Surgery RN (GI/Endoscopy) - Full Time

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 result, 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 problem list (plan of care) for each patient 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.

Follows procedures for surgical interventions along with preferences of surgeon.

Checks for availability and proper condition of necessary Instruments, supplies, and equipment prior to start of case.

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 1 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 intraoperative period.

Acts as a scrub/circulating nurse during the intraoperative phase.

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

Performs sponge, needle, and instrument counts according to policy and procedure.

Ensures safety of patients during the use of electrical equipment.

Preps the surgical site using aseptic technique.

Correctly collects and accurately labels specimens.

Confines and contains sources of contaminations.

Revises physician's preference cards and communicates changes to appropriate personnel.

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 documentation by nurse administering med, tin1e given, reason for omission, and site for injection (if applicable).

Demonstrates proper access, documentation of narcotics in the Pyxis and EMR.

Accurately and promptly documents unusual occurrences noted during the perioperative phase.