Registered Nurse PreOP PACU

Position Responsibilities

PRE-OP/PACU Specifics

Modifies the interview techniques to adequately assess the newborn, infant, child, adolescent, adult, and geriatric patient by identifying the physical, psychosocial, and educational needs common to these age group observing parent/child interactions, child's general appearance, encouraging and adolescent/adult patient related to increased stressors, altered perceptions regarding dependency vs. independence and anxiety related to potential changes resulting from illness. _____newborn _____infant _____children ______ adolescent _____adult _____geriatric

Assesses potential for compromised skin integrity, nutritional deficiencies, functional deficiencies, pain management history, and changes in elimination patterns within the new born, infant, child, adolescent, adult and geriatric patient(s) making environmental changes or referrals as necessary.

Completes physical assessment including discharge planning and care plan within departmental guidelines/times frames. Assesses patient readiness to learn and provides ongoing patient education, documenting all interventions and outcomes using approved hospital forms. Involves patient/family in developing plan of care and accomplishing outcome goals. Consistently and actively participates within interdisciplinary team.

Reviews and updates head to toe assessment as unit policy dictates and/or as patient condition indicates.

Prepares the pre-op holding area/PACU appropriately to receive a new admission/transfer, greeting the patient and family (if applicable), upon arrival and placing the appropriate monitoring equipment, applicable to specialty area and/or patient condition, within the standards of practice for the specialty area.

Evaluates, assesses and documents patient's hemodynamic response to therapeutic intervention by accurate cardiovascular monitoring. Reports abnormal rhythm to physician.

Evaluates, assesses and documents patient's cardio-respiratory status including O2 saturation, and cardiac rhythm interpretation and reports abnormal values to physician.

Competent in section and discontinuation of catheters, tubes and/or drains (or assisting with the insertion).

Competent in the care of catheters, tubes and drains as per hospital guidelines/policies.

Administers medications per physicians orders wit zero errors, respecting patient rights and performing assessment, reassessment, assessing effectiveness and documentation according to hospital policy.

Accurately documents supply usage on preference lists and recommends revisions/updates as needed.

Delegates responsibilities to assigned care givers based upon patient needs and staff competencies.

Responds to Code Blue, in department, and initiates CPR. Demonstrates a calm, professional manner during a crisis or emergency situation at all times within the patient care environment.

Provides all patient care respectfully demonstrating/reviewing patient rights utilizing the nursing process and documenting in the acceptable hospital charting format.

Maintains patient care equipment, alerts chain of command about necessary repairs, "red tags" broken equipment, and initiates calls to engineering/biomedical engineering as needed

Initiates and maintains intravenous therapy as per hospital and infection control guidelines. Safety administers blood and blood products.

Attempts all alternative measures to avoid patient restraints; when in use, provides ongoing observation, interventions and documentation as per hospital policy.

Implements all new physician orders within two hours of initiation for routing and within 30 minutes or less for stats.

Adheres to and complies with all regulatory standards globally to profession and specific to unit, consistent with their scope of practice.

Assessment

Performs initial vital signs and admission history to include introduction to patient and family. Assessment of chief complaint and notification of physician within 15 minutes of arrival to procedure area.

Obtains and documents a complete nursing admission assessment, including physiological and psychological factors to develop a plan of care within eight hours of admission.

Performs and documents an accurate systems assessment at the beginning of each procedure.

Responds to diagnostic data and initiates appropriate action or intervention.

Assesses patient education needs on admission.

Assesses psychosocial needs specific to patient's age, growth, and development.

Planning

Initiates a plan of care within eight hours of admission.

Establishes priorities for patient care based on patient needs as evidenced by completion of assigned duties within shift.

Implementation

Verbalizes understanding of patient diagnosis and plan of care.

Safely and correctly initiates and documents nursing interventions in emergency situations.

Performs 24-hour chart check at the beginning of each procedure.

Prepares intravenous solutions using aseptic technique.

Administers, observes, and documents intravenous therapy according to hospital policy.

Administers medications within 30 minutes of scheduled time. Observes and documents effectiveness. Recognizes and reports adverse reactions immediately.

Provides individualized instructions each procedure to patient/significant other regarding the plan of care.

Demonstrates safe and correct use of unit specific equipment.

Ensures that each patient's general hygiene needs are met.

Performs pre-operative and post operative care and instruction for each assigned surgical patient during shift.

Adheres to standard precautions including hand hygiene guidelines at all times.

Documents specific patient valuables on designated form when received and immediately arranges for appropriate storage.

Performs dressing changes using aseptic technique.

Collects and labels specimens per policy when ordered by physician.

Performs bedside glucose monitoring according to policy.

Reports all abnormal findings immediately to physician.

Initiates wound and skin protocol upon identification of risk.

Performs ostomy care to include irrigation, appliance usage, and reinforcement of teaching.

Inserts intermittent or indwelling urinary catheter using aseptic technique.

Administers oxygen therapy according to physician order.

Transfers patients in/out of the unit in an efficient manner, by obtaining a complete and correct set of physician's transfer orders. Completes and documents transfer summary. Ensures appropriate completed referral forms accompany intra-facility transfers, and giving/receiving of report.

Demonstrates safe and correct use of restraints.

Evaluation

Documents/reports patient responses or outcomes resulting from: nursing interventions, treatments/procedures, interpersonal interactions, and patient/family education.

Evaluates and documents patient's progress towards established goals/objectives.

Updates/revises patient care problem list and individualized patient care standards based on patient/family responses, progress towards goals, and/or change in medical status.

Professional and Staff Development

Obtains 100% mandatory hospital and unit specific in-services annually, prior to evaluation date.

Plans, presents, and documents unit in-service as required by level.

Documents competency in clinical skills annually.

Attends staff meetings as required.

Uses established lines of communication for resolution of problems and interpersonal conflict.

Leadership

Presents a minimum of 2 in-services, 2 patient conferences.

Attends 75% staff meetings.

Serves as a preceptor/clinical resource.

Functions as a Charge Nurse and assists in applying financial management principles - e.g. staffing, scheduling, decreasing LOS, Triaging, supply management.

Chair or Co Chair unit based PI committee meetings.

Participates in clinical competency compliance of staff.

Qualifications

License/Registration/Certification

Current Licensure in the State of Florida. BLS and ACLS required. CPAN preferred.

Education

Graduated from an accredited school of Nursing. BSN preferred.

Experience

Level III: Min 2 year RN. Min 2 years in area of specialty preferred.

Mount Sinai Medical Center