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PACU Standards of Care
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NEW ENGLAND BAPTIST HOSPITAL
Surgical Services Department
Post Anesthesia Care Unit
Standards of Care
Policy:
The Post Anesthesia Care Unit Standards of Care define the nursing care delivered to all patients. The standards are
also a framework to assess achievement of effective nursing care as related to quality improvement monitoring.
Responsibility:
Registered Nurse
Plan of Nursing Care
The patient’s health status data is collected in a systematic and continuous manner. It is recorded, easily retrievable and
communicated on an ongoing basis. Patient data is collected through interview of the individual or significant other, physical exam,
medical record or consultation.
The plan of nursing care is developed utilizing the Nursing Process as a guide for assessment, planning, implementation, and
evaluation of nursing care and achievement of nursing and patient goals.
Standard I
Standard II
Standard III
Standard IV
Standard V
Standard VI
Standard VII
Standard VIII
Potential for Respiratory Dysfunction
Potential for Alteration in Cardiac Output
Potential for Alteration in Level of Consciousness
Potential for Alteration in Body Temperature
Potential for Alteration in Gas Exchange
Potential for Nausea Related to Administration of Anesthesia
Potential for Pain Related to Surgical Procedure
Standard of Care for a Patient with a Latex Allergy
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PACU Standards of Care
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POSTOPERATIVE / POST ANESTHESIA MANAGEMENT
Standard I:
Potential for Respiratory Dysfunction
Nursing
Diagnosis /Problems
Desired Outcomes
Potential for respiratory
dysfunction
The patient’s respiratory function will be
maintained or improved. This will be evidenced by:
a. Airway patency
b. Adequate respiratory function and oxygen
saturation
c. Regular respiratory pattern
d. Clear breath sounds
e. Pulse oximetry > 94% saturation or equal to
the patients baseline
f. Ability to cough and deep breathe
.
Paula Wheeler, RN, CPAN, Level IV
Nursing Interventions
1.
The PACU nurse will assess airway patency, respiratory rate and competency, breath sounds
and oxygen saturation. The assessment will include but is not limited to the following:
a. Respiratory rate - Obtain respiratory rate on admission to the PACU and continue to
document every 15 minutes X 4, every 30 minutes X 4 then every hour X 4.
b. Respiratory rhythm - Document chest expansion and depth of respirations.
c. Breath sounds - Auscultate and document breath sounds.
d. Pulse oximetry - Initiate on all patients upon admission to the PACU.
e. Airway - Assess patency and document findings related to airway patency.
f. Oxygen delivery system - Apply oxygen mask, oxygen cannula, T-piece, open face mask, or
ventilator, as requested by Anesthesiologist or Anesthetist.
2.
The PACU nurse will provide interventions for ineffective breathing patterns that include but are
not limited to the following:
a. Upper airway obstruction - Reposition head, apply jaw thrust and/or chin lift, insert oral
and/or nasal airway(s), suction as needed and notify Anesthesiologist. If respiratory rate is
below 8 / minute, encourage patient to cough and deep breath, notify Anesthesiologist and
have reversing agents available.
b. Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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PACU Standards of Care
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Standard II: Potential for Alteration in Cardiac Output
Nursing
Diagnosis /Problems
Potential for alteration
in cardiac output.
Content Authors:
Desired Outcomes
The patient’s baseline hemodynamic status will be
maintained or improved. This will be evidenced by
stable vital signs, cardiac rhythm and intake and
output.
Patricia Nugent, RN, CPAN, Level IV
Paula Wheeler, RN, CPAN, Level IV
Nursing Interventions
1.
The PACU nurse will assess and document findings related to:
a. Heart rate - Obtain heart rate upon admission to the PACU, every 15 minutes X 4, every 30
minutes X 4, then every hour X 4.
b. EKG rhythm - Place patient on a cardiac monitor, document rhythm and any changes in
rhythm while in the PACU. Notify Anesthesiologist and/or Cardiologist of any changes.
