REGISTERED NURSE - Pre-Op/PACU (PRN)

Pre-Op/Pacu Registered Nurse

The Pre-Op/PACU Registered Nurse is responsible for assessing, planning, directing, evaluating and delivering safe, appropriate care within the scope of their practice to patients in the Perioperative setting. Demonstrates ability to work in Pre-Op and PACU patient care settings and must be available to take on-call as scheduled.

Essential Functions

Standard I. Assessment: The Registered Nurse Collects Health Data

Rationale: GRMC nursing practice is characterized by a high degree of autonomy and requires a broad-base of subjective and objective data.

• The priority of data collection is determined by the patient's immediate condition or needs.
• Pertinent data is collected by using appropriate assessment techniques.
• Data collection involves the patient, significant others, health care providers, and other GRMC personnel, when appropriate.
• The data collection process is systematic and ongoing.
• Relevant data is documented in a retrievable form.

Standard II. Diagnosis: The Registered Nurse analyzes the assessment data in determining diagnoses.

Rationale: The Registered Nurse at GRMC uses independent judgment and available data to formulate a nursing plan of care.

• Plans of care are derived from assessment data.
• Plans of care are validated with the patient, significant others, health care providers, and records maintained by other departments, when needed.
• Plans of care are documented in a manner that facilitates the determination of expected outcomes and care plan.

Standard III. Outcome Identification: The Registered Nurse identifies expected outcomes individualized to the patient.

Rationale: The Registered Nurse at GRMC identifies outcomes based on unique factors that affect the Registered Nurse's ability to provide services.

• Outcomes are derived from the diagnoses.
• Outcomes are documented as measurable goals.
• Outcomes are mutually formulated with the patient and health care providers, when possible.
• Outcomes are realistic in relation to the patient's present and potential capabilities.
• Outcomes are attainable in relation to resources available to the patient.
• Outcomes include a time estimate for attainment.
• Outcomes provide direction for continuity of care.

Standard IV. Planning: The Registered Nurse develops a care plan that prescribes interventions to attain expected outcomes.

Rationale: Effective planning is essential for appropriate interventions.

• The plan is individualized to the patient's condition or needs.
• The plan is developed with the patient, significant others, health care providers, and other GRMC personnel, when appropriate.
• The plan reflects current nursing practice.
• The plan is documented.
• The plan provides for continuity of care from the time of entry into the healthcare system, through transfers to other departments, to final discharge from GRMC, when appropriate.
• The plan provides for discharge follow-up based on the patient's need for health care, when appropriate.

Standard V. Implementation: The Registered Nurse implements the interventions identified in the care plan.

Rationale: The Registered Nurse is the most appropriate health care provider at GRMC for ensuring that actions are taken to meet the physical, mental, and health education needs of the patient.

• Interventions are consistent with the established care plan.
• Interventions are implemented in a safe, appropriate, and timely manner.
• Interventions are documented.

Standard VI. Evaluation: The Registered Nurse evaluates the patient's progress toward attainment of outcomes.

Rationale: The Registered Nurse at GRMC uses the nursing process to evaluate the outcome of nursing actions, interventions, and patient education. The Registered Nurse may alter the care plan, expand the database, introduce new interventions, and develop patient education activities.

• Evaluation is systematic and ongoing.
• The patient's responses to interventions are documented.
• The effectiveness of interventions is evaluated in relation to outcomes.
• Ongoing assessment data are used to revise diagnoses, outcomes, and the care plan, as needed.
• Revisions in diagnoses, outcomes, and the care plan are documented.
• The patient, significant others, health care providers, and other GRMC personnel are involved in the evaluation process, when appropriate.

Standard VII. Quality of Care: The Registered Nurse systematically evaluates the quality and effectiveness of nursing practice.

Rationale: The Registered Nurse at GRMC ensures that quality nursing care meets measurable community standards.

• The Registered Nurse participates in quality-of-care activities as appropriate to the individual's position, education, and practice environment. Such activities may include the following:
• Identifying aspects of care important for quality monitoring.
• Identifying indicators used to monitor the quality and effectiveness of nursing care.
• Collecting data to monitor the quality and effectiveness of nursing care, as appropriate.
• Analyzing quality data to identify opportunities for improving care, as appropriate.
• Formulating recommendations to improve nursing practice or patient outcomes.
• Implementing activities to enhance the quality of nursing practice.
• Participating in the work of interdisciplinary teams that evaluate clinical practice or health services.
• Developing policies and procedures to improve the quality of care.
• The Registered Nurse uses the results of quality-of-care activities to initiate changes in practice, as appropriate.
• The Registered Nurse uses the results of quality-of-care activities to initiate changes throughout the health care delivery system, as appropriate.

Standard VIII. Performance Appraisal: The Registered Nurse evaluates his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations.

Rationale: The Registered Nurse at GRMC balances professional performance with the maintenance of safety and quality patient outcomes.

• The Registered Nurse regularly engages in performance appraisal, identifying areas of strength as well as areas for professional and practice development.
• The Registered Nurse seeks constructive feedback regarding his/her own practice.
• The Registered Nurse takes action to achieve goals identified during performance appraisal.
• The Registered Nurse participates in peer review as appropriate.

Standard IX. Education: The Registered Nurse acquires and maintains current knowledge in nursing practice.

Rationale: The diverse health care needs at GRMC and the need for nursing autonomy require the Registered Nurse to engage in ongoing education.

• The Registered Nurse participates in ongoing educational activities related to clinical knowledge and professional issues.
• The Registered Nurse seeks experiences to maintain clinical skills.
• The Registered Nurse seeks knowledge and skills appropriate to the practice setting.

Standard X. Collegiality: The Registered Nurse contributes to the professional development of peers, colleagues, and others.

Rationale: The Registered Nurse at GRMC has the responsibility and opportunity to positively influence peers, colleagues, and others regarding health care issues, education, and practice.

• The Registered Nurse shares knowledge, skills, and information with peers, colleagues (including other GRMC personnel), and others.
• The Registered Nurse provides peers with constructive feedback regarding their practice.
• The Registered Nurse contributes to an environment that is conducive to the clinical education of nursing students, as appropriate

Standard XI. Ethics: The Registered Nurse's decisions and actions on behalf of patients are determined in an ethical manner.

Rationale: The Registered Nurse at GRMC has an ethical commitment to the patient and the nursing profession that must not be compromised.

• The Registered Nurse's practice is guided by The Code for Registered Nurses and related ANA position statements, such as the Patient Bill of Rights and JCAHO standards, Standards for nursing care for the patient care unit and Nurse Practice Act.
• The Registered Nurse maintains patient confidentiality.
• The Registered Nurse acts as a patient advocate.
• The Registered Nurse delivers care in a non judgmental and nondiscriminatory manner that is sensitive to patient diversity.
• The Registered Nurse delivers care in a manner that preserves and protects patient autonomy, dignity, and rights.
• The Registered Nurse seeks available resources to