MAIN PRE/POST RN INSTRUCTIONS
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POST ANESTHESIA, SURGERY, PROCEDURE RECOVERY PROCESS
When you get your call out, find your patient under “patient station” using their MR # or name.
Open their chart; go to HSD out/inpatient and “Device Select.” Then make sure you have
PACU orders, look at history, etc. If you have time you can figure NPO loss, get ordered lab
requisitions, gather pumps you’ll need, etc.
ON PATIENT ARRIVAL: Perform a rapid initial assessment ABC’s. Document arrival
time
 Place patient on monitor: obtain vital signs including temperature SpO2, BP, EKG, put
on Oxygen as appropriate.
 Auscultate Heart & lung sounds, and then get report from anesthesia.
 Safety Check with OR nurse. They will report dressings, drains, etc.
 Full Assessment, and treat immediate pain, nausea, etc.
O2 DOCUMENTATION
 POST PROCEDURE DOC FLOWSHEET
1. Post Procedure, IV/OR Procedure Fluids, Med. Admin, Output, and Bedside
Safety Check info all can be filled out from verbal report, anesthesia cheat sheet
and OR nurse report.
2. VITALS/PAIN/NAUSEA: Validate initial vitals and then vitals at minimum every
15 minutes until anesthesia sign out. Make sure you chart O2 delivery/FiO2, and
heart rhythm. Pain and nausea assessment are every 15 minutes. Chart
interventions for these as you go along.
3. ASSESSMENT: For admission assessment chart on all blanks as necessary on
Neurology-Skin.
4. NPO Loss: Calculate using formula. (Look under “Details” box).
5. PARS: Chart this score on admission, q 15 minutes for first hour, q 30 minutes
for the next 2 hours, and then every hour until signed out.
6. Chart on Treatments/Equipment and Transfer/Discharge Report as Necessary.
Make sure you document the EXACT time the patient is signed out and WHO
signed them out. (Per Anesthesia’s sign-out note time)
 LINES, DRAINS, WOUNDS, AND AIRWAYS
1. Add all lines, drains, wounds, and airways into O2 and chart admission
assessments on all of these.
 MAR
1. LINK ALL OF THE MEDICATIONS you give to their ANESTHESIA or SURGERY
order. EVERYTHING we pull out of our Accudose is an “Override,” therefore we
must link what we pull to the order itself!!!!!!! Pay attention and make sure the
correct ADMINISTRATION TIME is charted.
 IVF MANAGEMENT
1. Go to “Add Group,” type “fluid,” choose the basic “IV Fluid,” and name it “PACU.”
Then as you give crystalloids or colloids, you can chart them all under this
category and specify under the comment what KIND of fluid it was (i.e. Hespan,
LR, NS, etc.)
 ORDERS
1. PACU orders should already be released. Make sure to release admission room
orders and other post-op orders as needed.
MAIN PRE/POST RN INSTRUCTIONS
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2. Initiate PNCs, PCAs, PCEAs, Maintenance IVF once NPO is met, give
prescribed pain meds, etc.
 PROCEDURES
1. Chart under “procedure” flowsheet for blocks, epidurals, ECT, etc
CARE PLAN & PATIENT EDUCATION:
 Update patient care plan and education. Apply all the problems that are relative to your
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patient condition from the problem list. When selecting a problem review the goals and
interventions. Not all of them will pertain to your patient. Interventions are recommendations
based on evidence to help achieve the goal.
Discharge Planning needs to be selected on each patient
Education teaching points are populated from care plan problems.
If the patient has never been admitted to the hospital before, create a new learning
assessment
If the patient has been admitted here before, review and update the past learning
assessment
DISCHARGE
1. Patient Education: Review all teaching points under “Education Management” tab
2. Every teaching point must be resolved prior to discharge. It is never too early to start
this process.
3. Give patient discharge instructions including: yellow copy of instructions and
prescriptions. (if faxing prescriptions to KU out patient pharmacy place a patient sticker
on the prescription and write the patients allergies, address, and phone # on each) Do
not fax prescriptions to outside pharmacies please.
ANESTHESIA SIGN OUT
 Once patient meets discharge criteria and pain/nausea are under control, the patient
can be signed out by our anesthesia resident and then go home, back to their inpatient
room, become a bed hold, etc.
 After 2 hours as a bed hold status, all admission orders must be released, just like in
SDS.
 Upon sign out by anesthesia, a FULL discharge assessment must be done and charted
along with a second assessment of current Lines/Drains/Wounds/Airways.
 DISCONTINUE all PACU orders AFTER SIGN OUT. Sign them off “STANDARD” and
put the staff anesthesia for the case as the doctor.
 Make a 2 sided copy of the yellow anesthesia documentation form keep the copy in the
chart, put the original in the file next to the copy machine.
 Complete patient charge form and green charge card, place a sticker on each turn in a
main desk immediately after patient leaves Pre/post unit
 Document: Time patient arrives to unit, procedure times as needed, time patient is
signed out by anesthesia provider (check the anesthesia note in the computer), time
patient becomes a bed hold (for same day admissions & extended recovery patients
only), time patient is transferred from unit or time patient is discharged from the unit.
 Document on Doc/Flow sheet if this patient was an “On Call” case or not
 Document on Doc/Flow sheet if the patient was a “Fast Track” (ASAI,II)
 Document when and how (cart, wheel chair, etc) the patient was transferred to (acute
care floor, ICU, extended recovery, SDS, etc) or discharged (home, rehab, skilled
nursing facility, etc)