Registered Nurse

Job Summary

Follows the nursing process from preoperative holding area to PACU; communicates with surgeon and anesthesia care provider about relevant patient medical/surgical history and medication allergies; pulls supplies, instruments, and equipment needed for surgical case; opens surgical case with scrub technologist, maintaining aseptic technique; counts with scrub technologist prior to incision; performs the Time Out; is at the patient’s side during induction and intubation and extubation;

safely positions patient with health care team; obtains additional supplies, instruments, and equipment as needed; performs final counts and makes sure they are correct; accurately documents and charges patient; gives report to PACU nurse with anesthesia care provider; performs biological testing for OR autoclaves, knowledgeable of immediate use steam sterilization policies and principles. Follows recommended practices of AORN.

• The Perioperative Registered Nurse is responsible for providing quality nursing care utilizing the nursing process as reflected in AORN Standards of Perioperative Nursing Practice. Perioperative nursing practice includes, but is not limited to the role of scrub person, circulator, clinical coordinator and educator.
• Provides Safe and Appropriate Nursing Care to Patients Utilizing the Nursing Process and Demonstrates the Ability to Perform Clinical/Technical and Administrative Tasks
• Coordinates use of instruments, supplies and equipment for intraoperative phase based on patient’s needs and surgeon’s preference card
• Systematically assesses the health status of the patient and records health data
• Assesses knowledge level of patient preoperatively and provides basic teaching related to procedure and monitoring
• Is proactive in the Time Out process to be sure the patient’s procedure is performed on the correct site, side, and level
• Establishes nursing diagnoses; plans, implements, and evaluates nursing interventions – initiates changes when appropriate
• Protects the patient from injury caused by extraneous objects and chemical, electrical, laser, mechanical, and thermal sources
• Performs interventions to protect patient from surgical site infections
• Maintains patient’s normothermia
• Properly labels specimens and requisition forms
• Demonstrates flexibility and adaptability to changes as they occur
• Adheres to hospital policy for sponge counts, sharps, and instrument counts; protects patient from retained surgical items
• Provides education consistent with the patient/family’s learning abilities and preferences; evaluates outcomes

• Reports pertinent observations regarding patients to physicians and other health care team members
• Hand-off report is given accurately and concisely; hand-off paperwork is completed
• Documentation on the patient’s medical record is accurate, complete and concise to ensure continuity in the provision and coordination of patient care
• Patient advocate – ethical and moral decision making per patient or family member’s wishes
• Uses problem solving and conflict resolution skills to foster effective work relationships with team members

• Completes the Pre-Procedure form so that problems can be anticipated and corrected prior to the patient entering the OR
• Maintains National Patient Safety Goals, including participation in the Time Out process
• Verifies, coordinates and carries out physicians orders/preferences accurately
• Coordinates interdepartmental transfers smoothly and efficiently
• Coordinates interdepartmental activities related to SCIP measures to ensure timely efficient care
• Communicates and coordinates with coordinator and other nurses to ensure timely discharge, patient satisfaction, and quality care along the continuum of care
• Practices Standard Precautions
• Demonstrated knowledge of and practices department safety procedures, including safe handling of equipment and hazardous substances
• Responds to emergency situations to promote optimal patient outcomes by recognizing changes in the patient’s health status
• Initiates incident reports appropriately