PRE-OP/PACU Registered Nurse

Position Summary:

Centurion Surgery Center is seeking an experienced and patient-focused PRE-OP/PACU Registered Nurse to join our ambulatory surgery team. This dual-role position provides comprehensive nursing care by supporting patients throughout the surgical experience—from pre-op through post-anesthesia recovery.

The PRE-OP/PACU Registered Nurse serves as a circulating nurse during surgical procedures and provides skilled post-anesthesia care, ensuring patient safety, clinical excellence, and exceptional patient outcomes. The ideal candidate is a collaborative, adaptable professional with strong perioperative nursing skills and a commitment to delivering high-quality outpatient surgical care.

Essential Responsibilities:

• PRE-OP Nurse.

Patient Identification & Safety:

• Verify patient identity using two approved identifiers.
• Confirm scheduled procedure, operative site, surgeon, and laterality.
• Verify allergies and ensure allergy alerts are appropriately documented.
• Apply and verify patient identification and allergy bands as applicable.
• Confirm required fall-risk and other safety assessments.

Preoperative Documentation:

• Verify a current History & Physical (H&P) is present and meets facility requirements.
• Ensure the required day-of-surgery H&P update/reassessment is completed by the appropriate provider.
• Confirm surgical/procedure and anesthesia consents are complete, signed and witnessed as required.
• Review preoperative orders and verify completion.
• Complete the nursing preoperative assessment and required documentation in the EMR.
• Identify incomplete documentation and elevate deficiencies before the patient proceeds to the OR/procedure room.

Clinical Assessment:

• Obtain and document baseline vital signs, pain level, height, and weight.
• Complete medication reconciliation, including verification of the patient's last doses.
• Review medical history, surgical history, and relevant anesthesia history.
• Assess for changes in the patient's condition since the preoperative evaluation.
• Verify NPO status and document the patient's last oral intake.
• Screen for recent illness, infection, fever, wounds, or other conditions that could affect the procedure.
• Complete pregnancy testing when clinically indicated and required by facility policy.

Preoperative Preparation:

• Ensure the patient is appropriately changed and prepared for the procedure.
• Secure personal belongings according to facility policy.
• Remove jewelry, dentures, contacts, hearing aids, or other items when appropriate.
• Initiate IV access and administer IV fluids according to orders.
• Administer ordered preoperative medications and antibiotics within the appropriate timeframe.
• Complete skin preparation, clipping, or other procedure-specific preparation when ordered.
• Apply SCDs or other prophylactic measures when indicated.

Surgical & Anesthesia Readiness:

• Confirm the anesthesia provider has completed the required pre-anesthesia assessment.
• Verify the surgeon has completed required documentation and site marking when applicable.
• Confirm implants, special equipment, medications, blood products, or other patient-specific needs are available when applicable.
• Communicate relevant clinical concerns to anesthesia, the surgeon, and the OR/procedure team before transport.
• Ensure all required preoperative checklist elements are complete before releasing the patient to the operative team.

Patient Education & Communication:

• Explain the preoperative process and what the patient can expect before and immediately after the procedure.
• Reinforce postoperative instructions as appropriate.
• Address patient questions and notify the provider when questions require clinical clarification.
• Verify the responsible adult/driver and postoperative transportation arrangements when required.
• Maintain patient privacy, dignity, and confidentiality throughout the preoperative process.

Handoff & Transfer to OR:

• Complete a thorough handoff to the OR/procedure-room nurse using the facility's standardized communication process.
• Communicate allergies, medications, abnormal findings, relevant medical history, IV status, antibiotics, implants, and special precautions.
• Verify the chart and required documentation are complete before transport.
• Ensure the patient is transported safely and appropriately to the OR/procedure room.

Pre-Op Nurse Accountability:

The Pre-Op RN serves as a final clinical safety checkpoint before the patient enters the operative environment. Any missing documentation, abnormal findings, change in condition, consent discrepancy, incorrect procedure/site, or other unresolved safety concern should be escalated and resolved before the patient proceeds.

PACU Nurse:

Immediate Post-Anesthesia Assessment:

• Receive a complete handoff from the anesthesia provider and OR/procedure-room nurse.
• Verify patient identity, procedure performed, operative site, allergies, and relevant intraoperative events.
• Assess and continuously monitor airway, breathing, circulation, neurological status, and level of consciousness.
• Obtain and document postoperative vital signs according to facility policy.
• Maintain appropriate oxygenation and administer supplemental oxygen as ordered or clinically indicated.
• Assess for airway obstruction, respiratory depression, apnea, or other anesthesia-related complications.

