RN-Operating Room PRN

Description

JOB PURPOSE & MISSION

To improve the quality of life of patients and families by coordinating patient care processes of assessment, planning, implementation and evaluation in collaboration with the patient, family, physician, and appropriate support services for the age population served, as defined in the department's scope of service.

Essential Job Functions include, but are not limited to:

1. Coordinates patient assessment through collection of patient's health data.

• Prioritizes data collection based on the patient's immediate condition or needs.
• Performs ongoing and systematic comprehensive physical and psychosocial assessments.
• Involves the patient, significant others and health care providers as appropriate.
• Performs functional, nutritional and other screenings and ensures triggers are complete.
• Identifies and coordinates the need for further assessment by discipline.
• Documents patient care assessments in the medical record.

2. Analyzes patient assessments to determine nursing diagnoses and identifies expected outcomes.

• Determines nursing diagnoses using assessment data.
• Identifies patient outcomes based on the nursing diagnoses.
• Outcomes are prioritized based on the patent's condition and needs.
• Nursing diagnoses and outcomes are documented in the medical record.
• Triage assessment on all patients and follows protocols according to established department guidelines and policies.
• Demonstrates ability to proficiently assess patients in every age group.
• Demonstrates proficiency in the management of patients receiving Procedural Sedation.

3. Coordinates an interdisciplinary plan of care that prescribes interventions to attain expected outcomes.

• Collaborates with appropriate disciplines and integrates various assessments to formulate an individualized plan of care based on patient needs and current nursing practice standards.
• Reviews and updates the plan of care as the patient condition changes, at least every day.
• Documents the plan of care in the medical record.

4. Implements the interventions identified in the plan of care.

• Collaborates with the interdisciplinary health care team to deliver direct patient care utilizing nursing practice standards, and universal blood and body fluid precautions.
• Uses interventions that are consistent with the patient's plan of care.
• Maintains patient rights.
• Ensures that patients receive the appropriate treatments and medications in a timely manner.
• Delegates patient care to other members of the health care team; ensures the delegated task(s) are within the scope of practice of the assigned individual and maintains oversight and accountability.
• Coordinates direct patient care from appropriate support services.
• Provides individualized patient education to patient and families.
• Collaborates with the interdisciplinary team to plan patient discharge.
• Documents all treatments, medications, patient/family education and ongoing assessments.

5. Evaluates the patient's progress toward attainment of outcomes.

• Performs ongoing and systematic reassessment according to department standard or more frequently based on patient condition.
• Revises nursing diagnoses, outcomes and plan of care based on reassessments.
• Involves the patient, significant others and healthcare team in the evaluation and update of plan of care as appropriate.
• Evaluates the effectiveness of treatments, medications and patient teaching.

6. Provides ongoing patient assessment and emotional support to the patient prior to the induction of surgical procedures and during the procedure.

• Demonstrates proficiency in the assessment and documentation of patient status.
• Demonstrates the ability to build rapport and communicate effectively with patients to help alleviate fear and stress.
• Confirms identity, verifies operative site, surgical procedure, NPO status, and any patient allergies.
• Identifies baseline skin condition, body mobility, sensory impairments, cardiovascular and respiratory status.
• Assesses and reports any deviations from normal in preoperative diagnostic studies.
• Assesses readiness to learn based on patient's perceptions and expectations of care.
• Identifies any spiritual, cultural and/or philosophical beliefs that may impact care provided.

7. Provides intraoperative nursing care.

• Implements aseptic technique by creating and maintaining a sterile field.
• Monitors physical status of patient, to administer drugs and solutions as prescribed.
• Monitors and controls the environment and considers all assessment information for the plan of care and demonstrates individual choice based on identified patient needs.
• Applies safety devices.
• Assesses the timing and need for a sponge, needle, and instrument count and performs required counts accurately.
• Manages culture/specimen collection, handling, and disposition according to hospital policy and procedure.
• Classifies surgical wounds per policy.
• Collaborates in fluid management.
• Provides status report to family/support person.
• Peer review ratings consistently excellent in maintaining communication.
• Patient/family compliment/complaint ratings consistently positive.

8. Sets up equipment and supplies for surgical procedures based on patient needs.

• Obtains correct supplies and accurately sets up for procedure according to department guidelines and policy.
• Follows department policy and procedure to ensure the creation and maintenance of a safe environment (surgical counts for instruments, sponges, and sharps), as well as performing equipment checks.
• Minimizes the length of invasive procedure by planning care: anticipates needs for equipment and supplies and selects in an organized and timely manner.
• Uses supplies and equipment within safe parameters by ensuring all equipment if functioning before use and removing malfunctioning equipment for use.
• Implements protective measures to prevent injury due to electrical, laser, radiation, chemical, thermal, or mechanical sources.
• Uses supplies and equipment in a judicious and cost-effective manner and documents utilization.
• Records devices implanted during the operative or invasive procedure.

9. Administers and monitors Procedural Sedation.

• Demonstrates proficiency in management of patients receiving Procedural Sedation.

10. Performs all other duties as assigned.

JOB REQUIREMENTS

Experience

Required: None

Preferred: 1 year of nursing experience

Education

Required: Completion of the AORN Periop 101 Course (offered during the orientation process; Manager's discretion to accept current CNOR status and/or previous OR experience in place of AORN Periop 101 Course)

Certifications & Licensure

Required: Current Louisiana RN licensure

Special Skills or Knowledge

Required: None

HIPAA & SAFETY REQUIREMENTS

HIPAA - Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records without limitation both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, medical records related to quality data, patient financial information, patient billing 3rd party, patient related complaints, information related to patient location, religious beliefs and/or public health records.


SAFETY - Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wastes, sharps and linen, PPE, exposure control plans, hand washing, environment of care, patient identification, administers/collects medications/blood order, transports/monitors or observes patients with infusion pumps, and monitors clinical alarms.

PERFORMANCE CRITERIA & STANDARDS

Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
• Takes initiative in living our Everyday Excellence values and vital signs.
• Takes initiative in identifying customer needs before the customer asks.
• Participates in teamwork willingly and with enthusiasm.
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
• Keeps customers informed, answers customer questions and anticipates information needs of customers.

Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
• Maintains accurate and reliable patient/organizational records.
• Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
• Upholds the ethical standards of the organization.

Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
• Initiates or redesigns to continuously improve work processes.
• Contributes ideas and suggestions to improve approaches to work processes.
• Willingly participates in organization and/or department quality initiatives.

Cost Management - Employee demonstrates effective cost management practices.

• Effectively manages time and resources.
• Makes conscious effort to effectively utilize the resources of the organization - material, human, and financial.
• Consistently looks for and uses resource saving processes.

Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
• Employee proactively reports errors, potential errors, injuries or potential injuries.
• Employee demonstrates departmental specific patient and employee safety standards at all times.
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.