PACU Phase I amp II Flowsheet - bmhcnetbbnetb 2025

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Patients emerging from anesthesia can present with a range of symptoms, from confusion and agitation to pain and nausea. So, PACU nurses must conduct comprehensive assessments to evaluate the patients airway, breathing, circulation, and neurological status.
The PACU is organized into three different phases of care to facilitate the perianesthesia/periprocedural continuum of care Preanesthesia (Preoperative holding), Postanesthesia Phase I (Main Recovery), Phase II (Ambulatory Surgery/Discharge Area) may be utilized for extended care when indicated.
The patient is discharged from Phase I when he or she meets specified criteria. The patient must be easily arousable, have stable blood pressure and normal body temperature, maintain adequate ventilation and protect their own airway, and achieve adequate nausea and pain control.
Once care is accepted in the PACU the initial assessment should include: Physical Assessment. Airway, Breathing, Circulation Disability Assessment (RCH Nursing Guideline: Nursing Assessment) Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature.
There is no uniform definition of which variables should be evaluated to determine if a patient is eligible for discharge from PACU. The domains most commonly evaluated are vital signs, pain, level of consciousness, and nausea and vomiting, with variations in the way of assessing them between the instruments.
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During a hand-off report from the operating room nurse to the PACU nurse, critical information such as client identification, anesthetic and surgical details, vital signs, fluid and medication data, and special considerations must be communicated. This ensures safe and effective patient care during the transition.
Phase I emphasizes ensuring the patients full recovery from anesthesia and return of vital signs to near baseline. Phase II recovery focuses on preparing patients for hospital discharge, including education regarding the surgeons postoperative instructions and any prescribed discharge medications.