Postoperative Monitoring & Patient Safety:

• Maintain continuous monitoring appropriate to the patient's condition and type of anesthesia.
• Monitor heart rate/rhythm, blood pressure, respiratory rate, oxygen saturation, temperature, and pain level as required.
• Assess surgical/procedure sites, dressings, drains, and devices for bleeding or other abnormalities.
• Monitor IV sites, fluids, and medications.
• Maintain fall precautions and appropriate side-rail/stretcher safety.
• Identify changes in patient condition promptly and initiate appropriate interventions.
• Immediately elevate significant changes or complications to the anesthesia provider and/or surgeon.

Pain & Symptom Management:

• Assess and document pain using the facility-approved pain scale.
• Administer postoperative analgesics according to provider orders.
• Reassess and document the patient's response following pain interventions.
• Assess for postoperative nausea and vomiting and administer medications as ordered.
• Utilize non-pharmacologic comfort measures when appropriate.
• Monitor for adverse medication effects, including excessive sedation and respiratory depression.

Postoperative Clinical Care:

• Assess circulation, sensation, and movement when applicable to the procedure.
• Monitor for postoperative bleeding, hematoma, swelling, or other procedure-specific complications.
• Monitor urinary status when clinically indicated.
• Assist with oral fluids and activity progression when appropriate.
• Maintain and discontinue IV therapy according to orders and patient readiness.
• Provide procedure-specific postoperative care according to surgeon and anesthesia orders.

Emergency Response & Complication Management:

• Recognize and respond appropriately to postoperative emergencies, including respiratory distress, hemodynamic instability, allergic reactions, excessive bleeding, altered mental status, uncontrolled pain, or other acute changes.
• Initiate emergency protocols and notify appropriate providers promptly.
• Maintain competency with emergency equipment, medications, airway management supplies, and resuscitation procedures.
• Participate in emergency response and transfer to a higher level of care when necessary.

Discharge Readiness:

• Assess the patient against the facility's approved PACU discharge criteria/scoring system.
• Verify the patient has achieved an appropriate level of consciousness, respiratory stability, hemodynamic stability, pain control, and nausea/vomiting control before discharge.
• Confirm surgical/procedure-site status is appropriate for discharge.
• Ensure discharge criteria are documented and required provider discharge orders are present.
• Notify anesthesia and/or the surgeon when the patient does not meet expected discharge criteria.

Patient & Responsible Adult Education:

• Review written and verbal postoperative/discharge instructions with the patient and responsible adult.
• Provide education regarding medications, pain management, wound/dressing care, activity restrictions, diet, and procedure-specific precautions.
• Review signs and symptoms that require contacting the surgeon or seeking emergency medical attention.
• Confirm the patient/responsible adult understands the instructions and has an opportunity to ask questions.
• Provide appropriate contact information for postoperative concerns.
• Verify a responsible adult is available to accompany the patient when required by facility policy.

Discharge & Documentation:

• Complete all required PACU documentation accurately and in real time.
• Document assessments, vital signs, medications, interventions, patient responses, pain reassessments, and discharge condition.
• Document postoperative education and confirmation of instructions provided.
• Verify all required prescriptions, instructions, belongings, and patient-specific materials are provided before discharge.
• Safely assist the patient with dressing, ambulation, transfer, and discharge as appropriate.
• Document the responsible adult receiving the patient and the patient's method of departure when required.

PACU Nurse Accountability:

The PACU RN is responsible for continuous assessment and safe recovery of the patient following anesthesia or sedation. The patient should not be discharged until established discharge criteria are met and any unresolved clinical concerns have been appropriately evaluated and addressed.

Post-Anesthesia Care Unit (PACU):

• Receive and assess patients following surgical procedures.
• Monitor airway, respiratory, cardiovascular, and neurological status during the recovery process.
• Assess and manage pain, nausea, and other postoperative needs.
• Administer medications and treatments as prescribed.
• Identify and respond appropriately to changes in patient condition.
• Educate patients and caregivers regarding postoperative care, discharge instructions, medications, activity restrictions, and follow-up care.
• Ensure patients meet discharge criteria before release.

General Responsibilities:

• Accurately document all perioperative and postoperative care within the electronic medical record (EMR).
• Collaborate with surgeons, anesthesia providers, surgical technologists, and interdisciplinary team members to deliver safe, efficient patient care.
• Maintain compliance with AAAHC, CMS, OSHA, HIPAA, infection prevention standards, and Company policies.
• Participate in quality improvement initiatives and support a culture of patient safety and continuous improvement.

Qualifications:

Required:

• Current, unrestricted Registered Nurse (RN) license.
• Current BLS and ACLS certifications.
• Minimum of two (2) years of preoperative, PACU, or critical care experience preferred.
• Strong assessment, critical thinking, and clinical decision-making skills.
• Knowledge of perioperative nursing standards, sterile technique, and post-anesthesia recovery care.
• Proficiency with electronic medical records (EMR).

Preferred:

• Previous Ambulatory Surgery Center (ASC) experience.
• Experience with outpatient orthopedic, spine, pain management, or interventional procedures.
• Experience with moderate sedation recovery and fluoroscopic procedures.