Perioperative RN

Perioperative Staff Nurse

Full Time - Day Shift

The Perioperative Staff Nurse is responsible for direct and indirect nursing care and the directing of other nursing care providers.

Education:

Graduate of an approved diploma, associate or bachelor nursing program.

Experience:

BLS certification to be obtained within first month of employment.

Current Georgia License as a Registered Nurse.

The Perioperative Staff Nurse provides care to patients of the indicated ages:

Infants (Newborn to One Year) Adolescent (Ten to 18 Years)

Toddlers (Two to Four Years) Adult (19 to 69 Years)

Child (Five to Nine Years) Geriatric (70 and Above)

Duties and Responsibilities:

• Utilizes cephalo-caudal approach to physical assessment.
• Develops assessments to include: Nutritional Screening, Fall/Risk, Functional, Pain, Skin Integrity, Cultural/Spiritual, Psycho-social, DVT Risk, Suicide, and Pneumococcal/Flu.
• Identifies complex problems in the assessment and initiates the plan of care utilizing nursing problems when appropriate.
• Notifies physician and charge nurse of any pertinent assessment findings.
• Reviews and updates plan of care to reflect changes in patient status.
• Notifies surgeon, anesthesia and charge nurse of any pertinent physical or emotional findings.
• Reassesses patient morning of surgery utilizing cepho-caudal approach.
• Demonstrates competency in clinical skills and knowledge pertinent to the practice and education of the Registered Nurse.
• Implements the physician's orders promptly and appropriately with understanding of the purpose of each as it relates to the patient's plan of care.
• Monitors the patient's condition and maintains accurate documentation (vital signs, alertness, mobility, condition of wound or operative site, etc.).
• Reports abnormalities or instability of the patient's condition in a timely manner to appropriate persons (charge nurse, physician, director, administrative supervisor, CARE Team).
• Ensures readiness of chart for procedure or surgery (pre-op checklist, lab, EKG, x-ray and documentation in the nurse's notes).
• Responsible with assistance of patient and/or family for surgery site marking by provider if applicable.
• Coordinates the care and preparation of patients for procedures, treatments or surgery (proper prep, dress and premedication).
• Assesses the patient upon return from surgery or other procedures and documents findings in the patient care profile.
• Performs verification (time out) prior to invasive procedures as designated by policy.
• Responds appropriately and timely to clinical alarms (IV pumps, monitor alarms, bed alarms, etc.).
• Implements Pain Management program.
• Performs and documents hourly rounding, or as appropriate for unit.
• Ensures the patient's hygienic needs are met (AM care, PM care, toileting, etc.).
• Implements and monitors restraint use per policy.
• Consults other disciplines as indicated by assessment findings.
• Administers emergency resuscitation of patients in cardiac arrest.
• Implements and maintains standard or high fall risk precautions as indicated.
• Confirms two patient identifiers (name, date of birth and/or hospital number) when providing care and specimen collection etc.).
• Administers medications in a safe, timely manner and correctly documents their administration.
• Utilizes two patient identifiers before giving medication: patient name band, patient hospital number
• Records the patient's response to the medications in the patient care profile when appropriate.
• Uses 5 "R"s for administering medications.
• Demonstrates knowledge of drugs used.
• Identifies and reports adverse drug reactions per policy.
• Demonstrates proper use of pyxis: resolves all discrepancies before end of shift, utilizes override feature in appropriate situations
• Performs venipuncture per policy.
• Maintains and accesses central lines/PICC's.
• Administers blood products.
• Checks and documents status of IV/INT per department policy.
• Demonstrates proper use of IV equipment.
• Adheres to medication reconciliation policy.
• Adheres to principles of medication security.
• Obtains narcotics from PYXIS/Pharmacy and documents administration and wastes per policy.
• Assesses/monitors PCA patients per policy.
• Gathers information pertinent to the medication(s) ordered: actions, purpose, normal dosage and route, common side effects, time of onset and peak action, nursing implications.
• Performs real-time documentation.
• Conforms to department documentation standards.
• Reports and records pertinent information related to nursing plan of care.
• Demonstrates proficient use of computer and adheres to departmental policy.
• Records accurately in the medical record nursing actions: reflect care given to the patient, observations made about the patient, patient's response to treatment or medications, restraints, pain management.
• Complies with "Do Not Use Abbreviations".
• Repeats and verifies all verbal/phone orders and test results.
• Provides the patient with an explanation of his/her condition and written information when possible.
• Participates in pre and post-operative teaching of surgical patients.
• Includes family and/or significant others in health teaching when possible.
• Plans with the patient, family and/or significant other for discharge.
• Reviews home care instructions with patient or responsible party and documents same in the patient care profile/discharge form.
• Initiates consultation with other health care professionals.
• Extends courtesy and demonstrates cooperation while communicating with others.
• Gives a concise, pertinent report to the oncoming nurse at the change of shifts.
• Utilizes effective communication skills with patients, families, Charge Nurse, Medical Staff, Director, Administrative Supervisor, peers and co-workers in a pleasant positive manner.
• Accepts suggestions and criticisms and whenever necessary undertakes to change personal behavior or seek further guidance.
• Delivers hand off communication when care provided or level/location of care changes.
• Effectively leads and directs activities of others in a positive manner.
• Assumes relief charge nurse, team leader or patient care responsibilities as necessary.
• Demonstrates flexibility and adaptability rotating to another shift or unit when need arises.
• Supports the philosophy, policies and procedures of the Division of Nursing.
• Assumes responsibility for completeness and quality of nursing care provided by his/her team members.
• Demonstrates skill in supervising subordinates in performing their duties.
• Makes appropriate staff assignments.
• Acts as liaison between physicians, patients, visitors and staff.
• Demonstrates ability to make prompt decisions based on sound judgement.
• Demonstrates critical thinking skills.
• Assumes responsibility for completeness and quality of nursing care provided by staff assigned to the unit.
• Uses physician preference cards and follows prescribed procedures.
• Controls verbal and tactile stimuli to patient and assists anesthetist as appropriate during induction of anesthesia.
• Does surgical prepping according to policy and procedure and documents appropriately on OR nurses notes.
• Initiates "Time Out Verification" for correct patient, correct procedure and correct site.
• Applies proper principles for patient positioning.
• Anticipates needs of the patient, providing for patient safety and comfort, adjusting physical environment to meet need.
• Anticipates needs of the scrub nurse and surgical team.
• Has equipment assembled and ready for use in each case.
• Provides for accurate care and handling of specimens and cultures with labeling and documentation in OR nurses notes.
• Directs and assists in accounting for all sponges, needles and instruments according to policy and documentation in OR nurses notes.
• Verbally reports to Perioperative Supervisor needed repairs; never allows unsafe equipment to be used.
• Assists and directs team members in correct use and precaution in handling surgical equipment and instruments.
• Demonstrates interest in cost containment.
• Demonstrates principles of