioningAdminister

oxygenB – BREATHING DBE

CoughingAdminister

oxygen

ASSESSMENTC – CIRCULATION VS q15 for 2h, q30 for 2h, q hour for

the first 24 houror until stable

Skin colorMonitor BT

ASSESSMENTC – CONSCIOUSNESS LOC

Ability to commandD – DRESSING Keep it dry and

intactD – DRAINAGE Tubings attached,

keep it patent and intact

D – DRUGS AntibioticsPain reliever

ASSESSMENTE – ELIMINATION Monitor I &

OMonitor

passing of flatusF – FLUIDS IVF 30 gtts/minF – FOOD NPO until

peristalsis returns (clear liquid → full liquids → soft diet → full diet/DAT

ASSESSMENTS – SAFETY/COMFORTSide rails upTurn to sides, early ambulation

Relief from discomforts

Prevent complications