(Archived) RN-Surgery

Description

POSITION SUMMARY:

The Perioperative Registered Nurse is responsible and accountable for the delivery if individualized nursing care to patients having surgical interventions. Incorporating current clinical knowledge with established nursing practice, he or she performs nursing interventions utilizing the nursing process. Assessing, planning, implementing and evaluating the nursing care delivered to assigned patients. Included within this assignment is the responsibility for ensuring effective communications between the nurse, the patient, other staff, supervision, physicians, anesthesia providers and other hospital departments.

Per the Departments Scope of Practice, this position requires providing quality care in an efficient and safe manner that demonstrates an understanding of the functional/developmental age of the individuals served. (Infant-older adults).

CORE COMPETENCIES:

Action Oriented -- Taking on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.

Collaborate -- Building partnerships and working collaboratively with others to meet shared objectives.

Customer Focus -- Building strong customer relationships and delivering customer-centric solutions.

Nimble Learning -- Actively learning through experimentation when tackling new problems, using both successes and failures as learning fodder.

Demonstrates Self-Awareness -- Using a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses.

Communicates Effectively -- Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.

Decision Quality -- Making good and timely decisions that keep the organization moving forward.

MAJOR RESPONSIBILITIES:

1. ASSESSMENT OF NURSING CARE BASED ON NURSING ASSESSMENT, THE PERIOPERATIVE EGISTERED NURSE WILL ASSIGN PATIENT CARE TO MEET INDIVIDUAL PATIENT NEEDS.

• Assesses patient on admission in a timely manner.
• Uses clinical assessment skills accurately, assessing each patient psychological, psychosocial, safety and educational needs.
• Notifies physician of any critical findings or changes following admission.
• Demonstrates that the care plan is utilized providing patient care.
• Documentation reveals that patients are assessed, changes in symptoms and reactions are evaluated, and appropriate action is taken in response to those changes.
• Accepts work assignments.

2. THE PERIOPERATIVE REGISTERED NURSE WILL INTERPRET AND COORDINATE THE IMPLEMENTATION OF PHYSICIAN'S ORDERS.

• Process physician's written and verbal orders in a timely manner.
• Is able to prioritize implementation of physician orders according to patient needs, physician request, and interdepartmental procedures.
• Demonstrates ability to carry out all assignments and procedures as ordered according to policy and procedures.
• Determines and documents all pertinent information from the patient record using the O.R. nursing record.
• THE PERIOPERATIVE REGISTERED NURSE WILL COMMUNICATE WITH THE MEDICAL STAFF AND ANCILLARY DEPARTMENTS TO PROVIDE COMPREHENSIVE AND COORDINATED PATIENT CARE SERVICES.
• Communicates patient needs to appropriate person and makes referrals to other departments when indicated.
• Notifies attending physician/surgeon and/or anesthesia provider of changes in patient's condition in a timely and appropriate manner.
• Interrelates with ancillary departments in a positive manner.
• Communicates major changes in level of care to the supervisor and/or the designated personnel.
• Documents patient response to all procedures in the O.R. nursing records.
• Thoroughly completes the O.R. nursing record in a prompt and accurate manner.
• Acts as an advocate in providing safe delivery of care at all times.
• Shows knowledge of chain of command in follow up of concerns.

4. THE PERIOPERATIVE REGISTERED NURSE SHALL ADMINISTER MEDICATIONS AS PRESCRIBED BY THE PHYSICIAN.

• Is able to knowledgeably /safely provide all medications as ordered.
• Periodically updates medication knowledge.
• Accurately documents medication administration including time, date, route, response, and signature in the O.R. nursing record.
• Documents allergies at the time of admission.
• Documents all allergic reactions to medications, blood, adhesives, etc.
• Initiates the teaching of patient, relating to medication being received.

5. THE PATIENT'S RIGHTS TO CONFIDENTIALITY WILL BE MAINTAINED BY ALL NURSING PERSONNEL.

• Handles all patient communication and documentation in a confidential manner.
• Does not release patient information/records without following hospital policy.

