RN- Perianesthesia- Same Day Surgery

Job Summary

Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem-solving strategies, and applies evidence-based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate and family centered care for Pre and Post Anesthesia care patients.

Job Summary:

Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem-solving strategies, and applies evidence-based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate and family centered care for Pre and Post Anesthesia care patients.

• Supports the Service Recovery Program. Ensures that behavior meets/exceeds acceptable Service Scores.
• Ensures completion of patient admission history, assessments, and pre-procedure verification process in accordance with universal protocol and hospital policy in a timely and accurate manner.
• Evaluates and manages the patient airway post-operatively, applying knowledge of the physiological changes to the airway as a consequence of anesthesia and surgery.
• Completes all nursing multisystem assessment that includes head to toe, vitals, pain management, and post anesthesia scores.
• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
• Follows physician’s orders, administers, and reconstitutes medications when needed. Adheres to six rights of medication administration per medication administration policy.
• Programs and troubleshoot PCA/NCA, syringe, and macro pumps according to orders, following policy and procedure for medication and blood/blood products.
• Performs reassessments as per policy and when there is a change in the plan of care or when an intervention is performed.
• Communicates and documents the patient’s progress including critical findings, critical lab results, and changes in the patient’s condition with the multidisciplinary team. Performs and documents discharge planning per policy.
• Accesses Electronic Medical Record (EMR) and performs charge reconciliation according to hospital policy and completes accurate and timely documentation in the patient’s electronic health record.
• Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician.
• Provides education and documents on patient/family teachings on health-related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care, etc.).
• Provides patient information and effectively completes the hand off process between phases of care, at shift change, and patient reassignments and documents handoff in EMR.
• Works to meet/exceed standards in achieving quality index goals by completing documents in a timely manner and being accountable to regulatory requirements of the DNV, CMS, DOH & other accrediting agencies.
• Accountable to optimize first case starts to prevent delay of patient care per departmental goal.
• Demonstrates knowledge and adherence to HAC/HAI prevention program protocols to minimize risk and harm to patients.
• Monitors surgical site and performs post-surgical site assessment, checking for circulation, color, temperature, and movement.
• Promotes a safe "error-free" working environment by consistently adhering to infection prevention on assigned shift and demonstrates proper personal protective equipment (PPE) indication and use.
• Participates in the environment of care rounds to ensure adherence to regulatory and safe standards.
• Responsible for providing care in the PACU I phase 50% of the time ensuring PACU I phase competencies.
• Maintains availability for on-call assignments (nights,…