V Located adjacent to OR

V Quiet, clean, painted with soft

pleasing colors and have indirect
lighting
V Has equipment that controls noise
(plastic emesis basins, rubber
bumpers on beds and tables)
V isolated but with visible quarters to
disruptive patients
V Should be ventilated
V Beds should provide easy access to
the patient, safe and easily
movable, can be readily placed in
shock position and has features
that facilitates care (i poles, side
rails, wheel brakes and chart
storage rack)
V Responsibility of the anesthesiologist
V New gown
V Transferred to stretcher
V Avoid the following during transfer:
1. Undue exposure
2. Rough handling
3. Hurried movements and rapid
changes in position
V Side rails up
V ðosition with the head to the
side and the chin extended
forward on a lateral Sims
position.
V if required to lie flat, carefully
monitor respiratory status.
V Elevate clientǯs upper arm on a
pillow.
V immediately make baseline:
1.Check airway patency
2. S, visual assessment (general
color, i infusion, drains, special
equipment, condition of the
dressing)
3.LOC
VAttach apparatus
VCommunicates intra-op info
(name, surgical procedure,
anesthesia, response to
surgery)
VArouse clients
V 4OCUMENTATiON:
1. Time of admission
2. Absence of reflexes
3. LOC
4. Skin color and dryness, S
5. Condition of dressing
6. i infusion, BT, drainage tubes, bladder
catheter
1.MAiNTENANCE OF
ðULMONARY ENTiLATiON Ȃ
to prevent hypoxemia and
hypercapnea
ASSESSMENT:
V Noisy and irregular respirations
V cyanotic
iNTER ENTiON:
VLeave plastic oral airway in
the mouth.
VAssess RR, Oxygen
saturation and breath
sounds
VCheck the order and apply
supplemental oxygen
Vðrevent choking
V Maintain patent airway (prevent
aspiration)
ÿTurning from one side
ÿElevate head of bed unless
contraindicated
ÿðrepare emesis basin always at
bedside Open mouth manually but
cautiously with padded tongue
depressor
ÿSuction as necessary
2.ðROTECTiON AN4
ðRE ENTiON OF iNJURY
V ðrovide side rails, place up
V Turn patient frequently and
placed in good alignment
V Never leave the patient alone
3.ðROMOTiON OF COMFORT
V Never leave the patient
alone
V Administer narcotic
analgesic to relieve pains
AREA OF ASSESSMENT:
1. Muscle activity
2. Respiration
3. Circulation
4. Consciousness level
5. Color
*Required for discharge from ðACU =
7 to 8 points
V Activity 2 able to move 4 extremities
1 able to move 2 extremities
0 not able to move

V Respiration 2 able to cough & deep breath

1 dyspnea or limited breathing
0 apneic
V Circulation 2 20% pre anesthesia
1 20-50% pre anesthesia
0 above 50% pre
anesthesia
V Consciousness 2 fully awake
1 rousable on calling
0 not responding
V Color 2 pink
1 pale, dusky, blotchy
0 cyanotic
V Activity Ȃ score of 2; able to obey commands.
V Respiration Ȃ score of 2; easy, noiseless
breathing.
V Circulation Ȃ 20 of pre anesthesia; Bð is within
+/-20 mmHg of the pre op level.
V Consciousness Ȃ score of 2; responsive.
V Color Ȃ score of 2; pinkish skin and mucus
membrane.
V Conscious and coherent
V Able to maintain a clear airway
and deep breathe and cough
freely
V S stable and/or consistent with
pre-op S for at least 30mins
V ðrotective reflexes are active
V Able to move four extremities
V Urinary output is adequate
V Afebrile or a febrile condition
has been attended to
V 4ressings are dry and intact, no
overt drainage
A Ȃ AiRWAY Maintain patent
airway
Head turned to side
Suctioning
Administer oxygen
B Ȃ BREATHiNG 4BE
Coughing
Administer oxygen
C Ȃ CiRCULATiON S q15 for 2h, q30
for 2h, q hour for
the first 24 houror
until stable
CRT not > 2-3s
Skin color
Monitor BT
C Ȃ CONSCiOUSNESS LOC
Ability to command
4 Ȃ 4RESSiNG Keep it dry and intact
4 Ȃ 4RAiNAGE Tubings attached,
keep it patent and
intact
4 Ȃ 4RUGS Antibiotics
ðain reliever
E Ȃ ELiMiNATiON Monitor i & O
Monitor passing
of flatus
F Ȃ FLUi4S i F 30 gtts/min
F Ȃ FOO4 NðO until peristalsis
returns (clear liquid
A
  A 


A
 
 
S Ȃ SAFETY/COMFORT
VSide rails up
VTurn to sides, early
ambulation
VRelief from discomforts
Vðrevent complications