SWHC/RMC GI - Pre-Op/PACU/Intra Op RN

SWHC Surgery Center Workforce Solutions LLC

Pre-Op/PACU/Intra op RN

(Full-Time position)

Position Summary:

The Pre-Op/PACU/intra op RN is the surgical team member who is responsible for coordinating and controlling the multi-disciplinary activities required to provide a safe environment for patients undergoing surgical intervention. The RN provides nursing care to patients during the preoperative intraoperative and postoperative phases. Involves assessment, planning, implementation, and evaluation of procedural patients.

Provides safe, knowledgeable, compassionate, educative, individualized and goal-directed nursing care to patients and their families in the immediate post-anesthetic period. Applies physiologic and psychosocial knowledge and skills to promote, restore, and maintain the patient's physiological processes in a safe, comfortable, and effective environment, while facilitating the patient's adaptation to their surgical experiences.

The Nurse supports the center’s policies and procedures as well as its nursing philosophy.

Accountable To: ASC Administrator/Supervisor/Manager

Pre-Op/PACU Responsibilities:
Pre-Op/PACU RN duties will consist of, but are not limited to:

• Assessment
  • Assesses the physical status of the patient through personal observation and interaction.
  • Assesses the individual psychosocial and spiritual needs of the patient and significant other.
  • Demonstrates understanding and interpretation of diagnostic measures such as labs, chest x-ray and EKG.
  • Obtains an overview of the patient's status by reviewing the patient's chart.
  • Consults with the peri-operative nurse who interviewed the patient pre-operatively.
• Planning
  • Plans for a safe, efficient, effective, and clean environment for preoperative and post-operative care.
  • Identifies problems and plans action to resolve problems.
  • Identifies goals for the individual patient and communicates these goals to others involved in the patient's care.
  • Assures that patient has appropriate discharge instructions; is accompanied by a responsible adult upon discharge; has the telephone number of the physician to call in the event of need during the first 24 hours post procedure.
• Implementation
  • Takes action to implement nursing care and resolve the problems identified for the individual patient.
  • Utilizes supplies, equipment, and resources to contain cost without compromising delivery of care.
  • Reduces chances of nosocomial infection by directing attention to infection control and environmental safety practices.
  • Reports and documents information accurately and in a timely manner.
  • Utilizes professional nursing judgment in the delivery of care.
  • Uses safe methods of handling equipment.
• Evaluation
  • Evaluates action taken to implement nursing care plan and resolve problems accordingly.
  • Modifies intervention to achieve goals if previous intervention was not effective.
  • Evaluates own nursing practice and seeks ways of growing professionally.
• Interpersonal Relationships
  • Recognizes and utilizes appropriate lines of communication.
  • Foster cooperative efforts in meeting the goals of nursing by sharing workload.
  • Communicates a positive and caring attitude toward unit, peers, staff, and all other contacts.
  • Seeks guidance, direction and assistance where needed.
  • Conveys ideas, concepts, and facts relative to patient care in a logical, understandable, and concise manner.
• Accountability
  • Seeks appropriate learning opportunities.
  • Demonstrates competence and expertise in nursing practice.
  • Assumes responsibility for professional nursing practice within the law.
  • Maintains confidentiality of all patient and Center's communications/documents.
  • Utilizes judgment in determining nursing actions.
  • Acts as patient advocate in the coordination of patient care.
  • Always maintains safety rules.
  • Has knowledge of equipment and supplies and is familiar with their location in Recovery Room and Procedure, i.e.: emergency call system, oxygen, mechanical ventilator assistance equipment, including airways, ambu bag, defibrillator, cardiac monitoring equipment, tracheostomy set, laryngoscope and endotracheal tubes, suction equipment, emergency drugs and supplies specified by the Medical Staff.
  • Monitors emergency equipment.
  • Has an in-depth knowledge of anesthetic agents and their actions, emergency drugs, impending complications, and emergency treatment of complications, should they occur.
  • Follows recovery room guidelines.

Intra OP Responsibilities:

Performance of the duties of the Procedure RN, according to the set standards, is crucial to the smooth flow of events before, during, and after a procedure. The RN duties will consist of, but are not limited to:

• Be thoroughly familiar with and totally comfortable in the role of patient advocate, as applied to Procedure Room nursing.
• Assume the responsibility for improvement of patient safety during the state of enforced dependency created intra-operatively.
• Responsible for creating a safe, therapeutic environment in which the patient's psychological, physiological, and physical needs are identified, anticipated, and met.
• Provide a channel of communication between events and team members in the procedure room and persons who may not be in the immediate area, but who are concerned with the patient's operative status.
• Make provisions for supplies and equipment requirements of procedures, as assigned.
• Responsible for documenting accurate, timely data appropriately. (This includes documentation of Charge sheets, Incident Reports, Nursing Notes and Logs.)

Pre-Operative

• For proper identification of patient and plan of action intra-operatively, check Procedure schedule to determine patient's name, physician, and the type of procedure.
• Review physicians order for proper medication preparation.
• To ensure patient's safety and comfort and smooth flow of procedure, inspect the room to be certain it is clean, complete, and safe. All equipment should be checked for safety, functioning capability, and complete assembly.
• Direct and assist GI technician in preparing for the procedure and the physicians preference card.
• To decrease patient's anxiety and help plan nursing actions intra-operatively, greet the patient in Pre-Op area for the purposes of identification, physical/psychological assessments.
• To ensure patient safety, accompany the patient via gurney to the procedure room.

Intra-Operative

• Anticipate the needs of the procedure team and provide supplies and equipment as requested.
• Coordinates all activities within the procedure room to provide for a non-eventful, safe, effective, and timely intervention.
• Provides for patient's needs, both physiologically as well as psychologically. Maintains an environment free of disturbing sounds and statements.
• Lead the team in the time-out process, to ensure that you can proceed with the procedure.
• Provide moderate sedation during the procedure under the physician’s direction.
• Complete and maintain accurate records of patient-oriented data during the procedure, i.e., vital signs.
• Be responsible for specimen recording -- to include accurate and complete identification on labels and tickets, and the placement in appropriate containers/solutions.

Post-Operative

• Remain with the patient as they are transported from the procedure room to recovery area.
• Give a hand off report to the nurse in the Recovery area with the procedure information and identify problems or potential problems.
• To ensure that appropriate specimens are identified and delivered to appropriate area, make certain that all specimens have been placed for dispatch and entered in Specimen Log.
• Direct and assist with between case clean-up to provide smooth flow of to-follow cases.
• To promote safe patient care delivery, inspect the room and proceed to preparation for the next case, as assigned.
• If last case of day, is responsible to direct or perform all terminal cleaning activities.

Other Responsibilities:

• Must comply with all HIPAA privacy regulations regarding the confidentiality of Protected Health Information (PHI).
• Must file an incident report for any unusual event that occurs to a patient or member of staff; this would include, but not be limited to, falls, needlestick injuries, aspiration of gastric contents, allergic reactions, and disruptive behavior by staff or patients. Also required to report any incidences or alleged incidences of abuse, harassment, or injury to self, other employees, or patients occurring at the Center or relating to the Center. Further specifications can be found in the Abuse Reporting documents and Code of Safe Practices, provided by the Director of Nursing.
• Meets the needs of the center as demanded by the procedure schedule, particularly when overtime hours and time changes become necessary.
• Serves as patients' advocate during the pre-operative, intra-operative, and post-operative phases of surgical intervention.

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