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, airway status, medications and timing, fluids, estimated blood loss, allergies, block/reversal status, and intraoperative events. Assess airway, breathing, circulation, neurologic baseline, surgical site, drains, pain, nausea, and temperature. Apply monitoring and reassessment intervals required by the patient's orders and your facility policy. Modified Aldrete may support Phase I readiness, but it never replaces the complete transfer criteria.
The complications that will scare you first
Airway obstruction or laryngospasm — stay bedside, call anesthesia, open/support the airway within training, and prepare the facility's airway rescue pathway. Post-op hypotension — verify the measurement, assess perfusion and bleeding, review losses, and prepare ordered support. PONV — review prophylaxis already given and use an ordered rescue from an appropriate class. Emergence delirium — protect the patient, reduce stimulation, and rule out hypoxia, pain, urinary retention, glucose abnormality, and medication effects. Medication and emergency actions depend on current orders and local protocols.
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.
Keep building your PACU study system
Preview the complete Baddie RN PACU study book with guided chapters, playbooks, cases, knowledge checks, and printable tools.
Preview the PACU study book →FAQ
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?
Length of stay varies by procedure, anesthesia, comorbidities, events, orders, and facility criteria. Phase I focuses on intensive recovery; Phase II focuses on safe transition, teaching, mobility, symptoms, and the discharge plan.
What's the nurse-to-patient ratio in PACU?
Assignments vary by patient acuity, age, airway status, phase of care, staffing model, and applicable facility/regulatory standards. Follow your unit's current policy rather than a universal ratio stated online.
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.