Incorporating nursing diagnoses in the postanesthesia care unit record

The staff in the PACU at Community Memorial Hospital in Menomonee Falls, WI decided to revise the PACU record using nursing diagnoses. We wanted our new record to reflect our standards of care. We identified three standard nursing diagnoses in our standards and used these as the basis for our new form. The three nursing diagnoses were: potential for ineffective airway clearance, potential for pain, and potential for injury. We also provided an area for nonstandard nursing diagnoses to address individual care if needed. We are currently revising this record after using it for 1 year, and we plan to include one more nursing diagnosis: Potential for fluid imbalance will cover intake and output as well as nausea and vomiting, a common problem in the PACU.