Pre & Post Op Nurse

Perioperative Nurse

Responsible for the delivery of safe, effective, and quality patient-family centered care in the pre-operative and post-operative services for all patient populations.

Promotes the mission, vision, and values of the organization.

Assesses patients at intervals as stated in policies and procedures.

Develops an individualized patient plan of care.

Implements the plan of care for Peri-Operative:

• Properly identifying the patient, verifying the patient's knowledge of the procedure to be performed including location and laterality;
• Determining whether a responsible adult is available to take the patient home following the procedure, and to assist the patient with home care;
• Reviewing the patient's medical record and current medication list and conducting a full assessment to establish baseline parameters for the patient;
• Reporting any concerns related to patient status to the surgeon and anesthesia provider;
• Verifying that the patient is marked appropriately to ensure that the procedure is performed on the correct site, side, and level;
• Reviewing the surgeon's orders and ensuring that all preoperative testing has been completed;
• Administering preoperative medications safely and correctly;
• Verifying the last time that the patient ate or drank anything and current medications being taken, and ensuring that all necessary preparations have been completed by the patient;
• Ensuring that informed consent is obtained;
• Actively involving the patient or designated support person in decisions affecting his or her perioperative plan of care and the rehabilitation process;
• Assessing the knowledge level of the patient or designated support person;
• Providing education regarding the procedure, expected psychosocial response, nutritional management, medication management, pain management, wound management, and other expected responses to the operative or invasive procedure;
• Ensuring patient complete preparedness for the procedure prior to transfer of care to the intraoperative nurse and transport to the operating room;
• Communicating all aspects of the patient's current status, including care, treatments, current condition, and recent or expected changes to the intraoperative nurse.
• Protecting the patient's rights, dignity, and privacy.
• Providing culturally and age-appropriate, ethical care within legal standards of practice; and
• Providing consistent and comparable care regardless of the setting.

Implements the plan of care for Post-Operative:

• Daily checking of equipment. Check crash cart for completeness.
• Obtain necessary equipment for patient monitoring and additional supplies based on the patient's acuity and surgical procedure. Ensure that the monitoring equipment is functioning properly.
• Obtain warm blankets and other supplies for patient comfort and safety.
• Verify the correct patient using two identifiers.
• Assess the patient's respiratory status. Supply oxygen to the patient if needed.
• Airway patency, breath sounds, and type of artificial airway placed
• Oxygen flow rate and delivery method (e.g., mask, nasal cannula)
• Oxygen saturation, and capnography (end-tidal carbon dioxide [ETCO2]), if available or indicated
• Assess the patient's vital signs.
• Cardiac Monitor
• Pulse oximetry
• Blood pressure
• Body temperature
• Pain score
• Blood glucose level if indicated
• Elevate the head of the bed if appropriate for the procedure performed.
• Obtain a concurrent transfer report from the anesthesia provider and circulating nurse. Minimize or eliminate interruptions and distractions during the transfer report and ensure that the report includes the following information:
• Verification of the correct patient
• The surgeon's name and type of procedure
• Type of anesthetic and timing of reversal agents, if applicable, and unplanned responses, including interventions provided and the outcome of those interventions
• Pain and comfort management interventions and plan
• Allergies
• Medications administered preoperatively and intraoperatively, including antibiotics and antiemetics
• Relevant health history, such as comorbidities, level of severity and management, advance directives, precautions (e.g., respiratory), and sensory aids
• Intake and output
• Estimated blood loss during the procedure
• Surgical site information (dressings, tubes, drains, packing)
• Surgical complications, as applicable
• Anesthesia provider and surgeon orders
• Patient, family, and/or significant other information
• Trace tubing or catheter from the patient to point of origin (1) before connecting or reconnecting any device or infusion, (2) at any transition (e.g., new setting), and (3) as part of the hand-off process.
• Continue to assess the patient's stability and intervene if necessary. Assess the patient at regular intervals per the organization's practice or more frequently as indicated by the patient's condition. Perform reassessments until the patient is stable.
• Create a culture of safety for the patient. Report adverse and serious safety events.
• Protecting the patient's rights, dignity, and privacy;
• Providing culturally and age-appropriate, ethical care within legal standards of practice; and
• Providing consistent and comparable care regardless of the setting.
• Assess the patient's discharge criteria by utilizing the Modified Aldrete Scoring system.
• Discuss the discharge instructions with the Patient, family, and/or significant other and make sure they are provided with a printed copy for their reference.
• Prepare the patient for discharge/transfer and make sure that a responsible person is with the patient for the discharge process.
• Evaluates the patient's progress toward attaining outcomes.
• Transfers care as appropriate.
• Delegates tasks as appropriate according to the state Nurse Practice Act and job descriptions.
• Documents nursing care accurately, completely, and legibly.
• Collaborates effectively with other disciplines as appropriate.
• Participates in quality review and performance improvement projects.
• Uses problem-solving and conflict resolution skills to foster effective work relationships with team members.
• Maintains required competencies.
• Pursues professional growth and participates in a professional organization.
• Acts as a patient advocate and maintains privacy and confidentiality of all appropriate information.