Credits to Ma'am Evangeline Teruel

5. 1. MAINTENANCE OF
PULMONARY
VENTILATION – to
prevent hypoxemia
and hypercapnea

6. 2. PROTECTION AND
PREVENTION OF
INJURY

7. 3. PROMOTION OF
COMFORT

8. AREA OF ASSESSMENT:
1. Muscle activity
2. Respiration
3. Circulation
4. Consciousness level
5. Color
*Required for discharge from PACU =
7 to 8 points

9.  Activity 2 able to move 4 extremities
1 able to move 2 extremities
0 not able to move
 Respiration 2 able to cough & deep breath
1 dyspnea or limited breathing
0 apneic

10.  Circulation 2 20% pre anesthesia
1 20-50% pre anesthesia
0 above 50% pre
anesthesia
 Consciousness 2 fully awake
1 rousable on calling
0 not responding
 Color 2 pink
1 pale, dusky, blotchy
0 cyanotic

11.  Activity – score of 2; able to obey commands.
 Respiration – score of 2; easy, noiseless
breathing.
 Circulation – 20 of pre anesthesia; BP is within
+/-20 mmHg of the pre op level.
 Consciousness – score of 2; responsive.
 Color – score of 2; pinkish skin and mucus
membrane.

13. A – AIRWAY Maintain patent
airway
Head turned to side
Suctioning
Administer oxygen
B – BREATHING DBE
Coughing
Administer oxygen

14. C – CIRCULATION VS q15 for 2h, q30
for 2h, q hour for
the first 24 houror
until stable
Skin color
Monitor BT

15. C – CONSCIOUSNESS LOC
Ability to command
D – DRESSING Keep it dry and intact
D – DRAINAGE Tubings attached,
keep it patent and
intact
D – DRUGS Antibiotics
Pain reliever

16. E – ELIMINATION Monitor I & O
Monitor passing
of flatus
F – FLUIDS IVF 30 gtts/min
F – FOOD NPO until peristalsis
returns (clear liquid
→ full liquids → soft
diet → full diet/DAT

17. S – SAFETY/COMFORT
Side rails up
Turn to sides, early
ambulation
Relief from discomforts
Prevent complications