The nursing checklist is the driving force behind the safest hour that many surgical patients will never remember. The post-anesthesia care unit is running on seconds, not minutes, because emergence is when fragile physiology is at its peak and surgical stress is a reality.
The first 60 minutes set the tone for the comfort, safety, and momentum of the rest of a patient’s recovery. When your team masters the “big three” of airway, pain, and PONV, the patient leaves Phase I recovery ready to receive a smooth handoff. This is a high-pressure process that requires critical care problem-solving with quick cycles.
- Snapshot of the role: What does a PACU nurse do?
- On-the-ground view: What is PACU nursing like?
Power move 1: Airway management nursing mastery
The airway always comes first because consciousness lags behind the removal of anesthetics. Residual muscle relaxants and opioids suppress tone, causing soft tissues to sag and the tongue to potentially obstruct airflow. In this window, airway management nursing focuses on early recognition and swift, skilled maneuvers.
Why airways falter after anesthesia
When the brainstem is under general anesthesia, it may be less active in its breathing reflexes. This is usually due to the after-effects of inhalational agents, such as Sevoflurane or Desflurane, or intravenous anesthetics. Even minimal doses of sedatives and opioids can affect respiratory efforts by delaying rates and depths.
One key element here is the concept of residual neuromuscular blockade (RNMB). Without full reversal of the muscle relaxant Rocuronium when given in high doses, "awake" but insufficiently strong patients may not have the muscle power to hold the airway open. The compromised muscle tissue and the presence of the massive tongue lead to obstruction.
The PACU nurse checklist is essential for patient survival.
Clinical insight: Combating atelectasis and V/Q mismatch
Beyond simple physical obstruction, the PACU nurse must manage the loss of functional residual capacity (FRC). General anesthesia and the use of high FiO2 (100% oxygen) during induction lead to absorption atelectasis. As nitrogen is washed out of the lungs, the alveoli lose their "internal struts" and collapse.
This creates a ventilation-perfusion (V/Q) mismatch, where blood shunts through non-ventilated lung tissue. In the first hour, the patient may have a "normal" respiratory rate but still show refractory hypoxemia.
The PACU intervention:
- Recruitment maneuvers: Don't just increase the oxygen flow. If the patient is drowsy, use a Bag-Valve-Mask (BVM) to provide 5–10 cmH2O of PEEP (Positive End-Expiratory Pressure) to physically re-expand collapsed alveoli.
- Early mobilization: As soon as the patient is rousable, prioritize "sigh breaths" or early incentive spirometry.
- Positioning: Elevate the head of the bed to at least 30 degrees immediately (unless contraindicated by the procedure) to reduce diaphragmatic pressure and improve lung expansion.
Nursing pearl: Remember that a high SpO2 on a non-rebreather mask can mask a significant V/Q mismatch. Always correlate the pulse oximetry with the patient’s actual work of breathing and tidal volume.
Listen and look for trouble
Use your ears and eyes before your hands. Assessment in the post-anesthesia care unit must be continuous:
- Snoring: Indicates partial upper airway obstruction (pharyngeal wall collapse)
- Silence: Indicates potentially complete obstruction (absent airflow despite chest movement) and requires emergency intervention
- Paradoxical breathing: Indicates upper airway obstruction being overcome by diaphragmatic effort (chest retraction with simultaneous abdominal rise)
- Tracheal tugging: Indicates increased respiratory effort (downward movement of the thyroid cartilage)
- Auscultation: Indicates bilateral air entry or potential bronchospasm/aspiration
A quick stethoscope sweep helps confirm bilateral air entry and rule out bronchospasm or aspiration.
Intervention tactics and airway adjuncts
- Repositioning: Adopt a sniffing position or turn the patient laterally to resolve a temporary obstruction.
- Jaw thrust: Advance the mandible anteriorly to displace the tongue from the posterior pharynx without hyperextending the neck (typically the most reliable PACU maneuver).
- Oral airway (OPA): Use only for an unconscious patient; in the presence of a gag reflex, it can provoke vomiting and laryngospasm.
- Nasopharyngeal airway (NPA) or nasal trumpet: Use for a semi-awake patient; it provides a conduit for airflow and is better tolerated than an oral device.
The nightmare scenario: Laryngospasm
Laryngospasm is a forceful, involuntary closure of the vocal cords, typically occurring during "Stage 2" of emergence. If you hear inspiratory stridor or see a "flat" capnography wave despite chest rise, take immediate action.
