How to Survive Your First Shift in PACU
You landed a PACU spot as a new grad or fresh transfer and now the panic is setting in. Breathe. Every PACU nurse you'll ever meet was terrified their first week. Here is the exact playbook we wish someone had handed us — what to bring, what to look for, and what to say when the anesthesiologist rolls in with your first patient.
The 5 things to prep the night before
1) Charge your stethoscope batteries and a penlight — you'll assess pupils and airways all day. 2) Print or bookmark your ACLS algorithms; laryngospasm and post-op hypotension move fast. 3) Review reversal agents: naloxone (opioid), flumazenil (benzo), sugammadex and neostigmine + glyco (paralytics). 4) Pack snacks and an insulated water bottle — you may not get a real break. 5) Set two alarms. Being late on day one is a story you'll retell forever.
Your first 15 minutes with any post-op patient
Anesthesia will hand off with SBAR. Listen for: procedure done, airway status (LMA, ETT, natural), meds given (opioids, paralytics, antiemetics, antibiotics), fluids in, EBL, allergies, and any intra-op events. As soon as they leave, do a full Aldrete assessment: activity, respiration, circulation, consciousness, O2 sat. Attach continuous cardiac + SpO2 + BP q5min for the first 15. Check the surgical site and drains. Warm blankets — hypothermia drives shivering and O2 demand.
The complications that will scare you first
Airway obstruction — snoring or stridor after extubation. Jaw thrust, oral or nasal airway, call anesthesia. Laryngospasm — silent chest and desat. Positive pressure with 100% O2, deepen anesthesia (propofol), sux if it doesn't break. Post-op hypotension — fluids first, then phenylephrine or ephedrine if MAP won't come up. PONV — ondansetron, then a second agent (dexamethasone, promethazine). Emergence delirium — protect the patient, low stimulation, dexmedetomidine if ordered.
The report you'll give when they leave PACU
You'll hand off to the floor, ICU, or discharge them home. Cover: procedure and time out of OR, current vitals and trend, pain scores and last meds given (drug, dose, route, time), lines and drains, PO/void status, any anesthesia issues, and pending orders. If you're discharging: verify a responsible adult is driving, review discharge instructions in plain language, and confirm follow-up is scheduled.
Mindset — you're going to make small mistakes
You will chart something in the wrong spot. You will forget to hit 'ok' on the pump. You will page the wrong resident. None of that will kill your patient. What matters is that you ask before you assume, escalate early, and never leave a desatting patient to go find help — call from the bedside. Your preceptor's job is to catch what you miss. Let them.
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Can a new grad start in PACU?
Yes. More hospitals are hiring new grads into PACU with 12-16 week orientations. You'll want ACLS and PALS within your first year, and most units expect BLS on day one.
How long is a PACU stay?
Phase 1 (immediate recovery) is usually 30-60 minutes until the patient meets Aldrete criteria. Phase 2 (step-down or discharge prep) can run another 45-90 minutes for outpatients.
What's the nurse-to-patient ratio in PACU?
Standard is 1:2 in Phase 1, sometimes 1:1 for unstable patients or peds. Phase 2 typically runs 1:3.
What certifications help in PACU?
CPAN (Certified Post Anesthesia Nurse) after 1,800 hours, plus ACLS and PALS. Some units expect CAPA for Phase 2.