c. Blood pressure - Obtain blood pressure upon admission to the PACU via BP cuff, automatic
BP machine, A-line, palpation and/or Doppler examination every 15 minutes X 4, every 30
minutes X 4, then every hour X 4. Blood pressure is checked more frequently as necessary
until stable and within acceptable limits.
d. Invasive monitoring - Monitor and document arterial, central venous and pulmonary artery
wave forms and pressures upon admission to the PACU then every hour (this should be
completed more frequently if unstable, as indicated by the patient’s condition). Obtain
wedge pressures and cardiac outputs as ordered by the Physician.
e. Intake and output - Maintain IV fluids and administer blood products as ordered. Observe
dressing(s) and wound drainage, if present. Document urine output as elimination occurs (if
a urinary catheter is present this should be done hourly or more frequently as the patient’s
condition warrants).
2.
The PACU nurse will provide intervention for post anesthetic cardiac emergencies including:
a. Hypotension - Administer a fluid challenge while notifying the patient’s physician or
Anesthesiologist.
b. Hypertension - Assess possible causes and notify the patient’s physician or
Anesthesiologist.
c. Dysrhythmias - Interpret rhythm and notify the patient’s physician or Anesthesiologist.
d. Life threatening arrhythmias - Prompt recognition of the dysrhythmias, CPR and ACLS
protocols should be initiated, as indicated. Refer to Department of Nursing Policy and
Procedure for Cardiopulmonary Resuscitation.
e. Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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PACU Standards of Care
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Standard III: Potential for Alteration in Level of Consciousness
Nursing
Diagnosis /Problems
Potential for altered
level of consciousness
Content Authors:
Desired Outcomes
The patient will be awake, oriented and have
appropriate responses to commands and to
questions.
Paula Wheeler, RN, CPAN, Level IV
Patricia Nugent, RN, CPAN, Level IV
Nursing Interventions
1.
The PACU nurse will assess and document findings related to the level of consciousness that
include but are not limited to the following:
a. Assess patient’s response to stimuli.
b. Assess patient’s ability to follow commands.
c. Assess patient’s verbal response to questions.
d. Assess patient’s orientation to surroundings.
e. Assess type of anesthetic agents used.
2.
The PACU nurse will provide interventions for altered level of consciousness that include but are
not limited to the following:
a. Orient patient to time, person, and place.
b. Reduce patient’s anxiety by providing support and reassurance.
c. Collaborate with the Anesthesiologist to explore possible causes of altered level of
consciousness.
d. Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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PACU Standards of Care
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Standard IV: Potential for Alteration in Body Temperature
Nursing
Diagnosis /Problems
Potential for alteration
in body temperature
Content Authors:
Desired Outcomes
The patient will be able to maintain a body
temperature of 96 F. upon discharge from the
PACU.
Paula Wheeler, RN, CPAN, Level IV
Patricia Nugent, RN, CPAN, Level IV
Nursing Interventions
1.
The PACU nurse will assess and document findings related to the body temperature that include
but are not limited to the following:
a. Temperature - Obtain and document upon admission to the PACU, hourly, PRN and at the
time of discharge from the PACU.
b. Skin temperature - Document upon admission to the PACU and as indicated by the patient’s
condition.
c. Observe for signs of shivering.
2.
The PACU nurse will provide interventions for altered body temperature that include but are not
limited to the following:
a. Initiate warming therapy and document type of therapy.
b. Assess skin temperature and observe skin for redness.
c. Administer medication from shivering as ordered by Physician (i.e., Demerol).
d. Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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PACU Standards of Care
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Standard V: Potential for Alteration in Gas Exchange
Nursing
Diagnosis /Problems
Potential for alteration
in gas exchange.
Ineffective breathing
pattern may result from:

