Cirillo B I, Hardy E
J Post Anesth Nurs. 1991 Oct;6(5):336-41.
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.
威斯康星州梅诺莫尼福尔斯市社区纪念医院麻醉后护理单元（PACU）的工作人员决定使用护理诊断来修订PACU记录。我们希望新记录能反映我们的护理标准。我们在标准中确定了三项标准护理诊断，并将其作为新表格的基础。这三项护理诊断分别是：无效气道清除的可能性、疼痛的可能性和受伤的可能性。我们还提供了一个区域用于记录非标准护理诊断，以便在需要时处理个体护理情况。在使用该记录1年后，我们目前正在对其进行修订，并且计划再增加一项护理诊断：液体失衡的可能性，这将涵盖出入量以及恶心和呕吐，这些都是PACU中常见的问题。
