JOB SUMMARY: Staff RN is directly accountable to the OR Charge Nurse and the Director of Surgical Services, and indirectly to the House Supervisor. The Registered Nurse is responsible for the delivery of direct and indirect patient care in the peri-operative setting through the nursing process of assessment, planning, implementation, and evaluation for neonates, pediatrics, adolescents, adults and older adults. The Registered Nurse coordinates the care of the patient with the surgeon and anesthesiologist, directs and guides the OR Technician and other personnel while maintaining standards of professional nursing. Works with other departments to provide a continuum of care and co-workers to provide continuous, quality patient care, efficient patient flow and unit maintenance and organization. Responsible for adherence to regulations, standards and hospital or unit policies and procedures. Responsible for participation in Performance Improvement activities, unit meetings and in-services. Acts as a resource for other personnel as appropriate.
Promotes and demonstrates vision, mission and values of the organization.
Communicates and coordinates patient’s plan of care with appropriate additional surgical team members.
Detects, corrects and/or reports incorrect instrument, sponge or needle counts.
Handles specimens in an appropriate manner according to facility policy.
Consistently and appropriately performs universal protocol “time out” according to facility policy and uses two different patient identifiers before the administration of medications or performing any procedures.
Follows policies and procedures consistently regarding Telephone/Verbal orders and Critical Values reports with the use of “read back”.
Monitors all patient care equipment during use, i.e. pneumatic tourniquets, electro-cautery and vital signs machines etc., ensuring they are set with the appropriate parameters for the patient and that any/all alarms are audible at all times.
Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling.
Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to 1) Appropriate use of lifting devices and equipment, 2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation, 3) Use of lifting devices to handle patients safely.
Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
Does not use unacceptable abbreviations in documentation (using read back on all telephone orders.) Monitors authentication and validation of telephone orders within 24 hours by the physician.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines) and demonstrates appropriate use of personal protective equipment (e.g., gloves, gown, masks, and goggles) and hand hygiene techniques.
Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e. suction and oxygen immediately available when needed.
Detects and reports medication errors and ADR’s according to hospital policy. Safely and accurately administers medications and documents properly on the MAR in a timely manner.
Complies with all regulatory requirements for clinical pathway, clinical assessments, interventions and documentation.
Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
Formulates, maintains and updates a goal directed plan of care on patients which is prioritized and based on patient outcomes.
Gives thorough, detailed efficient change of shift report or upon patient intra-department transfer to ensure consistency in the plan of care. Uses the SBAR communication methodology in all reporting.
Maintains current knowledge of advances in job-related technology and activities.
Uses two patient identifiers consistently when drawing lab, administering medications and performing procedures. Follows medication reconciliation policy consistently.
Performs other duties as assigned or required.
EDUCATION, EXPERIENCE, TRAINING