Anaesthetist-Vorlage
Post-Anaesthesia Care Unit (PACU) Note
Eine professionelle Anaesthetist-Vorlage für medizinisches Fachpersonal.
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Streamline your post-operative patient management with our PACU Note template, specifically designed for anaesthetists and recovery room staff. This comprehensive template ensures accurate and efficient documentation of a patient's critical recovery phase after surgery. Easily record vital information such as patient identification, procedure details, anaesthesia specifics, and intraoperative course. With Heidi, this template facilitates detailed post-operative assessments covering consciousness, respiratory and cardiovascular status, pain levels, and any complications. It's perfect for capturing all medications administered and outlining the clear plan for patient disposition, making it an essential tool for high-quality patient care documentation.
Vorlagenvorschau
Post-Anaesthesia Care Unit (PACU) Note
Patient Identification:
Sarah Elizabeth Johnson, Hospital Folder No. 789012, DOB: 15/03/1988, Female
Procedure Details:
Laparoscopic Cholecystectomy, Date of Surgery: 01 November 2024, Surgical Team: Dr. Alex Chen (Surgeon), Dr. Emily White (Assistant Surgeon)
Anaesthesia Details:
General anaesthesia with endotracheal intubation, duration of anaesthesia: 2 hours 30 minutes. Adjuncts: Fentanyl (100 mcg IV), Midazolam (2 mg IV) for induction. Regional block: Right Subcostal TAP block with 20 ml 0.25% Bupivacaine.
Intraoperative Course:
Haemodynamically stable throughout the procedure. Blood pressure maintained within 20% of baseline. Estimated blood loss: 50 ml. No complications noted. No transfusions required.
Postoperative Assessment:
Patient arrived in PACU awake but drowsy, stable, and able to follow simple commands.
Level of Consciousness:
Drowsy but easily arousable. Oriented to person and place. RASS score: -1 (drowsy).
Airway and Respiratory Status:
Airway patent and clear. Respiratory rate: 16 breaths/min, unlaboured. Oxygen saturation: 98% on 4 L/min via nasal cannula. No stridor or wheezing.
Cardiovascular Status:
Heart rate: 72 bpm, regular rhythm. Blood pressure: 118/76 mmHg. Perfusion adequate, capillary refill time < 2 seconds. No ST changes on continuous ECG monitoring. No vasopressor support required.
Pain Assessment:
Pain score: 4/10 at rest, 6/10 with movement. Analgesia administered: Fentanyl 50 mcg IV once in PACU. Oral analgesia planned: Paracetamol 1g PO and Ibuprofen 400mg PO.
Nausea and Vomiting:
Mild nausea present on arrival. Anti-emetic administered: Ondansetron 4 mg IV.
Temperature:
Temperature: 36.8°C. No active warming or cooling interventions required.
Fluids and Urine Output:
IV fluids: 500 ml 0.9% Normal Saline infused in PACU. Estimated urine output: 150 ml via foley catheter since PACU arrival.
Medications Administered:
Fentanyl 50 mcg IV at 14:15
Ondansetron 4 mg IV at 14:30
Complications/Adverse Events:
Mild nausea successfully treated with antiemetic. No other significant complications or adverse events.
Plan and Disposition:
Monitor in PACU for a further 60 minutes. Continue oxygen therapy at 4 L/min. Reassess pain and administer further analgesia as needed. Discharge to surgical ward once Aldrete score ≥ 9, pain controlled, and nausea resolved. Patient's destination: Surgical Ward A.
Clinician Signature:
Dr. Marcus Thorne, Anaesthetist, 01 November 2024, 15:00
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