6. DEMONSTRATES THE ABILITY TO ACCURATELY ASSESS AND DOCUMENT PATIENT CARE ACTIVITIES.

• Uses computer system(s) appropriately.
• Documents in the medical record according to policy and procedures.
• Complies with incident reporting.

7. OBTAINS KNOWLEDGE OF AND DEMONSTRATES COMPLIANCE WITH INFECTION CONTROL POLICY AND PROCEDURES.

Practices universal precautions in all patient care.

• Appropriately handles and disposes of sharps and biological matter.
• PROVIDES FOR THE EDUCATION/TRAINING OF THE PATIENT/FAMILY
• Identifies and documents patient/family educational needs upon initial assessment and thereafter.
• Identifies barriers to learning.
• Provides teaching based on identified needs.
• Evaluates the effectiveness of instruction provided.
• Assessment and teaching incorporates cultural and ethnic actors.
• Assessment and teaching incorporates functional needs.

8. DEMONSTRATES KNOWLEDGE OF UNIT SPECIFIC POLICIES AND PROCEDURES AND THE ABILITY TO SAFELY AND COMPETENTLY USE UNIT SPECIFIC PATIENT CARE EQUIPMENT IN THE DELIVERY OF QUALITY PATIENT CARE.

• Completed Unit Specific Annual Competency Checklist.
• Obtains necessary training prior to initial equipment use.
• Assures equipment is in operating order prior to use.
• Differentiates between patient complications and equipment malfunction.
• Uses medical equipment in accordance with manufacturer's operating guidelines.

9. DEMONSTRATES KNOWLEDGE OF O.R. DOCUMENTATION AND RECORD COMPLETION.

• Accurate and timely completion of O.R. nursing records.
• Accurate and timely completion of O.R. charges.
• Accurate and timely completion of O.R. implant documentation.
• Accurate and proper handling of specimens.
• Proper handling of chain of evidence.
• Accurate and proper handling of all lab work.

10. DEMONSTRATES KNOWLEDGE OF PATIENT DISCHARGE FROM THE OPERATING ROOM.

• Accurately and completely reports patient information on surgical procedure, patient condition, pertinent medical history and/or outstanding circumstances to PACU/Day Surgery/ICU receiving personnel.
• Checks surgeon's preference card for correctness.
• Helps set up sterile back table and trays with appropriate instruments and supplies based on surgeon's preference cards.
• Assists with draping of patients.
• Anticipates needs of surgeon during cases.
• Maintains operative field in a sterile, neat and dry environment.

11. SURGERY TECHNICIAN RESPONSIBILITIES

* At completion of case

* Proper disposal of sharps

* Returns instruments and supplies to case cart

* Places linen in linen hamper

* Places trash in appropriate receptacles

* Removes gown and gloves prior to leaving the operating room

* Assists in returning equipment and unused supplies to their proper places

* Assists in the cleaning and room turn over

* Assists in maintaining a clean, neat, appropriate operating room environment

* O.R. lounges

* O.R. halls

* O.R. store rooms

* O.R. central core

12. THE PATIENT'S RIGHTS TO CONFIDENTIALITY WILL BE MAINTAINED BY ALL NURSING PERSONEL.

• Handles all patient communication and documentation in a confidential manner.
• Does not release patient information/records without following hospital policy.

13. OBTAINS KNOWLEDGE OF AND DEMONSTRATES COMPLIANCE WITH INFECTION CONTROL POLICY AND PROCEDURES.

• Practices universal precautions in all patient care
• Appropriately handles and disposes of sharps and biological matter.

14. DEMONSTRATES KNOWLEDGE OF UNIT SPECIFIC POLICIES AND PROCEDURES AND THE ABILITY TO SAFELY AND COMPETENTLY USE UNIT SPECIFIC PATIENT CARE EQUIPMENT IN THE DELIVERY OF QUALITY PATIENT CARE.

• Completed Unit Specific Annual Competency Checklist.
• Obtains necessary training prior to initial equipment use.
• Assures equipment is in operating order prior to use.
• Differentiates between patient complications and equipment malfunction.
• Uses medical equipment in accordance with manufacturer's operating guidelines.