Siena College of Taytay

COLLEGE OF NURSING
E. Rodriguez Ave. San Isidro, Taytay, Rizal 1920

POST-ANESTHESIA CARE RECORD

PATIENT'S NAME BIRTHDAY HOSPITAL NO.
DATA

PROCEDURE SURGEON

ANESTHESIA ANESTHESIOLOGIST

Date of PACU Admission: Time of PACU Admission:

TIME BP MAP* PR RR TEMP O² SAT PAIN REMARKS
IN
ON-GOING ASSESSMENT
VISUAL ANALOG SCALE

TIME VAS INTERVENTION

15'
30'
60'
90'
120'
POST-ANESTHESIA RECOVERY SCORE ADMIN 15' 30' 60' 90' DISCHARGE

ACTIVITY 4 extremities 2 2 2 2 2 2
Able to move voluntarily or on 2 extremities 1 1 1 1 1 1
command
0 extremities 0 0 0 0 0 0
RESPIRATIONS Breaths/coughs freely 2 2 2 2 2 2
Dyspnea, shallow, limited 1 1 1 1 1 1
DISCHARGE CRITERIA:
EVALUATION

Apneic 0 0 0 0 0 0
Minimum score of 8; If
CIRCULATION BP ± 20 2 2 2 2 2 2
score < 8 notify MD and
Pre-op BP ____________ BP ± 21-49 1 1 1 1 1 1 let decide for discharge
BP ± 50 0 0 0 0 0 0 from PACU
CONSCIOUSNESS Fully awake 2 2 2 2 2 2
Arousable on calling 1 1 1 1 1 1
Not responding 0 0 0 0 0 0
COLOR Pink 2 2 2 2 2 2
Pale or others 1 1 1 1 1 1
Cyanotic 0 0 0 0 0 0
1/2 *MAP=DBP+1/3(SBP-DBP)
 INPUT OUTPUT REMARKS
SITE SOLUTION AMOUNT TIME
URINE
IFC/CBI
FLUIDS BALANCE

NGT
CT
HEM
JP

PACU TOTAL PACU TOTAL

TIME DRUG DOSAGE ROUTE GIVEN BY REMARKS
PACU INTERVENTION

FOCUS DATA-ACTION-RESPONSE
NURSING NARRATIVE

2/2 Prepared by: FGV Jaminit, RN, CNN, MAN - SCT-College of Nursing
-College of Nursing