PACU Admission

Clinical Protocol Page 1 of 2FSC PACU / JDH PACU Unit Practice ManualJohn Dempsey Hospital – Dept. of NursingUniversity of Connecticut Health SystemPROTOCOL FOR:PACU AdmissionPOLICY:1. Hand-off report will be received by the PACU RN from theanesthesia care provider or the RN responsible formonitoring the patient during the procedure. This reportwill occur prior to or upon patient arrival in JDH PACUand upon patient arrival in FSC PACU, and will includethe preoperative condition and the surgical / anestheticcourse.2. The transferring provider shall remain in the PACU untilthe PACU RN accepts responsibility for the nursing careof the patient.3. The patient shall be observed and monitored by methodsappropriate to the patient’s medical condition.Particular attention shall be given to monitoringoxygenation, ventilation, circulation, level ofconsciousness, and temperature.4. General medical supervision and coordination of patientcare in the PACU is the responsibility ofAnesthesiology. Patients who have not receivedanesthesia are the responsibility of the medical servicethat performed the procedure.5. Anesthesiology has primary responsibility to respond inurgent or emergent situations for patients in PACU whohave received anesthesia services and developcomplications or need resuscitation. At the JDH site,the Rapid Response Team or Code Blue Team has primaryresponsibility to respond for PACU patients who have notreceived anesthesia services. At the FSC site,Anesthesiology will be consulted as needed for PACUpatients who have not received anesthesia services.DESIRED PATIENTOUTCOME:1. The patient will receive a comprehensive healthassessment of major body systems upon arrival to thePACU.2. The patient will receive care guided by the assessmentdata.CLINICALASSESSMENTAND CARE:1. A comprehensive health assessment of major body systemswill occur with initial priority given to:UNIT17/pro/pacu admission

Clinical Protocol Page 2 of 2FSC PACU / JDH PACU Unit Practice ManualJohn Dempsey Hospital – Dept. of NursingUniversity of Connecticut Health SystemPROTOCOL FOR:PACU Admissionairway patency;breathing (respiratory drive);cardiovascular sufficiency;temperature andlevel of consciousness.2. A comprehensive health assessment of major body systemswill occur with secondary priority, as appropriate,given to: vascular access; EKG monitoring, as needed; infusing solutions and medications; pain level and comfort, including nausea / vomiting; temperature / thermoregulation; tissue perfusion / skin condition and dressings;pulse checks: eg, radial arterial, femoral dorsalpedalis, and posterior tibialis;sensory and motor function;laboratory values;disabilities;age-specific considerations;religious / cultural considerations; andother special needs as identified through report.APPROVAL:Nursing Standards CommitteeEFFECTIVE DATE: 1/98REVISION DATE: 5/00, 2/08, 8/09, 11/11UNIT17/pro/pacu admission