Apply firm pressure to the Larson Point (the "laryngospasm notch"). Place your fingers in the space behind the earlobe, anterior to the mastoid process, and posterior to the ramus of the mandible. Apply forceful pressure inward and toward the base of the skull while performing a vigorous jaw thrust. Simultaneously, provide 100% FiO2 via BVM with PEEP.
If the spasm persists, call for anesthesia immediately; they may need to administer a "breaking dose" of Succinylcholine (0.1–0.5 mg/kg) or Propofol.
Power move 2: Strategic post-op pain management
Pain comes early, but your patient will hardly be awake yet. The problem of pain control in Phase I post-op recovery is to provide pain control without causing arrest of respiration or alterations in hemodynamics.
The challenges of assessment
During the first hour, sedation clouds the patient's ability to use a 0–10 scale. Nurses must rely on soft nursing skills—intuition, observation, and empathy. Look for:
- Autonomic signs: Hypertension, tachycardia, and tachypnea
- Physical signs: Splinting (shallow breaths to avoid moving the surgical site), guarding, and restlessness
As the patient clears the fog of anesthesia, patient education becomes paramount. Explain that the goal is not "zero pain," which can be dangerous, but "tolerable pain" that allows for deep breathing and movement.
Pharmacological strategies
- Fentanyl: Preferred in the PACU because its high lipophilicity allows rapid blood–brain barrier penetration for a fast onset
- Hydromorphone: Preferred for longer-lasting analgesia when the patient’s respiratory effort is stable
- Morphine: Used less often in the first 30 minutes because its histamine release can cause pruritus/hypotension, and its peak effect is slower
Multimodal and non-opioid approaches
The modern PACU nursing checklist prioritizes "opioid-sparing" techniques:
- IV acetaminophen: Provides central analgesia without causing respiratory depression
- Ketorolac: Provides effective relief for bone and inflammatory pain (check renal function/bleeding risk first)
- Regional nerve blocks: Requires confirmation of effectiveness and screening for local anesthetic systemic toxicity (LAST)
- Comfort measures: Include ice packs, limb elevation, and a calm nurse-to-nurse shift change that ensures the patient feels safe and attended to
Power move 3: Conquer postoperative nausea and vomiting (PONV)
Post-operative nausea and vomiting (PONV) has been described by patients as being even more debilitating than pain. Various complications resulting from PONV include wound dehiscence, electrolyte disturbances, as well as delayed discharge from the post-operative care facility.
Identifying the high-risk patient
Effective management starts with the Apfel Score. We evaluate:
- Female sex: Women are statistically at higher risk.
- Non-smoker status: Non-smokers have higher rates of PONV.
- History: Prior PONV or motion sickness is a major red flag.
- Opioids: The use of postoperative opioids increases risk.
Prophylactic vs. rescue therapy
If the patient is already presenting with symptoms despite OR prophylaxis, you will need to switch to a different medication class.
- 5-HT3 antagonists (Ondansetron): Usually the first line
- Corticosteroids (Dexamethasone): Often given in the OR; has a long half-life
- Dopamine antagonists (Promethazine/Metoclopramide): Useful for "rescue" but can cause sedation or extrapyramidal symptoms
- Anticholinergics (Scopolamine): Best for patients with a high risk of motion sickness
The power of non-pharmacological rescue
While waiting for meds to kick in, try these:
- Isopropyl alcohol inhalation: Evidence suggests that having the patient take 3 deep sniffs of an alcohol prep pad every 15 minutes can be as effective as Ondansetron for acute relief. Note: This is a short-term bridge (lasting approx. 15–20 minutes) to provide comfort while waiting for IV antiemetics to take effect.
- Hydration: Ensure IV fluids are flowing at the ordered rate; dehydration is a main cause of nausea.
- Slow transitions: Avoid rapid bed movements or sitting the patient up too quickly.
The ultimate PACU nursing checklist: A 60-minute breakdown
This timeline ensures that no detail is missed during the critical transition of Phase I recovery.
The critical handoff: What to listen for
Before anesthesia leaves the bedside, you must confirm:
- Airway grade: Was it an easy intubation or a "Grade 4" difficult airway?
- Reversal status: Did they receive Neostigmine (check for bradycardia) or Sugammadex?