Anesthetic agents
administered

Muscle relaxants
administered

Other medications
administered (i.e.,
Narcotics,
Sedatives,
Analgesics, etc.)

Surgical procedure
performed

Fluid and blood
loss and
replacement

Hypothermia /
Shivering

Hypotension
Desired Outcomes
Patient will have a pulse oximetry measurement of
greater than 94% oxygen saturation on room air or
equal to the patient’s baseline measurement.
Patient will be able to maintain ventilation and
perfusion of lungs upon discharge from the PACU
as evidenced by:
a. Stable respiratory pattern.
b. Clear breath sounds.
c. Respiratory rate appropriate to patient’s age
and disease process.
d. Absence of restlessness and confusion, as
related to the patient’s baseline.
e. Stable vital signs.
f. Ability to maintain a patent airway.
g. Arterial blood gases (as ordered) are within
normal parameters or equal to the patient’s
baseline.
Nursing Interventions
1.
The PACU nurse will assess, document findings and provide interventions for altered gas
exchange that include but are not limited to the following:
a. Identify causes and contributing factors, as indicated by patient’s condition:

Auscultate breath sounds.

Assess respiratory rate.

Note breathing pattern.

Monitor vital signs.

Administer supplemental oxygen (refer to Pulse Oximetry for the PACU Patient Policy
and Procedure).

Elevate head of bed unless contraindicated by the surgery performed.

Assess level of consciousness.

Review laboratory data.

Protect airway in the event of emesis.

Utilize incentive spirometry, as ordered, to assist in increasing patient’s respiratory
effect.
2.
The PACU nurse will provide interventions related to the oxygenation and ventilation of the
PACU patient and initiate supplemental oxygen therapy, as indicated:
a. If oxygen saturation is greater than 94% on room air:

Stimulate patient, encourage the patient to cough and deep breath to maintain
oxygenation.

Elevate head of bed, unless contraindicated by the surgery performed.
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PACU Standards of Care
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Standard V: Potential for Alteration in Gas Exchange (cont.)
Nursing
Diagnosis /Problems
Desired Outcomes
Potential for alteration
in gas exchange (cont.)
Nursing Interventions
b.
c.
d.
Content Author:
Paula Wheeler, RN, CPAN, Level IV
Patricia Nugent, RN, CPAN, Level IV
If oxygen saturation is 92 - 94% on room air:

Stimulate patient, encourage coughing and deep breathing.

EIevate head of bed unless contraindicated by the surgery performed.

Re-apply supplemental oxygen as outlined in Pulse Oximetry for the PACU Patient
Policy and Procedure.

Auscultate breath sounds

Evaluate patient’s history (i.e., smoker, asthma, bronchitis, COPD). Notify
Anesthesiologist if there is no change in oxygen saturation level with supplemental
oxygen administration.
If oxygen saturation is 92% on room air:

Stimulate patient, encourage coughing and deep breathing.

EIevate head of bed unless contraindicated by the surgery performed.

Re-apply supplemental oxygen as outlined in Pulse Oximetry for the PACU Patient
Policy and Procedure.

Check for respiratory depression due to Narcotic or Muscle relaxant administration.

Auscultate breath sounds.

