Description
Job Description
Position Title: RN Clinical Level 1
Department: PACU
Job Summary:
Under the supervision of the Director of Surgical Services and /or Clinical Manager the Registered Nurse is responsible for organizing, planning, directing, coordinating, providing high quality, and individualized patient care. The nurse will demonstrate organizational, interpersonal, and time management skills. The nurse will demonstrate proficient performance standards in performing their daily work duties to meet the department expectations. The nurse works effectively and productively with shared responsibilities. The nurse will provide physical psychological and spiritual needs to the individual patient. Continuously seeks ways to improve processes and meet customer satisfaction with patients and physicians.
TECHNICAL SKILLS/JOB SPECIFIC SKILLS/*ESSENTIAL FUNCTIONS
TELEPHONE SKILLS - Demonstrates hospital telephone etiquette by answering the phones promptly, courteously and identifying department and self. Consistently exhibits a professional attitude.
POLICIES/PROCEDURES- Is aware of and follows all hospital and department policies and procedures.
TEAM WORK- Promotes positive co-worker relationships through team work and cooperation. Understands and supports the needs of individuals in other departments and promotes conflict resolution. Shares information, work knowledge and experience with coworkers, physicians and students in a non-threatening manner. Offers assistance and promptly responds to requests. Follows and utilizes the proper chain of commands when necessary.
PRODUCTIVITY -Maintains high productivity and performs efficiently regardless of whether the work volume is high or low. Appropriately prioritizes work activities. Responds to difficult situations with self-control and a positive attitude. Makes decisions independently and knows when to ask for assistance. Exercises good judgment and arrives at sound decisions.
ASSESSMENT
• Demonstrates accurately patient identification by using the patients name and date of bi1ih .
• Performs appropriate nursing history and physical upon admission and on an ongoing basis .
• Collects and documents patient data accurately. Demonstrates knowledge and proficiency in special procedures.
PLANNING
Provides continuity of care by communicating the plan of care and diagnostic data through hand off communication from one department to other and from one team to another. Assess safety of the patient care environment. Delegates task to unlicensed personnel to ensure smooth running of schedule.
IMPLEMENTATION
• Sets priorities and gives nursing care based on the patients needs .
• Follows through with care plan established by other team members ( i.e. anesthesia and physicians) .
• Coordinates the activities of others disciplines of the healthcare team to implement the individual care plan.
EVALUATION
Evaluates and recognize alterations in physiological and psychosocial status. Collaborates with other team members to revise the patient care plan according to changing needs of the patient. Document revisions of the goals and plan of care to meet the changing needs of the patient.
PROFESSIONAL CONDUCT-
• Demonstrates the philosophy of the team concept.
• Participates in staff meetings with suggestion that enhance the work environment
• and increase productivity .
• Communicates well with supervisor, reporting problems with equipment, supplies,
• or procedures .
• Complies with safety and infection control standards .
• Consistently projects positive professional image through appearance and behavior.
• Attends 75 % of staff meetings or reads and initials I 00% of meeting minutes .
• Completes assigned work within shift .
PERFORMANCE IMPROVEMENT
. Consistently work to improve identified hospital-wide problems .
• Complies with ensuring accurate system to documentation occurrences .
• Ensure regulatory compliance with Core Measures & National Patient Safety Goals .
• Meeting I 00 % compliance with SCIP components
• Is knowledgeable of performance improvement methodology and participation of collection of data.
ASSESSMENT-Demonstrates ability to effectively assess and care for postoperative patients during the immediate post anesthesia period. Collects and documents patient data on PACU nursing record and identifies potential patient problems, reporting findings to the anesthesiologist and/or physician.
MEDICATION ADMINISTRATION-Demonstrates competency in the knowledge and use of all drugs used in all types of anesthesia, including, general, regional block, epidural injection, spinal injection and moderate sedation. Knowledgeable in PCA pump set- up and usage, On Q Pain equipment and can trouble shoot devices. Understands rationale for usage and can educate patients accordingly. Able to access patients for appropriate narcotic usage and cases where patient is considered narcotic na"ive and follow hospital protocol. Assess the need for pain and/or nausea relief measures as necessary.
Follows PACU Pain and Nausea protocol developed by the Anesthesiologists. Provides a safe and therapeutic environment. Follows hospital policy and procedure for reporting patient outcomes. Uses Pyxis drug system appropriately.
Prepares patient for nerve blocks, educates patient and assists physician with procedure.
Completes all patient documentation in chart concisely and legibly. Prepares billing forms for each patient correctly. Collects data for cath lab patients, SOS patient, and ICU/CCU patients for monthly reports.
Actively performs and promotes process improvement activities within the department. Collects monthly data and encourages positive communication to improve outcomes. Promotes process change when desirable and indicated. Maintains all SCIP protocol when appropriate.
Identifies patient outcomes specific to the post anesthesia patient, which include respiratory and cardiovascular maintenance or improvement, stabilization of fluid and electrolyte balance, protection f om infection, management of pain and nausea, environmental safety, privacy and emotional support.
Assists new employees with orientation. Evaluates and mentors as necessary. Actively supports new staff in learning new skill sets and functions as mentors to staff and students.
Completes hand off communication to all depaitments in a concise and efficient manner. Allows for receiving department to ask questions as necessary. Assists department transporters to deliver patients when needed and required.
Maintains a clean working environment. Ensues that all equipment is clean and in working order prior to patient use. Daily assesses all equipment alarms are working and audible. Checks parameters for vital signs on all equipment prior to use. Checks crash cart and Malignant Hype1ihermia emergency equipment daily.
Performs any other duties or responsibilities, which may be assigned.
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