PAT Registered Nurse

Description

Job Summary:  

The Registered Nurse provides direct care in the PACU/HOLDING/PAT/OPS settings. The staff RN is accountable directly to the PACU Team Leader and the Nurse Manager, 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. 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.  

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) 
• Administer medications using Rights of Medication Administration. Initiates, titrates and safely monitors all IV medications and blood components. Consistently uses two patient identifiers when drawing labs, medicating, or performing any procedure on a patient and administering blood components 
• Adheres to procedures for the disposal of waste—household waste and biohazard waste as well as the proper disposal of sharps 
• Follow medication reconciliation policy 
• Adequately assess and reassess pain, after giving pain medication and upon discharge. Accurately documents information on the patient record 
• Document concise, timely and complete nursing care in EMR, using only appropriate abbreviations. 
• Reviews and implements new orders and keeps physician informed of changes in patients’ clinical status. Consistently follows policy regarding telephone/verbal orders and the using of “read back”.  Accurately records and/or processes orders in a timely manner 
• Initiates and updates patients plan of care 
• Initiate discharge and patient/family education planning with proper documentation in the EMR 
• Gives thorough, detailed and efficient change of shift report using the SBAR format to ensure consistency in the plan of care 
• Demonstrates empathy and respect for patients by explaining all procedures and care while providing privacy and allowing patients to express emotional needs. Understands, respects, and displays sensitivity to culture, age and persons with disabilities 
• Ensures crash cart and defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist 
• Knowledge of National Patient Safety Goals. Comply with federal, state, and local laws that govern business practices. Comply with all Department of Health Services requirements for CMS and The Joint Commision standards that apply to the position 
• Is in compliance with information contained in the Infection Control policies (OSHA Bloodborne pathogen standards, CDC Guidelines), and demonstrates appropriate use of personal protective equipment (I.e. gloves, gowns, masks, goggles) and hand washing techniques 
• Uses proper body mechanics at all times.  Seeks assistance when necessary to move heavy objects or to transport/transfer a heavy patient 
• Complies with all hospital safety and injury prevention policies and regulations (hospital safety policies and procedures) 
• Recognize signs of child and elder abuse and report appropriately to Social Services and/or Child/Adult Protective Services 
• Consistently ensure that all clinical alarms are set with the appropriate parameters for the patient and are audible at all times 
• Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them 
• Recognize and respond to priorities, accept new ideas, have insight into problems, and the ability to develop workable alternatives 
• Uses time effectively and constructively. Does not abuse supp