Surgery

Primary

Purpose:

To assess, plan, implement, and evaluate the care of all patients assigned to the operating room, recovery room, and outpatient surgery, as well as to manage the supplies and equipment in the OR/RR/ASU, and to provide pre and post-op education.

Formal Policy-Setting Responsibilities:
Formally responsible for providing input into policies associated with the job’s purpose and essential responsibilities.

Routine Decision Making:
If pre-op lab and results are sufficient; surgical case schedule; if patient meets criteria for discharge from PACU/ASU.Formal Supervisory Responsibility:
No formal supervisory responsibility.

Unusual

Working Conditions:

Risk of blood, body fluid contamination.

Age Specific

Competencies:

Provides care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

Essential Responsibilities and Tasks Assesses, Plans, implements and evaluates patients receiving high risk specialty procedures. (40% of time)
Performs pre-procedure interviews per paper/computer correctly on all patients, evaluates the information obtained, and formulates a plan of care prior to the patient procedure.

Identifies the patients using two patient identifiers prior to the procedure 100% of the time.

Performs a comprehensive nursing assessment on patients and documents completely including appropriate signatures, times and dates. Revises plan of care as indicated from the assessment.

Interprets physiological information from technical equipment, on each patient and applies this information to the plan of care.

Documents the findings from all assessments, evaluations and implementations on the patient record where, when, and how daily.

Reports all critical abnormal assessments and lab values to the physician, per hospital policy and implements further orders immediately and documents details on the patient record.

Adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.

Utilizes AIDET (acknowledge, introduce, duration, explain and thank) initiatives to include managing up with each patient.

Utilizes only approved abbreviations in patient documentation.

Provides patient education. (15% of time)
Provides pre-operative and post-operative teaching to all patients.

Evaluates patient learning ability and motivational levels. Implements alternative learning measures, as evidenced by patient or caregiver verbalization or return demonstrations, as documented on the patient record i.e.; effectively communicates.

Effectively communicates discharge instructions to patient and responsible party at the time of discharge, per departmental discharge policy.

Explains all procedures and medications to patients prior to implementation.

Maintains a safe and comfortable environment. (25% of time)
Removes malfunctioning equipment from unit immediately upon discovering problem.

Complete requisition for repair or malfunctioning equipment by the end of shift.

Cleans and stocks supplies within the department, as needed.

Effectively communicates the plan of care on each patient to ancillary departments, case management and pharmacy staff as indicated by the orders received, patient diagnosis or condition.

Ensures all required documents are on the chart prior to going into the procedure room (H&P, informed consent, test results if applicable).Evaluates the effectiveness of the communication, as evidenced by the preparedness of the patient and takes appropriate actions, including notifying performing physician.

Demonstrates thorough knowledge of location, care and operation of all…