The PACU Nurse Assessment 👑
Every patient. Same order. Airway first, always. This is the assessment PACU nurses actually run in the first five minutes — plus the red flags that mean you call anesthesia now.
The first 5 minutes: your admission assessment
Your PACU assessment starts before the stretcher stops moving. You are taking report and assessing at the same time. Run it in this order every single time so nothing gets skipped when the unit is loud and three patients roll in at once.
- Airway — patent? Snoring, stridor, obstruction? Jaw thrust or oral airway ready at the bedside.
- Breathing — rate, depth, effort, SpO2, accessory muscle use. Apply oxygen per order before you chart anything.
- Circulation — first full set of vitals, rhythm on the monitor, pulses, skin color and temperature.
- Neuro — level of consciousness, response to voice, pupils if the case warrants it.
- Surgical site — dressing dry and intact? Drains labeled, patent, and marked? Estimated blood loss from the OR.
- Lines and tubes — IVs patent, fluids running, Foley output, NG placement, PCA settings verified.
- Pain and nausea — baseline score now, so you can prove your interventions worked later.
What to get in handoff from anesthesia
A weak handoff is the number one reason a PACU nurse gets surprised 20 minutes in. Do not let the CRNA walk until you have these.
- Procedure performed and any intraoperative changes to the plan
- Anesthesia type — general, MAC, regional, spinal — and reversal agents given
- Airway history: difficult intubation, number of attempts, sore throat risk
- Last dose and time of every opioid, antiemetic, and paralytic
- Estimated blood loss, urine output, and total fluids in
- Relevant history: OSA, difficult airway, chronic opioid use, PONV history
- Surgeon-specific orders — positioning limits, drain care, weight-bearing status
Aldrete score: how PACU discharge readiness is measured
The modified Aldrete score grades five categories from 0 to 2. Most units require a score of 9 or 10, with a stable airway and controlled pain, before phase I discharge. Know your facility's threshold — it governs your charting.
| Category | 2 points | 1 point | 0 points |
|---|---|---|---|
| Activity | Moves all 4 extremities | Moves 2 extremities | Moves 0 extremities |
| Respiration | Breathes deeply, coughs freely | Dyspnea, shallow breathing | Apneic |
| Circulation | BP ±20 mmHg of baseline | BP ±20–50 mmHg | BP ±50 mmHg or more |
| Consciousness | Fully awake | Arousable on calling | Not responding |
| O2 saturation | >92% on room air | Needs O2 to keep >90% | <90% with O2 |
Red flags: stop charting and escalate
These are the findings that end the routine assessment and start a phone call. If you see one, get help before you document.
- Stridor, retractions, or a falling SpO2 that oxygen does not fix — think laryngospasm or airway edema
- Respiratory rate under 8 with pinpoint pupils after opioids — naloxone conversation, now
- Sudden hypotension with rising heart rate — bleeding until proven otherwise; check the dressing and the drains
- Saturated dressing or a drain filling fast — mark it, time it, call the surgeon
- Temperature spike with masseter rigidity and rising end-tidal CO2 — malignant hyperthermia protocol
- Shivering with hypothermia — active warming; shivering triples oxygen consumption
- Agitation that will not settle — rule out hypoxia and a full bladder before you call it emergence delirium
Phase I vs phase II assessment
Phase I is intensive recovery: continuous monitoring, vitals every 5 to 15 minutes, one nurse to one or two patients. Phase II is discharge preparation: vitals every 15 to 30 minutes, focus shifts to ambulation, voiding, oral intake, pain controlled on oral medication, and the responsible adult who is driving your patient home. Your assessment frequency and documentation change with the phase — make sure your charting reflects which one you are in.
Frequently asked
What does a PACU nurse assess first?
Airway, always. Before vital signs, before the dressing, before the chart. The PACU nurse confirms a patent airway and adequate breathing, then moves through circulation, neuro status, surgical site, lines and tubes, and finally pain and nausea.
How often do PACU nurses take vital signs?
In phase I recovery, vital signs are typically documented every 5 minutes for the first 15 minutes, then every 15 minutes until discharge criteria are met. Phase II is usually every 15 to 30 minutes. Follow your facility policy — it is what you will be held to.
What is a normal Aldrete score for PACU discharge?
Most facilities require a modified Aldrete score of 9 or 10 out of 10, along with a stable airway, controlled pain, and controlled nausea, before a patient leaves phase I recovery.
What are the most common PACU complications?
Postoperative nausea and vomiting, uncontrolled pain, airway obstruction, hypotension, hypertension, hypothermia with shivering, emergence delirium, and delayed emergence. Airway problems are the least common but the most lethal, which is why airway leads every assessment.
How long does a patient stay in PACU?
Phase I recovery typically runs 45 minutes to 2 hours depending on anesthesia type, procedure, and how quickly discharge criteria are met. Patients who required general anesthesia or had significant blood loss usually stay longer.
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