Registered Nurse

Description

The purpose of this position is to manage individualized, goal-directed nursing care through use of the nursing process and the principles of primary nursing in accordance with departmental and company policies and procedures. This position will also assess patient health problems and needs, develop and implement nursing care plans, and maintain medical records and administer nursing care to ill, injured, convalescent, or disabled patients. Working across the pre-operative, intra-operative, and post-anesthesia care phases, the Registered Nurse plays a critical role in ensuring safe surgical outcomes, patient readiness, and a smooth continuum of perioperative care. While this role is intended to serve at a particular location, it is within the company’s right to assign staff to other locations when there are staffing shortages.

Assesses patient status on admission to the pre-op area, the operating room and/or the post-op area, and on a continuing basis.

· Provides safe, quality care to patients by utilizing the nursing process and nursing diagnosis in a timely manner. Coordinates nursing interventions to achieve expected patient outcomes and ensure readiness for discharge.

· Practices in compliance with evidence-based standards (i.e. AORN, ASPAN, CDC, OSHA, CMS) and other applicable accreditation standards.

· Consults and coordinates with healthcare team members to assess, plan, implement, and evaluate patient care plans.

· Operates specialized clinical and surgical equipment safely and proficiently, reporting any malfunctions or unsafe conditions to the appropriate team member and removing equipment from service as indicated.

· Observes, assesses, and documents patient status, needs, and responses to care on an ongoing basis.

· Consistently follows the Nursing Plan of Care for the patient.

· Actively participates in time-outs by confirming patient identification, correct procedure, side/site, and any other required safety checks.

· Maintains patient safety and dignity throughout all phases of care.

· Effectively communicates with all providers and staff members.

· Accurately monitors, records, and reports patients’ medical information and vital signs.

· Provides pre- and post-operative education to patients and families specific to the planned procedure, recovery expectations, activity restrictions, medication management, and discharge instructions, ensuring comprehension and addressing questions prior to discharge.

· Assists in pre- and post-operative care by preparing the patient for the procedure, correctly identifying the patient, procedure to be performed, and procedure site.

· Updates and confirms medication and allergy profiles.

· Completes appropriate clinical lab work (glucose reading, INR, pregnancy test, as indicated).

· Completes and documents vital signs, pain status, and HPI.

· Reinforces pre- and post-operative teaching.

· Reviews consent and orders for accuracy.

· Uses the five rights when administering medication.

· Documents modified Aldrete score and discharge readiness using approved scoring systems.

· Assists in discharge of patient with appropriate paperwork.

· Performs chart review on a daily basis to ensure completeness and accuracy of patient documentation.

· Conducts pre- and post-operative phone calls with patients and communicates any concerns to the appropriate provider or team member.

· Maintains competencies required to function in the RN role within the specific assigned area.

· Actively applies and enforces principles of asepsis, sterile technique, infection prevention, and universal precautions throughout all phases of patient care.

· Monitors patients receiving moderate/conscious sedation, including assessment of airway status, level of consciousness, hemodynamic stability, oxygenation, and pain response, in accordance with applicable standards and the organization’s sedation policy.

· Collects, labels, and ensures proper chain of custody for surgical specimens in accordance with facility policy and laboratory requirements.

· Responds promptly and competently to clinical emergencies within the ASC, including but not limited to anaphylaxis, malignant hyperthermia, respiratory distress, and cardiac arrest, in accordance with established emergency protocols and ACLS guidelines.

· Verifies surgeon preference card accuracy prior to each case, confirms availability of required instrumentation and implants, and communicates any discrepancies or missing items to the appropriate team member in advance of the procedure.

· Driving may be required when working in clinic roles.

· Demonstrates competency in and routinely performs duties in at least one of the following specialized surgical areas:

· Surgical (Circulator): Applies and monito