RN-PACU

This job description reflects the general details considered necessary to fulfill the essential job functions and shall not be construed as a detailed description of all work requirements inherent in this position. Other specific job-related knowledge and skill may be required. Should be calm and have the ability to perform under pressure.

MISSION OF DEPARTMENT:

The Ohio County Healthcare Nursing Department exists to provide quality nursing services to the patients/customers of Ohio County Hospital Corporation, holistically addressing physical, educational, mental, emotional, cultural, social and spiritual needs, by utilizing the nursing process.

JOB SUMMARY:

Responsible for delivery of safe, effective and quality patient family centered care in the PACU and other areas for all patient populations.

PURPOSE OF JOB:

Responsible for the delivery and supervision of safe, effective and quality patient family centered care in the recovery room for all patient age groups. Responsible for assisting the manager/director in departmental budget planning, developing departmental policies and procedures and nursing standards of care. Must offer effective problem solving techniques, communication and demonstrate decision making abilities as well as critical thinking skills.

ESSENTIAL JOB FUNCTIONS:

Assesses and diagnoses nursing care of patients in all age groups

1. Pertinent assessment data are collected using appropriate assessment techniques (interview, observation, inspection, auscultation, palpation and review of reports and records).
2. Data collection involves the patient and other health care providers.

Assess patient’s postoperative status at intervals according to facility or health care organization policies and procedures utilizing data/information from patient, other team members. Interpret data accordingly from various noninvasive and invasive monitors.

1. Cardiovascular system
2. Respiratory system and airway management needs
3. Neurological system
4. Hemodynamic stability
5. Pain and comfort needs
6. Mental status

1. Describe the physiology associated with various anesthetic techniques and surgical or procedural interventions.
2. Apply the relevant scoring system/discharge criteria for patient transfer utilizing the Aldrete PAR score accurately as defined by hospital policy.
3. Develop an individualized peri anesthesia plan of care to attain expected outcomes.
4. Implement the plan of care including the following interventions individualized for each patient

1. Managing patient recovery from anesthesia – general
2. Managing patient recovery from anesthesia – monitored anesthesia care
3. Managing patient recovery from anesthesia – regional
4. Managing patient recovery from anesthesia – local
5. Patient outcomes are derived from patient problem listing/nursing diagnoses and are documented as measurable goals
6. Outcomes are mutually formulated with the patient, significant other and other health car providers when possible
7. Outcomes are measurable and realistic in relation to the patient’s age and present capabilities
8. Outcomes are attainable in relation to the resources available to the patient

Collaborate effectively with other disciplines as needed

Prescribes, delegates, supervises, performs and evaluates patient care for all age groups

1. Develops a comprehensive plan of care to be delivered to attain the expected outcomes
2. The plan of care reflects current nursing practice based on scientific knowledge and is documented
3. The plan of care provides for continuity of care
4. Delegates responsibility for nursing interventions according to the support staff’s level of education, orientation, experience and scope of practice as mandated by licensure and regulations
5. Performs nursing interventions which are outside the scope of practice for other team members. Performs all nursing interventions assigned in a safe manner according to established policy and procedure and documents appropriately in the medical record.
6. Reassessments are appropriate to the condition of the patient, documents reassessments.
7. Evaluates the patient’s progress towards attainment of established outcomes (via reassessments) and communicates the progress or lack of progress to the physician and other healthcare providers. Collaborate with the interdisciplinary team as well as patient and significant others to modify the plan of care as needed.
8. Revisions in patient problems / nursing diagnoses, outcomes and plan of care are documented.
9. Gives concise and pertinent hand off communication providing necessary information relative to patient care and the patient’s progress toward established outcomes.
10. Checks and validates medical orders and assures that medical orders were communicated to all affected ancillary staff.
11. Discusses with physician/provider any orders which do not seem appropriate or are incomplete or unclear. Initiates peer review process when collaboration is not effective.
12. Communicating the patient’s current status throughout the peri anesthesia continuum of care.
13. Providing acute pain and comfort management as needed.
14. Administering medications correctly by implementing the 7 rights of safe medication practices (i.e. right patient, right medication, right dose, right time, right route, right indication, right documentation)
15. Performing interventions to maintain the integrity of the patient’s wound and tissue perfusion at or above baseline levels
16. Performing interventions to maintain the status of the patient’s genitourinary, gastrointestinal, musculoskeletal, endocrine, respiratory, cardiovascular, and neurological systems, and fluid, electrolyte, and acid-base balances at or above baseline levels
17. Performing interventions to ensure the patient is at or returned to normothermia at the conclusion of the immediate postoperative period
18. Performing interventions to protect patient from infection
19. Managing patient’s other co-morbid conditions as applicable
20. Managing patient’s fluid as prescribed
21. Evaluate the patient’s progress toward attaining outcomes
22. Document nursing care completely, accurately, and legibly
23. Providing age-specific, culturally competent, ethical care with legal standards of practice
24. Providing consistent and quality care regardless of the setting

