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Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comPACU / Post-Anesthesia

PATIENT 1

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0800	0900	1000	1100	1200	1300	1400
HR
BP
RR
Temp
SpO2
Pain

ALDRETE SCORE

Criteria	Arr	15m	30m	DC
Activity
Respiration
Circulation
Consciousness
O2 Sat
TOTAL

ANESTHESIA

Type (GA/Regional/MAC):

Agents:

Airway:

PROCEDURE

Procedure:

Surgeon:

OR Time:

PAIN MANAGEMENT

PCA Settings:

Nerve Block:

Last Narcotic:

PONV

Nausea (0-10): ____ Emesis: ____

Antiemetic Given:

DISCHARGE CRITERIA

Aldrete >= 9

Pain controlled

No active bleeding

Tolerating PO

Voided

Escort present

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

PATIENT 2

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0800	0900	1000	1100	1200	1300	1400
HR
BP
RR
Temp
SpO2
Pain

ALDRETE SCORE

Criteria	Arr	15m	30m	DC
Activity
Respiration
Circulation
Consciousness
O2 Sat
TOTAL

ANESTHESIA

Type (GA/Regional/MAC):

Agents:

Airway:

PROCEDURE

Procedure:

Surgeon:

OR Time:

PAIN MANAGEMENT

PCA Settings:

Nerve Block:

Last Narcotic:

PONV

Nausea (0-10): ____ Emesis: ____

Antiemetic Given:

DISCHARGE CRITERIA

Aldrete >= 9

Pain controlled

No active bleeding

Tolerating PO

Voided

Escort present

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comPACU / Post-Anesthesia

PATIENT 3

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0800	0900	1000	1100	1200	1300	1400
HR
BP
RR
Temp
SpO2
Pain

ALDRETE SCORE

Criteria	Arr	15m	30m	DC
Activity
Respiration
Circulation
Consciousness
O2 Sat
TOTAL

ANESTHESIA

Type (GA/Regional/MAC):

Agents:

Airway:

PROCEDURE

Procedure:

Surgeon:

OR Time:

PAIN MANAGEMENT

PCA Settings:

Nerve Block:

Last Narcotic:

PONV

Nausea (0-10): ____ Emesis: ____

Antiemetic Given:

DISCHARGE CRITERIA

Aldrete >= 9

Pain controlled

No active bleeding

Tolerating PO

Voided

Escort present

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

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