Post-Operative PACU Assessment Checklist

Comprehensive post-operative PACU assessment including vital signs monitoring, pain management, and discharge readiness criteria.

  • Industry: Healthcare
  • Frequency: PACU admission/Ongoing
  • Estimated Time: Throughout PACU stay
  • Role: PACU Nurse
  • Total Items: 32
  • Compliance: ASPAN Standards, Joint Commission Standards, Hospital PACU Policy

PACU Admission Assessment

Initial assessment

  • Verbal report received from OR?
  • Airway patent?
  • Initial vital signs documented?
  • Level of consciousness assessed?

Pain Management

Pain assessment and treatment

  • Pain level assessed?
  • Pain treated per order?
  • Pain reassessed after treatment?

Nausea/Vomiting

PONV management

  • Nausea assessed?
  • Antiemetic given if needed?

Ongoing Monitoring

Continuous assessment

  • Vital signs monitored per protocol?
  • Surgical site assessed?
  • Drains/output documented?
  • IV fluids per order?

Discharge Criteria

Readiness for discharge

  • Aldrete/discharge score documented?
  • Vital signs stable?
  • Pain controlled?
  • No excessive bleeding?
  • Voided (if required)?

Pre-Assessment Information

Initial assessment documentation and patient/facility identification

  • Assessor Name / Credentials
  • Assessment Date
  • Department / Unit
  • Assessment Type (Routine/Annual/Complaint)
  • Previous assessment findings reviewed?

Infection Prevention & Control

Verify infection control practices per CDC and Joint Commission standards

  • Hand hygiene compliance observed?
  • Appropriate PPE available and properly used?
  • Isolation precautions properly implemented?
  • Sharps containers available and not overfilled?
  • High-touch surfaces properly disinfected?

Patient Safety & Identification

Verify patient safety protocols and identification procedures

  • Two patient identifiers used before procedures?
  • Fall risk assessment completed?
  • Call light within patient reach?
  • Bed in lowest position with brakes locked?

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