Postoperative Nursing Care Guide 2026: PACU, Complications, and Recovery

Contents: PACU Assessment Priorities Aldrete Score Airway Complications Common Complications DVT Prevention Post-Op Pain Discharge Criteria NCLEX High-Yield

PACU (Post-Anesthesia Care Unit) Assessment Priorities

When receiving a patient from the OR, perform a systematic handoff assessment BEFORE the anesthesia provider leaves. Use the SBAR format to receive information about the procedure, anesthesia type, intraoperative events, estimated blood loss, fluids given, and current orders.

This article was created with AI assistance.

Initial PACU Assessment (First 15 Minutes)

Airway: Patent? Snoring/stridor? Jaw-thrust needed? SpO2?
Breathing: Rate, depth, effort; SpO2; supplemental O2 in place?
Circulation: HR, rhythm, BP (compare to pre-op baseline); color, capillary refill; IV access and fluids running
Level of consciousness: RASS or orientation to person/place/time; emergence from anesthesia progressing normally?
Pain: Assess using 0–10 NRS or behavioral scale if not yet verbal; anticipate pain from incision
Surgical site: Dressing intact and dry? Drains patent and output documented? Any excessive bleeding through dressing?
Temperature: Hypothermia common post-op (core temp <36°C); apply warm blankets or forced-air warming device
Urine output: Foley catheter output or first void after catheter removal

Modified Aldrete Scoring System

Used to determine readiness for PACU discharge to floor or home. Score of ≥9 (out of 10) required for discharge from PACU in most facilities:

Category	Criteria	Score
Activity	Moves all extremities voluntarily or on command	2
	Moves 2 extremities	1
	Unable to move extremities	0
Respiration	Breathes deeply and coughs freely	2
	Dyspnea or shallow breathing	1
	Apneic	0
Circulation (BP)	±20 mmHg of pre-anesthetic level	2
	±20–50 mmHg of pre-anesthetic level	1
	±50 mmHg of pre-anesthetic level	0
Consciousness	Fully awake	2
	Arousable on calling	1
	Not responding	0
O2 Saturation	SpO2 ≥92% on room air	2
	Needs O2 to maintain SpO2 ≥90%	1
	SpO2 <90% even with O2	0

Post-Op Airway and Respiratory Complications

Complication	Signs	Nursing Action
Laryngospasm	Inspiratory stridor; crowing sound; partial = some airflow; complete = no airflow + paradoxical chest movement; SpO2 dropping	Jaw thrust; 100% O2 BVM; call anesthesia; succinylcholine for complete laryngospasm if SpO2 falling rapidly; prevent by suctioning secretions before emergence
Post-Extubation Stridor	Harsh high-pitched inspiratory sound after extubation; laryngeal edema	Cool mist O2; racemic epinephrine nebulizer; heliox (He/O2 mixture reduces airflow resistance); dexamethasone; prepare for re-intubation
Respiratory Depression (Opioid)	RR <10; SpO2 declining; difficult to arouse; pinpoint pupils	Stimulate patient (sternal rub); supplemental O2; naloxone 0.04–0.1 mg IV titrated; call anesthesia; monitor for re-sedation
Atelectasis	Decreased breath sounds at bases; SpO2 trending down; low-grade fever in first 24–48 hr post-op	Deep breathing exercises; incentive spirometry (q1h while awake); coughing with pillow splinting; early ambulation; suction if unable to cough effectively
Aspiration	Coughing; respiratory distress; SpO2 drop; new crackles; fever	Suction oropharynx; supplemental O2; position HOB 30 degrees; notify provider; CXR; bronchoscopy if large aspiration

