Successfully reported this slideshow.

Pacu care

1,553 views

Published on

Credits to Ma'am Evangeline Teruel

Published in: Health & Medicine, Spiritual
  • Be the first to comment

  • Be the first to like this

Pacu care

  1. 1. 1. MAINTENANCE OF PULMONARY VENTILATION – to prevent hypoxemia and hypercapnea
  2. 2. 2. PROTECTION AND PREVENTION OF INJURY
  3. 3. 3. PROMOTION OF COMFORT
  4. 4. AREA OF ASSESSMENT:1. Muscle activity2. Respiration3. Circulation4. Consciousness level5. Color*Required for discharge from PACU = 7 to 8 points
  5. 5.  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
  6. 6.  Circulation 2 20% pre anesthesia 1 20-50% pre anesthesia 0 above 50% pre anesthesia Consciousness 2 fully awake 1 rousable on calling 0 not responding Color 2 pink 1 pale, dusky, blotchy 0 cyanotic
  7. 7.  Activity – 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.
  8. 8. A – AIRWAY Maintain patent airway Head turned to side Suctioning Administer oxygenB – BREATHING DBE Coughing Administer oxygen
  9. 9. C – CIRCULATION VS q15 for 2h, q30 for 2h, q hour for the first 24 houror until stable Skin color Monitor BT
  10. 10. C – CONSCIOUSNESS LOC Ability to commandD – DRESSING Keep it dry and intactD – DRAINAGE Tubings attached, keep it patent and intactD – DRUGS Antibiotics Pain reliever
  11. 11. E – ELIMINATION Monitor I & O Monitor passing of flatusF – FLUIDS IVF 30 gtts/minF – FOOD NPO until peristalsis returns (clear liquid → full liquids → soft diet → full diet/DAT
  12. 12. S – SAFETY/COMFORTSide rails upTurn to sides, early ambulationRelief from discomfortsPrevent complications

×