Assess, plan, and evaluate all aspects of patient care within the Pre-op/Post-op unit. Responsibilities include performing diagnostic procedures, administering medications, and coordinating discharge planning with a multidisciplinary team.
Requirements summary
Requires a nursing degree and a current state RN license, with CPR and ACLS certifications. Candidates should have 1-3 years of RN experience, preferably in orthopedic, neurosurgical, or pain management specialties.
Shift: DayJob Summary Under the direction of the Clinical Manager and the Pre-op/Post-op Coordinator, this position assesses plans, organizes and evaluates all aspects of patient care for assigned unit/patients.
Reports to: Nurse Coordinator/Nurse in Charge Essential Job Functions Utilizes the nursing process to provide quality patient care according to established standards of care which includes planning, implementing, evaluating and adjusting plan of care, and discharge planning based on expected patient outcomes. Admits, transfers, and discharges patients. Completes ongoing patient assessment and documents according to policy. Completes nursing assessment within 2 hours of admission, or designates reason for incompleteness. Reviews database and nutrition screen. Participates in the development of patient plan of care to include patient problems, goals, evaluations and interventions. Reports symptoms and significant changes in patient’s condition to appropriate personnel. Assesses, collaborates and coordinates patient’s discharge planning needs and readiness for discharge with other members of the care team. Demonstrates appropriate application of age specific standards, policies and procedures and guidelines in caring for adolescent, adult, and geriatric patients. Follows age specific standards in administering medications based on patient’s age. Follows age specific standards of care during altered states of consciousness related to analgesia, conscious sedation or anesthesia. Uses age specific standards, policies and procedures and guidelines to perform treatments and procedures that are routine for unit/clinic based on patient’s age. Incorporates cultural and developmental needs into plan of care. In collaboration with the patient/family, and in a developmentally and culturally appropriate manner, implements the plan of care. Demonstrates competency in the provision of nursing care according to established standards of nursing practice and in a developmentally appropriate manner. Demonstrates critical thinking skills, ability to provide and delegate activities to staff based on patient assessment and the requirements to deliver care in a safe efficient manner maximizing positive outcomes for the patient. Provides documentation of patient care in the patient record according to established standards of nursing care. Collaborates and works cooperatively with physicians and other members of the multidisciplinary health care team in formal and informal teaching of patients and/or family about his or her disease process and wellness promotion plan and discharge planning. Assesses patient/family learning needs, abilities, preferences, and readiness to learn. Utilizes a collaborative interdisciplinary process to provide appropriate patient/family education. Utilizes available information to evaluate the effectiveness of teaching in producing the desired patient outcomes and makes adjustments in teaching as indicated. Participates in performance improvement activities which include collecting, analyzing data to identify quantifiable measures to maintain quality and the promotion of desired outcomes. Also includes participation in development of patient care delivery systems, standards, policy and procedures, and problem solving teams. Demonstrates an awareness and relevance of research in nursing. Evaluates practices to identify areas for improvement or opportunities for research. Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment. Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position. Maintains and protects confidentiality regarding all aspects of patient care, personnel and strategic issues. Adheres to Confidentiality Policy. Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s Guidelines for Appropriate Conduct in the HR Manual. Displays honesty and mutual respect when communicating with peers and other departments. Follows through on problems that may compromise effective job performance by using appropriate chain of command. Pre-op/Post-op area specific duties may include unit specific functions addressing the nursing process aspects of assessment, planning, implementation, and evaluation as well as nursing functions of teaching, risk management, time management, and communication in the following manners:
Assessment: Reviews preoperative/postoperative physician orders to determine patient needs. Obtains/ Reviews patient’s medical history for accuracy upon admission. Reviews and assesses diagnostic data (or absence thereof) and collaborates with physicians and other health care workers to provide appropriate follow-up actions. Utilizes clinical experience and knowledge to anticipate potential patient care problems and collaborates with appropriate individuals. Performs/Reviews assessment of patient, family members, and/or significant others’ knowledge base, health care practices, attitudes of health and illness, and level of understanding.
Planning
Plans patient care based on identified assessment analysis and established standards, policies, and procedures. Involves patients and family/significant others in perioperative planning, including but not limited to care of the discharged patient. Collaborates with anesthesia providers and surgery to allow time for required preoperative care and to avoid surgical delays.
Implementation
Performs preoperative diagnostic procedures accurately and according to standards, policies, and procedures. Demonstrates competency in performing phlebotomy, obtaining various types of laboratory specimens, electrocardiograms, or other diagnostic tests. Administers intravenous solutions and medications skillfully and correctly. Capable of completing admission/discharge information, physician orders, or other information data entry. Maintains standards of accurate and complete recording and reporting.
Evaluation
Evaluates patient care goals, quality and appropriateness of care provided, and patient outcomes.
Teaching
10.14 Effectively explains perioperative instructions, perioperative treatments, patient care principles, and nursing goals to patient and family/significant others.
QualificationsMinimum
Requirements
Education: Graduation from accredited school of nursing; Bachelor of Science in Nursing is preferred.
Certification,
Licensure: Current state license as a registered nurse; current CPR certification; ACLS certification required within 90 days of employment.
Experience,
Training,
Knowledge: One (1) to three (3) years experience as an RN. Experience in orthopedic, neurosurgical, pain management specialties preferred. Physical Requirements Position requires lifting, carrying, pushing, and/or pulling up to fifty (50) pounds while administering patient care; stooping, kneeling and/or crouching; standing and walking five (5) or more hours per day; reaching, grasping, and handling and/or feeling five (5) or more hours per day. Visual acuity to correctly distinguish skin tone variations, evidence of IV infiltration, infection and to read telemetry, blood pressure gauges, etc; audio acuity to correctly distinguish various body sounds, i.e. respirators, heart sounds, bowel sounds and to discern sounds made by various types of machinery or equipment which would indicate dangerous or improper operation. Must be able to distinguish between all ranges of color. Must be able to read, speak, and write English fluently. Working Conditions/Environmental Exposures Environmental hazards such as chemicals, solvents, needles, needle containers, sharps, blood, body fluids, various infectious/communicable diseases, infectious medical waste, radiation, and/or radioactive materials and/or radioactive waste, proximity to moving mechanical parts. Protective clothing/equipment may be necessary. THE JOB DESCRIPTION IS NOT INTENDED TO BE AN EMPLOYMENT CONTRACT, NOR DOES IT DISSOLVE THE "AT WILL" EMPLOYMENT RELATIONSHIP.