Common Post-Op Complications

Complication	Onset	Signs	Nursing Action
Hemorrhage	First 24 hr (primary) or days 7–10 (secondary from infection)	Excessive blood on dressing (mark edges); increasing HR; falling BP; pallor; urine output declining; increasing drain output	Apply pressure; elevate affected area if applicable; notify surgeon STAT; IV access; labs (H&H, coags); prepare for return to OR if not controlled
Wound Dehiscence	5–10 days post-op	Wound edges separating; may see underlying tissue; preceded by serosanguineous drainage; "popping" sensation reported	Cover wound with sterile saline-moistened gauze; keep patient calm and still; NPO; notify surgeon; if evisceration: do not push organs back; cover with moist sterile gauze
Paralytic Ileus	2–5 days post-op abdominal surgery	Absent bowel sounds; abdominal distension; nausea/vomiting; no flatus or stool; inability to tolerate oral intake	NPO until ileus resolves; IV fluids; NGT for decompression if vomiting; ambulate ASAP (key prevention strategy); gum chewing (stimulates gut); correct electrolytes (especially K+)
Urinary Retention	First 6–8 hr post-op	Lower abdominal distension; restlessness; patient unable to void; BladderScan >300–400 mL	Ambulate to bathroom if safe; run water; privacy; bladder scan; in-and-out catheterization; notify if unable to void 6–8 hr after surgery
Post-Op Fever (5 W's)	Varies by W	Temperature >38.5°C	See 5 W's below

5 W's of Post-Op Fever

Day	"W" Cause	Mechanism
Day 1–2	Wind (atelectasis)	Collapsed alveoli from shallow breathing; stimulate breathing
Day 3–5	Water (UTI)	Urinary catheter; UA and culture
Day 3–5	Wound	Surgical site infection (SSI); most common organism: S. aureus
Day 5+	Walking (DVT/PE)	Deep vein thrombosis progressing to PE
Any day	Wonder drugs (medications)	Drug fever from antibiotics, blood products, IV contrast

DVT Prevention

Sequential compression devices (SCDs) on lower extremities BEFORE induction; remove only when patient is ambulatory
Early ambulation: first ambulation within 8–24 hr post-op if clinically stable (single most effective intervention)
Pharmacologic prophylaxis: enoxaparin (Lovenox) or heparin SC ordered per protocol; usually starts 12–24 hr post-op
Hydration: IV fluids to prevent hemoconcentration
Assess for signs of DVT with every VS: calf pain, tenderness, swelling, redness, warmth; Homans sign (calf pain with dorsiflexion) is NOT a reliable test
If DVT suspected: elevate extremity; notify provider; Doppler ultrasound ordered; therapeutic anticoagulation started

Post-Operative Pain Management

Multimodal approach: scheduled acetaminophen + NSAIDs + regional analgesia + opioids PRN breakthrough (ERAS protocol)
Assess pain score BEFORE and 30–60 min AFTER each intervention; document both
Opioids in PACU: give in small IV doses, titrate to response; monitor SpO2, RR, and sedation closely
PCA (Patient-Controlled Analgesia): patient presses button for small opioid doses; educate patient and family (NEVER let family press the button — "PCA by proxy" causes oversedation)
Epidural analgesia: assess dermatomal level of block; monitor for hypotension (most common side effect); respiratory depression (high block); motor block; epidural hematoma (back pain + motor deficit = EMERGENCY)
Pillow splinting: teach patient to hold pillow firmly against incision during coughing or movement

PACU Discharge Criteria

Modified Aldrete score ≥9 (or facility-specific criteria)
Stable vital signs for at least 30–60 min
Pain controlled (NRS ≤4 at rest)
Nausea/vomiting controlled
Surgical site stable (no active hemorrhage)
Consciousness and orientation appropriate
SpO2 maintained on room air or same level of O2 as pre-operatively
Temperature ≥36°C
Voided (or catheter in place) for outpatient procedures

NCLEX High-Yield Points

First post-op fever (day 1–2): Wind = atelectasis; treat with IS, deep breathing, ambulation
5 W's of post-op fever: Wind (atelectasis), Water (UTI), Wound, Walking (DVT/PE), Wonder drugs
Aldrete score ≥9 = safe PACU discharge; checks activity, respiration, BP, consciousness, SpO2
Post-op urinary retention: assess if no void 6–8 hr; bladder scan; in-and-out catheterization
Evisceration: cover with MOIST sterile gauze; do NOT push organs back; NPO; call surgeon STAT
PCA: patient presses button only; NEVER family — "PCA by proxy" causes opioid overdose
Epidural hematoma: back pain + new motor deficit = emergency; MRI immediately
Incentive spirometry: q1h while awake post-op; prevents atelectasis (primary cause of post-op fever days 1–2)
Post-op hypothermia (<36°C): warm blankets, forced-air warming; causes shivering, coagulopathy, increased O2 demand

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