Evaluate patient’s history (i.e., smoker, asthma, bronchitis, COPD). Notify
Anesthesiologist if there is no change in oxygen saturation level with supplemental
oxygen administration.
Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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Policy & Procedure is the OFFICIAL copy.
May 4, 2017 3:03 AM
PACU Standards of Care
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Standard VI: Potential for Nausea Related to Administration of Anesthesia
Nursing
Diagnosis /Problems
Potential for nausea
related to administration
of anesthesia.
Content Authors:
Desired Outcomes
Patient will be free from nausea and vomiting.
Janet Bridges, RN, Level II
Denise Cody, RN, Level II
Nursing Interventions
1.
The PACU nurse will assess, document findings and interventions for nausea and vomiting post
anesthesia administration that include but are not limited to the following:
a. Assess patient for verbal complaints of nausea.
b. Assess past medical history for nausea and vomiting with surgery.
c. Assess patient’s history and physical for evidence of a history of gastrointestinal disturbance
(i.e., hiatal hernia or gastoesophageal reflux disease.
d. Monitor patient for diaphoresis, vagal response or restlessness.
e. Maintain intravenous fluids, as ordered.
f. Protect patient from aspiration by positioning patient.
g. Administer antiemetics, as ordered.
h. Evaluate effectiveness of interventions, document nursing action and/or intervention with
outcome.
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May 4, 2017 3:03 AM
PACU Standards of Care
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Standard VII: Potential for Pain Related to Surgical Procedure
Nursing
Diagnosis /Problems
Pain Secondary to:
 Psychologic response
to surgery
 Physical pain from
surgery
 Separation from
significant others
 Immobility
 Position
 Shivering/shaking
Content Author:
Desired Outcomes
Patient will exhibit increased level of comfort upon
discharge from PACU as evidenced by:
 Verbalization of comfort or of decreased amount
of pain.
 Vital signs within preoperative baseline range.
 Absence of restlessness.
 Patient is as comfortable as physiologic
parameters allow.
Paula Wheeler, RN, CPAN, Level IV
Patricia Nugent, RN, CPAN, Level IV
Nursing Interventions
1.
The PACU nurse will assess, document findings and interventions related to pain management
that include but are not limited to the following:
a. Identify cause of contributing factors:
 Assess type and amount of anesthesia administered.
 Assess physiologic response to pain, including: Monitoring blood pressure, pulse,
respiratory rate, oxygen saturation and mental status.
 Assess non-verbal response to pain, assess body language and body position.
 Assess possible causes of pain including: Patient report, patient history and objective
signs.
 Assess patient’s ability to process information.
 Assess psychologic discomfort and contributing factors including: Disorientation, fear of
the unknown, anxiety about outcome of surgery, alteration in body image, and separation
from significant other.
b. Provide interventions for causative factors:
 Titrate pain medication.
 Provide comfort measures and/or emotional support.
 Reposition patient, if indicated.
 Involve family, as applicable.
 Orient patient to PACU environment, time and place.
 Explain pain management regimen to patient.
 Establish plan to alleviate complications related to pain medications.
c. Documentation of pain and management of pain will include:
 Location of pain.
 Intensity of pain.
 Response to and effectiveness of pain relief measures.
 Identify level of pain using pain scale.
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PACU Standards of Care
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Standard VIII: Standard of Care for a Patient with a Latex Allergy
Goal:
To minimize exposure by creating an environment that is latex safe.
POSTOPERATIVE MANAGEMENT
1. Room Set-up
a. Patients will be admitted to the PACU.
b. Remove all materials containing latex.
c.. Refer to the master list of all latex free products.
2. Miscellaneous
a. Check to make sure the patient has a latex free ID and allergy band in place.
Desired Outcomes
Nursing
Diagnosis /Problems
Nursing Interventions
POST-OPERATIVE:
Potential for impairment
of skin integrity/injury
1.
2.
Patients’ contact with latex will be avoided.
Patients’ risk will be decreased by limiting
exposure to latex.
1.
2.
3.
Documentation of latex allergy in the patient’s chart and allergy bracelet.
Latex free supply cart will be brought into the PACU with the patient from the Operating
Room.
Non-latex products will be used.
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Nursing
Diagnosis /Problems
Desired Outcomes
Nursing Interventions
POST-OPERATIVE
(cont.):
Potential for Impairment
of respiratory status
related to latex allergy
Promote and maintain a
safe environment
Knowledge deficit
related to latex allergy
Content Author:
1.
Patients will be free from latex allergy reaction.
Prevention of potential complications during patient
transfer to the nursing unit.
Patient will receive information related to the use of
latex-free products while in the PACU, as appropriate.
Patient’s anxiety will be minimized, as much as is
possible.
Jean Kay, RN, Level II
1.
The following guidelines will be followed:
a. When drawing up medications, remove vial top and rubber plug with a kelly clamp, then
draw up medication.
b. When adding medication to an IV bag, open IV bag and inject medication prior to spiking
the bag with IV tubing.
c. Document nursing interventions.
2.
Monitor patient for signs and symptoms of anaphylactic shock
a. Urticaria.
b. Respiratory distress.
c. Bronchospasm.
d. Hypotension.
e. Tachycardia.
f. Respiratory and cardiac arrest.
3.
Nursing priorities
a. Maintain patent airway.
b. Administer oxygen at 2-4 L via nasal cannula to maintain oxygen saturation at 94% OR
greater.
c. IV solutions as ordered by physician.
d. Vital signs should be checked every 5 minutes.
e. Cardiac monitoring and pulse oximetry should be monitored according to PACU
standards of care.
f. Call a code green or blue, as necessary.
1.
2.
3.
4.
Assess and document the patient’s skin condition.
Assess and document patient’s respiratory status.
Communicate points to be related in report, this should include any pertinent information to
promote continuity of patient care.
Verify latex allergy status with the patient’s primary nurse.
1.
2.
3.
Instruct patient to verbalize latex allergy to all nursing and non-nursing personnel.
Reassure patient that latex-free products are being utilized for their care.
Instruct patient to notify nursing personnel of signs and symptoms of latex allergy reaction.
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PACU Standards of Care
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Reference:
Standards of Perianesthesia Nursing Practice, (1995), The American Society of Post Anesthesia Nurses, Thorofare, New Jersey.
Litwack, K., Post Anesthesia Care Nursing.
New England Baptist Hospital, Nursing Department, Pain Standard of Care.
Original:
Reviewed:
Revised:
Approval:
1/96
1/97, 11/98, 12/01, 12/04
12/04
Operating Room Committee 2/6/96