Post-Anaesthesia Care Unit (PACU) Note

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