Assessments

Post Anesthesia Care Unit (PACU) Initial Assessment

• PACU nurses conduct a head–to-toe assessment of the patient.
• They check vital signs, IV lines, art lines, intake and output, plus the skin condition and colour. They also check for pain or discomfort, any safety needs, and provide comfort measures such as warm blankets. Nurses check for the appearance and amount of drainage from dressings and drains.
• They assess the initial Aldrete score from 0-10
  • Activity
  • Respiration
  • Circulation
  • Consciousness
  • Oxygen Saturation

Initial assessment in the PACU includes documentation of the following:

• Integration of the data received from the hand-off report for transfer of care.
• Vital signs
  1. Respiratory status: airway patent, breath sounds, type of artificial airway, mechanical ventilator settings, oxygen saturation, and ETCO2, if indicated.
  2. Blood pressure: cuff or arterial line
  3. Pulse: apical, peripheral
  4. Cardiac monitor, rhythm
  5. Temperature/route
  6. Hemodynamic pressure reading, if indicated, including the central venous, arterial blood, pulmonary artery wedge, and intracranial pressure
• Pain, sedation and comfort assessment including a need for emotional support
• Neurologic function including the level of consciousness
• Position of the patient
• Condition and colour of the skin
• Patient safety needs
• Neurovascular, peripheral pulses and sensation of extremity or extremities, as applicable
• Condition of dressings or suture line, drains, tubes, receptacles
• Amount and type of drainage
• Muscular response and strength/mobility status
• Pupillary response, as indicated
• Fluid therapy– location of lines, condition of IV site, security and amount of solution given and infusing, including crystalloid, colloid and blood component therapy
• Intake and output
• Post anesthesia score, if scoring system is used
• Procedure-specific assessment

(Odem-Forren, 2019)

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Assessment and Management of Pain

Pain is assessed upon arrival to PACU:

1. Location (guarding behaviour)
2. Intensity (moaning, crying, VS)
3. Pain scales (numeric scale, visual analogue)

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Choosing an Appropriate Pain Assessment Scale

Self-report pain scales can be used in adults and pediatric patients who are alert and able to report how they are feeling.

No Pain

Mild Pain

Moderate Pain

Severe Pain

Very Severe Pain

Worst Possible Pain

Numerical rating scale works well for adults and pediatric patients as young as 5 – if they have a concept of numbers.

0	1	2	3	4	5	6	7	8	9	10
No Pain					Moderate Pain					Worst Possible Pain

Faces rating scale – This can be used in children as young as three. It is important that nurses do not use this as an objective measure such as looking at the patient’s face and trying to match it to a face on the scale. It is also important not to use words such as happy or sad – as you do not want the patient to consider how the face looks but how they are feeling.

0	2	4	6	8	10
No hurt	Hurts a little bit	Hurts a little more	Hurts even more	Hurts a whole lot	Hurts worst

Visual Analogue Scale (VAS) – This scale can be used with adults or pediatric patients usually starting around ages four and up. Although this scale can be helpful since the patient can show where along the line their pain resides, it can be challenging to monitor precisely and to assess for slight changes in pain level.

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