Teaching

1. Assessing knowledge level of patient or designated support person and providing education regarding the expected psychosocial response, nutritional management, medication management, pain and comfort management, wound management, and expected responses to the operative or invasive procedure.
2. Involving patient or designated support person actively in decisions affecting his or her perioperative plan of care and the rehabilitation process
3. Provides “on the spot” coaching to personnel observed in unacceptable behavior such as not following policy or procedure or in actions inconsistent with the hospital’s purpose, vision and values. Coaching is done in a constructive manner and in private. Informs the charge nurse of coaching occurrences.
4. Teaching needs and plan are included in the patient’s plan of care.
5. Appropriate teaching methods and supporting materials are used
6. Documentation in the medical record reflects content and type of instruction and the patient’s response to the instruction. This provides information to oncoming staff for continuity of teaching.
7. Evaluates patient teaching. Measures patient’s progress toward meeting learning goals and documents in the medical record. (i.e. return demonstration, verbalized understanding, etc.)
8. Documents instructions to patient and/or significant other about physical activity, medications, diet and follow up care for the patient after discharge from the hospital
9. Documents referrals made for each learning goal that was not met by the time of discharge. Necessary information is forwarded to the referral agency.

Maintains safe and therapeutic environment of care for patients in all age groups

1. Protecting patient from injury caused by positioning, thermal sources and extraneous objects
2. Accounts for all drugs according to hospital policy
3. Makes appropriate request to operating room supervisor/operating room manager for supplies or equipment needs
4. Uses equipment and supplies in safe, efficient and cost conscious manner. Correctly charges for supplies. Seeks to reduce waste in the work place.
5. Removes any faulty equipment from service, labels it “out of service” noting the problem and notifies the charge nurse/house supervisor.
6. Event reports are completed accurately and completely and are forwarded to the charge nurse/house supervisor. Operating room manager / operating room supervisor is notified immediately of any incident with significant liability potential.
7. Knows and responds appropriately to all emergency codes.
8. Knowledgeable of and utilizes proper body mechanics.
9. Reports any safety and infection hazard or risk to the charge nurse/house supervisor.
10. Checks emergency equipment as assigned by the charge nurse/house supervisor.
11. Applies pediatric safety guidelines as appropriate
12. Takes necessary safety precautions of lowering stretcher position in all age groups
13. Applies safety measures as appropriate for all paitents
14. Accountable for ensuring patient safety during the course of performing his/her duties
15. Adheres to blood and body fluid precautions. Knows where to locate personal protective equipment and uses appropriately.
16. Adheres to other infection control policies, to include the exposure control plan and employee health protocols.
17. Knowledgeable of and implements emergency operations plans as indicated.

Upholds standards of nursing practice for all age groups and code of ethics

1. Code of ethics and standards of nursing practice are continually met.
2. Performs all nursing procedures according to the established policies and procedures of the OCH nursing department.
3. Meets licensure requirements.
4. Recognizes and supports the patient’s Bill of Rights and maintains confidentiality in all hospital matters.
5. Acts as a role model for nursing staff, providing leadership and direction consistent with the purpose, vision and values of OCH.
6. Follows and upholds hospital wide personnel policies.
7. Committed to continuous performance improvement and actively participates in and supports the hospital’s improvement efforts.
8. Adheres to legal compliance policies.

