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