Registered Nurse - Outpatient Surgery

Job Title

Competent Management of the Post Anesthesia Patient

Essential Job Functions

Provides total comprehensive care to patients by applying the nursing process in an organized and systematic manner according to the Center's policy in keeping with patient safety principles.

• Completes initial assessment according to policy.
• Reassesses patient condition per policy.
• Interprets and utilizes clinical data in the plan of care.
• Assesses patient for potential risk factors and intervenes to mitigate risk and prevent harm.
• Recognizes and integrates patient special needs and individualizes care.
• Adheres to infection control standards specific to patient care.
• Assumes accountability for managing the delivery of patient care. Promotes safety in all activities.
• Acts as a patient advocate and uphold patient rights.
• Assesses and responds to individual, psychosocial, and spiritual needs of the patient.
• Administers medications correctly within the restrictions and limitations defined by the New Jersey State Practice Act and the Center's policies and procedures.
• Prioritizes and organizes work assignment and adjusts priorities based on changing situations.
• Promotes and maintains a safe clean and orderly environment.
• Anticipates potential length of stay or discharge problems.

Communicates proactively to the health care team plan of care changes in patient condition, the patient progress, the discharge plan and other relevant information.

• Participates in discharge planning.
• Initiates appropriate nursing measures.
• Communicates and documents change in patients condition to all appropriate individuals.
• Documents medication use and controlled substance.
• Appropriately secures patient belongings on admission and throughout discharge.
• Maintains open collaborative dialogue with the management team.
• Effectively communicates and interacts with physicians, patients, families and the public.

• Regularly attends staff meeting, orientations, and in-services. Services on assigned committees.
• Able to assist with teaching aseptic technique, safety program, infection prevention and control, and relevant nursing topics.
• Reports promptly and accurately all significant event and problems to the manager.

Computer Systems

• Demonstrates knowledge and the skill understanding and using the Center's computer system for documentation, charging list reports and inventory. Participates in training classes as needed.
• Maintains confidentiality of all information in the medical record and assigned computer codes.

Professionalism

• Maintains current knowledge of outpatient post anesthesia / peri-operative nursing practice. Utilizes opportunities for professional growth by attending continuing education programs.
• Attends seminars and meetings relevant to PACU as requested by the Center.
• Becomes involved with research, new equipment, procedures for the Center.
• Maintains and ensures dress code and decorum. Prominently wears name identification badge at all times. Introduces self to patients and patient family members.
• Promotes good image of Center to patients, physicians, vendors and community.
• Demonstrates professional behavior by being technically competent, skilled and responsive to the Center's customers in a compassionate, efficient and effective manner.
• Maintains competencies identified by the Center including but not limited to mandatory education, equipment and skill competency review lists, BLS, ACLS, and PALS as required by patient population.
• Makes self-knowledgeable as to the contents of the Center's Policy and Procedure Manual.

Competent Management of Care of the Post Anesthesia Patient

• Recovers patients per Recovery Phase I and II policy.
• Demonstrates knowledge of anesthesia agents.
• Interprets dysrhythmias, documents, and intervenes appropriately.
• Keeps family/significant others informed of patient progress.

Demonstrates the ability and competency to respond quickly and efficiently in emergency situations.

• Demonstrates knowledge of surgical emergency preparedness, Malignant hypothermia. Cardiac Arrest, Latex Allergy.
• Maintains BCLS and code blue competency per policy.
• Recognizes changes in patient condition and responds appropriately.
• Reprioritizes and delegates other responsibilities during emergency situations.
• Functions calmly and efficiently.
• Proficient in the use of emergency equipment.
• Checks code cart and emergency equipment according to policy.
• Documents emergency intervention according to policy.

Demonstrates the knowledge of nursing responsibilities regarding anesthesia administration:

• Able to describe AGA classification code for the surgical patient.
• Identifies agents and routes used in administration of anesthesia.
• Identifies risks of all phases of anesthesia and verbalizes nursing actions.

General Job Functions:

• Participates in the preparation of the patient for surgery Include as a bullet and other job duties as required.
• Conducts patient pre-operative phone calls for complete review of medical and surgical history and provides preoperative instructions.
• Assists in obtaining pre-admission testings (PATs) and medical clearances as needed.
• Facilitates anesthesiologist's review of PATs and medical clearances.
• IV placement skills
• Follows physician orders for administration of pre-operative medications etc.
• Maintains communication with reception area and O.R.'s to assure efficient movement of patients
• Implements and insures that physician orders are performed including orders delegated to other health care professionals.
• Demonstrates understanding and interpretation of diagnostic measures such as lab tests, radiology exams and EKG.
• Ensures that the Code carts are fully equipped, defibrillators are in operational readiness and that daily checks are completed.
• Works flexible hours assuming responsibility and accountability for providing patient care.
• Maintains knowledge of asepsis, infection control and standard/universal precautions.
• Reduces chances of nosocomial infection by directing attention to infection preventing and control and environmental safety practices.
• Conducts patient postoperative follow up calls and completes all documentations within the defined timeframe.
• Performs preoperative assessments and reviews in a timely manner
• Demonstrates the skill to assume charge nurse responsibilities in the absence of the nurse manager as assigned.
• Maintains confidentiality of all information and the medical record and assigned computer codes.
• Actively communicates and supports the Organization's Mission, Values, Ethics, Philosophy, Objectives, and Policies and Procedures.
• Demonstrates an understanding of how the success of the surgery center is linked to the success or failure of the customer process.
• Demonstrates safe habits in the work place with a concern for the safety of patients, families, and staff.
• Maintains current knowledge of the Center's Emergency Preparedness protocols and procedures.
• Applies OSHA standards.
• Provides a summary of post-op instructions to patients prior to discharge from the center.
• Identifies strategies to increase competency of team members

Education, Certification, Computer and Training Requirements:

• Associates degree required. Bachelor's degree preferred.
• New Jersey State Nursing License required. BLS and ACLS required. PALS preferred.
• 2-4 years experience required. 5+ years preferred.
• Ability to communicate in English, both orally and in writing required.
• Strong interpersonal and organizational skills required.
• Ability to perform diverse work assignments with time limitations with a high degree of accuracy required.
• Ability to use problem solving, critical thinking and priority setting skills required.
• Must be able maintain annual competencies.
• Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail) preferred.
• Experience with Standard Office Technology