Which patient is ready for discharge from Phase 1 PACU care to the clinical unit?
a. arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
b. difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
d. arouses, blood pressure higher
than pre-op and respiratory rate is 10 no excess bleeding, SaO2 is 90%
c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2 below
90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.
Sets with similar terms
What is the priority nursing assessment when a patient is admitted to the PACU?
Assessment of the patient's pain is the first priority.
What are 3 priority assessments of the PACU nurse?
To PACU.
Assess air exchange status and note patient's skin color..
Verify patient identity. The nurse must also know the type of operative procedure performed and the name of the surgeon responsible for the operation..
Neurologic status assessment. ... .
Cardiovascular status assessment. ... .
Operative site examination..
What should the PACU nurse assess first?
When transferring care from PACU to the ward, patient identification and handover should occur utilising the Handover Flowsheet. Initial patient assessment should include: Physical Assessment of patient including Airway, Breathing, Circulation & Disability (Link to Nursing Assessment)
What are the priority assessments for postoperative patients?
Immediate postoperative care.
Respiratory rate;.
Oxygen saturation;.
Temperature;.
Systolic blood pressure;.
Pulse rate;.
Level of consciousness (this will be impaired in patients who have had recent sedation or are receiving opioid analgesia, which should be taken into consideration in assessment)..