PACU documentation

[Carrollrn]

Hi everyone: question.

When admitting a patient into the PACU, besides documenting LOC, vitals etc, do you document on PERRLA or just document PERRLA on neuro cases?

[dianah, ASN]

Moved to PACU Nursing forum

[HeySis, BSN, RN]

We do not do neuro surgery in our hospital, it maybe different for those that do, I've never worked in different PACU.

Ours does not document PEARLLA.... Any patient that is under anesthesia and not yet "coming around" will have pin point pupils that are not reactive to light. We look at them when we see no signs of them waking to see where they are at. As the anesthesia wears off we start to see some reaction and the pupil will get larger... then we start to see other signs such as swallowing and vital signs coming back to base line, holding airways without jaw thrust or chin tilt.

There are lots of things we do document, some that you have not mentioned. VS, airways, aldrette, NAMDU, pain, incision/dressing site, LS, LOC, comfort level, positioning, oxygen use, IV site, heart rhythm, application of any appliances (splints, slings, ted hose, sequential compression stockings), use of warming or cooling techniques, skin assessment, catheter if placed. If an extremity was worked on we do CRT, peripheral pulses, temp, color and then later sensation and motor. Back cases we do a neuromuscular check for the levels below the surgery. If the patient has received spinal or epidural anesthesia we check dermatomes (same for nerve blocks) for sensation and movement. (this is what I can think off of the to of my head without looking at my charting).

May answer maybe overkill, but I hope it helps.

[meepmeep]

I guess it depends on your hospital's policies. I've only ever worked in one PACU. The PACU I work at doesn't do any neuro surgery but we do document PERRLA, vision, and oculomotor check for all sinus surgery patients since a loss of vision/abnormality could indicate a complication like an orbital hematoma or injury to optic nerve requiring immediate attention by the surgeon. We will also document PERRLA and neuro asessment for any patients who had surgery on their carotid arteries to watch for complications like stroke or hyperperfusion syndrome.