Professional self development

1. Attends a minimum of 50% of in-services pertaining to area of practice and applicable to RN’s. these in-services shall include fire, safety, mass disaster, and infection control (exposure control plan, HIV, TB and other infectious disease update). Completes mandatory annual in-services as required.
2. Maintains BLS, ACLS and PALS.
3. Maintains contact hours in nursing continuing education as required for licensure.
4. Maintain clinical skills as evidenced through competency testing and ongoing observation by direct supervision.
5. Accepts supervision. Seeks guidance as needed and accepts supervisory feedback non-defensively.
6. Attends 80% of staff meetings per year.

Exhibits positive human relations

1. Demonstrates a cooperative attitude when interacting with others.
2. Tactful – maintains composure and is diplomatic in all situations.
3. Treats all hospital associates, patients and visitors with courtesy, compassion and respect. Exhibits caring attitude towards co-workers.
4. Shows enthusiasm for job and supports the hospital’s purpose, vision, values, and policies.
5. Uses time effectively and set appropriate priorities.
6. Follows up on all patient complaints / concerns in an effective manner immediately and communicates to charge nurse / house supervisor as indicated. (care reports completed and submitted within 24 hours of concern if not resolved to satisfaction of patient)
7. Shows evidence of prompt and thorough response in handling assignments by charge nurse / house supervisor.
8. Adheres to lines of authority and uses proper channels for communication.
9. Dress and grooming reflect pride in self and hospital.
10. Courteous, friendly and helpful to new employees, students, and personnel from other areas temporarily assigned to the operating room. Explains work accurately, clearly and according to established policy and procedure.
11. Demonstrates reliability and dependability in attendance and punctuality.

• Perfect attendance
• Absent 1 – 5 occurrences – meets requirements
• Absent 6 or more occurrence – needs improvement; does not meet requirement
• Cooperates with staffing needs, assists with covering open shifts when needed.
• Supports organizational accountability and demonstrates such through work.
• May be requested to be member of QI team.

1. Protect the patient from injury caused by extraneous objects and chemical, electrical, laser, mechanical and thermal sources.
2. Performing accounting procedures to protect the patient from unintended retained surgical items
3. Performing interventions necessary to ensure that the patient’s procedure is performed on the correct site, side and according to hospital policy.
4. Managing the patient’s specimens according to organizational policy and procedures
5. Communicating the patient’s current status to relevant parties throughout the continuum of care
6. Administering medications safely and correctly
7. Assessing the knowledge level of the patient or designated support person
8. Providing education regarding the expected psychosocial response, nutritional management, medication management, pain management, wound management, and expected responses to the operative or invasive procedure
9. Involving the patient or designated support person actively in decisions affecting his or her perioperative plan of care and the rehabilitation process
10. Protecting the patient’s rights, dignity and privacy
11. Providing age specific, culturally competent, ethical care within legal standards of practice
12. Providing consistent and comparable care regardless of the setting
13. Participate in quality review and performance improvement projects
14. Participate in the performance appraisal process
15. Use problem solving and conflict resolution skills to foster effective work relationships with team members
16. Maintain required competencies
17. Pursue professional growth and participates in a professional organization
18. Act as a patient advocate and maintain privacy and confidentiality of individuals and health information
19. Frequently accesses email to stay up to date on information within the organization and provides a way of communication between staff members.
20. Performs all procedures in accordance with established policies and procedures of OCH and adheres to legal compliance policies and other regulatory issues

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

1. Physically demanding, high stress environment
2. Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions
3. Pushing and pulling heavy objects
4. Full range of body motion including handling and lifting patients
5. Manual and finger dexterity
6. Hand and eye coordination
7. Standing and walking for extensive periods of time
8. Lifting and carrying items weighing up to 50 lbs
9. Corrected vision and hearing to within normal range
10. Working under stressful conditions
11. Working irregular hours including call hours
12. Travel may be required periodically