Surgery RN PACU - Per Diem*

Patient Care

Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients.

Verification of patient Identity, operative procedure, operative site, surgeon, consents, patient's allergies, NPO Status and when the patient last voided.

Assesses psychological status, including level of understanding, perception of surgery and anxiety level.

Obtains pre-operative medical history and documents clearly in the patient record in accordance with department's policy and procedures.

Checks the current history and physical, laboratory results, the execution of preoperative orders, and results of ordered diagnostic tests.

Reviews completed chart with the Anesthesiologist on duty as necessary.

Communication

Develops, discusses, and communicates a realistic plan of care in collaboration with each patient/family/significant other, to address all identified needs.

Develops patient/family teaching and discharge plan, ensuring patient/family is adequately informed of perioperative instructions.

Follows procedures/preferences for pre-operative anesthesia interventions

Communicates with and keeps family informed.

Judgment

Demonstrates the skills and judgment necessary to implement medical plan Of care, nursing interventions and procedures as necessary for the care of the patient.

Demonstrates knowledge of hospital policies and procedures for administering, transcribing, and recording medications.

Demonstrates knowledge of commonly used meds: action, dose, and side effects.

Observes 10 rights of medication administration: right med, right dose, right time, right route, right patient, right education, right documentation, right to refuse, right assessment, right evaluation.(policy 105.724).

Demonstrates proper procedures in all methods of medication administration.

Initiates and maintains IV access according to hospital policy and procedures.

Identifies priorities and executes nursing care accordingly.

Provides emotional support and comfort measures.

Gives information or explanation to patients and their families.

Applies and monitors principles of aseptic technique throughout the perioperative period.

Assures safe transfer/transport of patient to and from operating room.

Documentation

Maintains up to date accurate documentation of nursing care provided to assure the integration of information for use by the health care team, to ensure quality care.

Nursing assessment is complete and accurate during pre-operative and post-operative phase of admission per policy.

Medication administration record must reflect full signature and title of nurse administering med, tin1e given, reason for omission, and site for injection (if applicable).

Demonstrates proper access and documentation of narcotics in pyxis and EMR.

Accurately and promptly documents unusual occurrences noted during the perioperative phase