Perioperative RN

Description

Job Summary: 

The Registered Nurse provides direct care in the Perioperative settings. The Perioperative RN is directly responsible to the Team Lead Operating Room Manager and Director of Surgical Services and indirectly to the House Supervisor. Communicates with physicians/Nurse Manager/ Team Lead/coworkers, as appropriate, about changes in the patients’ clinical condition including results of diagnostic studies and symptomatology and act as a patient advocate. The Registered Nurse is responsible for the delivery of patient care through the nursing process of assessment, planning, implementation, and evaluation. The Registered Nurse is able to respond quickly and accurately to changes in condition or response to treatment. They will need to perform general nursing duties as appropriate for level of care. Additionally, they will participate in performance improvement, quality and service excellence activities.

Responsibilities: 

• Assess the health status of assigned patients by data collection through interview, observation, inspection, auscultation, palpation, reports, and records
• Consistently completes an accurate initial assessment and reassessments on all patients requiring Perioperative care
• Adjusts frequency of assessment as appropriate for patient’s condition and reassess nursing action for effectiveness in achieving desired outcome. Accurately documents patients’ physical assessments and report abnormalities to the practitioner
• Follows guidelines for perioperative patients according to hospital policy (I.e., history and physical, consent, site mark, PACU discharge criteria, etc.)
• Monitor hemodynamic status of the patient and correctly interpret the results and communicate to the physician any abnormal results
• Assist physicians with special tests and procedures in the unit using time out for bedside procedures (Universal Protocol policy)
• Works with other departments to provide a continuum of care and co-workers to provide continuous, quality patient care, efficient patient flow and unit maintenance and organization.
• Responsible for adherence to regulations, standards and hospital or unit policies and procedures. Responsible for participation in Performance Improvement activities, unit meetings and in services.
• Ensure crash cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart check list.
• RN conducts timely and accurate assessments, initiates appropriate interventions, and communicates with surgeon and anesthesia.
• RN evaluates and anticipates changes in patient condition or surgical course. Is able to manage and/or prevent emergencies or adverse events.
• Completes all work in organized and timely manner ensuring that all orders written are carried out within the appropriate time frame and documentation is performed in “real time” in the current operating room module.
• RN adheres to the current Patient safety standards, OSHA bloodborne pathogens standards and CDC guidelines, such as proper hand washing and using two patient identifiers (MAR’S, SBAR, Hand off communication).
• RN demonstrates knowledge and environmental awareness by maintaining clean/unobstructed work area. Communication style (verbal and nonverbal) is professional, courteous, polite, and respectful to all customers.
• Makes clear and logical decisions while using resources appropriately (including self).
• Demonstrates flexibility to assignment, schedules, and staffing.
• Prepares surgical suite for the operation. Demonstrates appropriate counting of instruments, sponges, and sharps per departmental protocol/policy. Exhibits knowledge of appropriate protocol for an incorrect count.
• Ensures that all proper documents are on the chart and completed within the designated time frame prior to leaving the Holding Room. (Anesthesia consent, surgical consent, H&P, etc.). Ensures the patient is marked by the appropriate staff per policy if undergoing a procedure with a predetermined laterality.
• Monitors sterile field until released by anesthesia, reports and corrects any break in sterile technique.
• Monitors all instrumentation and equipment during use, (i.e. electrocautery instruments, electric & pneumatic drills, light sources, insufflation devices, etc.) for placement, settings and functioning, paying attention to any and all audible alarms.
• Verifies medication name, route, dosage, and expiration date with surgical tech before medication is placed on surgical field. Ensures medication on the field has been labeled appropriately by the surgical tech.
• Demonstrates appropriate handling/labeling of surgical specimens.
• Consistently and appropriately performs “time out”