- Narcotic timing: When was the last dose of Fentanyl or Morphine given?
- Fluids/EBL: What is the total intake vs. estimated blood loss?
- The "unexpected": Did the patient have any laryngospasm or arrhythmias during the case?
0–15 Minutes: The arrival and "the quick look"
The moment the stretcher hits the bay, the clock starts.
- Assess vitals: Record initial BP, SpO2, and EKG rhythm immediately.
- Check airway: Perform the "look, listen, feel" check and ensure oxygen is flowing.
- Receive handoff: Listen to the anesthesia provider regarding EBL and airway difficulties.
- Inspect surgical site: Check dressings and drains immediately for hidden hemorrhage.
15–30 Minutes: Stabilization and assessment
- Perform neurological check: Determine if the patient is rousable and following commands.
- Manage temperature: Treat hypothermia with forced-air warming (Bair Hugger) to prevent shivering.
- Titrate pain meds: Administer small, frequent doses of analgesics once the airway is stable.
- Monitor for emergence delirium (ED): Watch for agitation, especially in pediatric patients, and reduce sensory overload.
Emergence delirium and neuro-vigilance
As the brain transitions from the GABAA-mediated suppression of anesthesia back to consciousness, some patients experience emergence delirium. This state of agitation and disorientation is particularly common in pediatric populations and patients who have received high doses of volatile agents. It poses a significant safety risk, including self-extubation or injury. The post-anesthesia care unit environment must be optimized to reduce sensory overload. Integrating soft nursing techniques, such as maintaining a quiet environment and providing orientation cues, is essential.
30–45 Minutes: Optimization and therapeutic intervention
- Treat PONV: Administer antiemetics now if the patient is nauseated, before they attempt to move.
- Verify fluid status: Check the IV site for patency and ensure the primary bag isn't empty.
- Assess bladder health: Perform a bladder scan to rule out postoperative urinary retention (POUR). This is especially critical for patients who received spinal anesthesia, long-acting opioids, or have a history of BPH. A distended bladder is a hidden cause of postoperative hypertension and emergence delirium agitation that pain meds won't fix.
45–60 Minutes: Disposition and the Aldrete score
- Analyze trends: Confirm that vitals are stable or trending toward baseline.
- Calculate the Aldrete score: Determine if the patient meets the criteria for discharge.
- Finalize documentation: Verify that all real-time logging (vitals, pain scores, medications) is accurate and recorded. Charting should occur as you go, not be saved for the end.
- Update family: Call the family to reduce anxiety.
Understanding the Aldrete score: The green light
In the post-anesthesia unit, healthcare professionals ensure safety without relying on "gut feelings." Instead, they utilize the Aldrete Scale. The Aldrete scale allows the patient to reach a predetermined level of physiological stability before discharge from Phase I recovery.
The score evaluates 5 categories (0–2 points each):
- Activity: Can the patient move four extremities on command?
- Respiration: Can they breathe deeply and cough?
- Circulation: Is the blood pressure within 20% of their pre-op baseline?
- Consciousness: Are they fully awake or easily rousable?
- Oxygen saturation: Can they maintain SpO2 > 92% (or return to their pre-operative baseline) on room air? Note: Modern nursing uses the "modified Aldrete score," which replaces the subjective "skin color" assessment with objective SpO2 metrics.
A score of 9 or 10 is the standard requirement for transfer to a lower level of care.
The "big three" respiratory red flags
Educational resources
In case you are looking to advance your career or are starting off, here are a few highly recommended resources that you can explore:
- New to the unit? Check out tips for new PACU nurses.
- The path to certification: Read how to become a post-anesthesia care nurse.
- Market research: Compare this role against the highest paying nursing specialties (NICU, ICU, ER, etc.) to see where you fit best.
- Job search: If you're ready for a change, browse the best nursing jobs available in your area.
Owning the critical hour: Beyond the checklist
The PACU nursing checklist is more than just completing steps; it is about developing discernment before disaster strikes. A wise investment of your passion for airway management nursing, postoperative pain, and preemptive PONV management will even make the "safest hour" of recovery your most comfortable hour.
The post-anesthesia care unit is a place where things move quickly. In a mere 60 minutes, you are able to transform a medicine-induced weakness into a strength. It is among the most gratifying and challenging positions in a hospital setting.
Browse open PACU shifts on Nursa to put these skills to work.
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