PACU flowsheet

I'll keep trying to figure out how to attach.

Surgeon: OR Nurse: Anesthesiologist:

Procedure: Type: Spinal:

Pre-op vitals: Allergies: Reversals: Block:

[TABLE=width: 100%]

[TR]

[TD]Meds Given

Fentanyl Dilaudid Tylenol Toradol Prometh

[/TD]

[/TR]

[/TABLE]

History: ABX: EBL:

1^st Temp Resp Rhythm Strip

1^st Head to Toe and Focused Assessment

Patient on Board / Admit note / VS / Pains and Passes / I & O / SCIP / Care plan / Education / Belongings

[TABLE=width: 100%]

[TR]

[TD]IV sites Fluid In

Dressings Urine

Drains Spinal Level

Foley PCA/Epi/Q-ball

[/TD]

[/TR]

[/TABLE]

Floor RN: Room:

Last Temp

Handover note / Acuity / Transport / Verify

IN_______________ OUT_______________

Surgeon: OR Nurse: Anesthesiologist:

Procedure: Type: Spinal:

Pre-op vitals: Allergies: Reversals: Block:

History: ABX: EBL:

[TABLE=width: 100%]

[TR]

[TD]Meds Given

Fentanyl Dilaudid Tylenol Toradol Prometh

[/TD]

[/TR]

[/TABLE]

1^st Temp Resp Rhythm Strip

1^st Head to Toe and Focused Assessment

Last Temp Floor RN: Room:

Fluid In: Urine out: Spinal Level:

Irishlassi,

This is close, it was rearranged but the basic information is there. In the heading I have the basic routine for all patients, releasing orders, ordering the bed, calling the floor, checking labs, allergies, hooking them up to the BDI etc. (assuming I have time!!) I made a box for the most commons meds I give. I find this is the information most floor nurses like to have. In my hospital the drugs anesthesiology administer do not show up on the MAR so I am careful to let the floor nurses know if IV Tylenol or tordol was given in surgery and at what time.

I hope you find this useful.