The development of a postanesthesia record incorporating the nursing process

Area of Science:

• Nursing
• Healthcare Administration

Background:

• Nursing practice involves assessment, planning, implementation, and evaluation.
• Nursing diagnoses, goal setting, and progress evaluation are integral to the nursing process.
• Current PACU documentation may not fully reflect a comprehensive nursing plan of care.

Purpose of the Study:

• To develop and implement a new nursing record for the Post-Anesthesia Care Unit (PACU).
• To integrate nursing diagnosis, goal setting, and evaluation into PACU documentation.
• To meet the standards of the American Society of Perianesthesia Nurses (ASPAN) and Joint Commission requirements.

Main Methods:

• A literature search identified the need for improved PACU documentation.
• A new nursing record was developed by PACU staff at St. Francis Hospital.
• The record was tested over a 30-day period and implemented in September 1988.

Main Results:

• Staff response to the new record was highly positive.
• Nurses reported improved documentation quality.
• The record increased individual accountability for nursing interventions.

Conclusions:

• The developed nursing record effectively enhances professional nursing practice in the PACU.
• The record supports adherence to professional standards and accreditation requirements.
• Implementation led to improved documentation and nurse accountability.