PACU SURGINET DOWNTIME FORM
PDF1
Please Copy and return to the Theatre Information Office
Title:
Mr
Mrs
Miss
First name:
Ms
Master
Dr
Other
Surname:
Date of birth:
Gender:
.
Male
Female
MRN:
(Or cover above with label)
Ward:
Theatre:
Surginet unavailable
Patient coming from A&E
Reason for Downtime:
Other (please specify)
PACU Times
In Recovery:
Time:
Conscious at:
Time:
Ready for discharge:
Time:
Discharge from recovery:
Time:
Pain Score on waking (between 0 and 10):
:
:
:
:
am
pm
Date:
Date:
Date:
Date:
/ 10
PACU Receiving Nurse:
PACU Breathing, Circulation, Pain Relief
Breathing (Refer to standards 1 & 2)
Assess and Monitor airway
Oxygen given
Oxygen Saturations Recorded
Maintenance of Circulation (Refer to standard 3)
Anticoagulant Therapy
Blood Given
Blood Glucose
BP and Pulse Recorded
Distal Pulse Recorded
Insulin Infusion
IV Infusion in Progress
POP Observations
Venflon in situ
Venflon Removed
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
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Pain Relief – Sleep and Rest (Refer to standards 7, 8, 9, and 12)
Antiemetic given
Epidural infusion
I.M. analgesia
I.M. cannula in situ
I.V. opiate bolus
I.V. opiate infusion
IV Paracetamol
Nerve block in situ
Non-steroidal I.V
Non-steroidal P.R.
Oral analgesia
P.R. analgesia
Patient controlled analgesia
None Given
Referral to Acute Pain Service:
Yes
No
N/A
PACU Diabetes
Is the Patient Diabetic?
Yes
No
If Yes:
Blood Glucose Result on Arrival
Blood Glucose Checked Time
:
am
pm
Is Sliding Scale Insulin Infusion running in PACU
Yes
No
Has the Patient required Insulin Subcutaneous Bolus in PACU?
Yes
No
Extra Glucose given in PACU?
Yes
No
Blood Glucose Result on Discharge from PACU
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
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PACU Maintenance of Temperature
Warming Type
None Used
Admitting
Temperature
°C
Discharging
Temperature
°C
Extra blankets Applied
Bairhugger Patient warming System
Fluid Patient Warming System
PACU Hygiene
Hygiene (Refer to Standard 14)
Linen/Gown
Checked
Changed
Bed Bath
Oral Hygiene
PACU Elimination
Elimination (Refer to standard 11, 12, and 13):
Bladder Washout Performed
Care of Colostomy
Care of Ilial Conduit
Catheter Type
Has Passed Urine
N/G Tube Aspirated 2 Hourly
N/G Tube in Situ
Patient Catheterised in PACU
Patient Incontinent of Urine
Suprapubic Catheter in Situ
Urethral Catheter in Situ
Bladder Irrigation in Progress:
None
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
Intermittent
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Continuous
PACU Preventing Infection
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Op Site in tact at:
Redressed at:
Time:
:
Time:
Date
:
Date
:
Blood Loss from drains on Discharge
ML
Vaginal Loss
None
Slight
Moderate
Heavy
Wound Drain
Antibiotics Prescribed?
Yes
No
Antibiotics to Continue?
Yes
No
Number of Wounds
1
2
3
4
other
PACU Prevention of Pressure Ulcers
Regular Position Changes?
Yes
No
Pressure Areas Inspected?
Grading and Assessment of
Pressure Areas:
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
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Yes
No
PACU High Dependency Care
Ventilatory Assistance
Yes
No
Removed
Arterial Line:
In Situ
N/A
Arterial Line Position:
Removed
CVP Line:
In Situ
N/A
CVP Line Position:
X-Ray Needed?
Yes
No
N/A
PACU Communication (Refer to Standard 10)
Notes and Xrays with Patient?
Yes
No
Orientation of
Patient
Yes
No
Operation note printed and
with patient?
Yes
No
TTAs prescribed?
Yes
No
Relatives:
All of Criteria monitored and
Recorded on Anaesthetic Chart?
Contacted
Yes
Visited Patient
No
Signed:
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
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Unaware Of Situation
PACU All Staff Involved
Staff (name)
Patient Care
Start time
Relief
Reason
Role Performed
/
:
Break
Patient Care
Stop time
/
Dinner
Lunch
Staff (name)
Patient Care
Start time
Relief
Reason
/
:
Sickness
Break
Patient Care
Stop time
/
Dinner
Lunch
/
Other
:
Shift Change
/
Sickness
/
Other
Role Performed
/
:
Break
Patient Care
Stop time
/
Dinner
Lunch
Staff (name)
Patient Care
Start time
Relief
Reason
Shift Change
/
Role Performed
Staff (name)
Patient Care
Start time
Relief
Reason
:
:
Shift Change
/
Sickness
/
Other
Role Performed
/
:
Break
Patient Care
Stop time
/
Dinner
Lunch
:
Shift Change
/
Sickness
/
Other
PACU Discharge / Delays
Pain Score On Discharge (between 0 and 10)
Abandoned
Abandoned
Patient Died in Recovery
Patient Died in Recovery
Returned to Ward
Returned to Ward
Returned to Theatre
Recovery
Outcome:
Sent to ITU
Sent to Main Theatre Recovery
Secondary
Recovery
Outcome:
Returned to Theatre
Sent to ITU
Sent to Main Theatre Recovery
Sent to DSU Recovery
Sent to DSU Recovery
Sent to PAW Recovery
Sent to PAW Recovery
Transferred to Other Hospital
Transferred to Other Hospital
Discharging
Nurse:
Discharged To:
Delay Reason:
/ 10
No Delay
No Bed Space Available
Lack of Ward Staff
Incident on Ward
No Bed Allocated
Op Note Not Completed
Theatres Post Op (PACU) Downtime Form (Version 3.4 - October 2014)
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