Preop​/PACU Registered Nurse; RN

General Summary of Position

Independently assesses plans implements and evaluates the nursing care of patients from admission through discharge. In collaboration with the patient and family provides theory-based professional nursing care and coordinates care delivery with the physician and other members of the healthcare team. Med Star Ambulatory Services is committed to providing world‑class compassionate care to every patient every time at every touch point.

All associates are accountable for their role in meeting patient experience standards.

• Adheres to surgical schedule and case turnover consistent with standards. Is ready for first case of the day consistent with OR scheduling policies. Maintains communication with control desk anticipating delays or completion of case.
• Anticipates needs of surgical team by correctly assembling needed supplies for each procedure according to physician preference card. Verifies that all equipment is functioning at the beginning of and during the case recognizing own problem‑solving limitations and seeks assistance as needed. Maintains a sterile field throughout the case by practicing aseptic techniques in accordance with standards of care and infection control guidelines;
  
  or anticipates needs of the perioperative patient in the PACU setting.
• Communicates patient's clinical information clearly and accurately in verbal and written format. Clearly and accurately documents pertinent information in the patient's medical record. Consistently demonstrates effective documentation practices and develops strategies to ensure complete documentation of patient care.
• Completes timely initial and ongoing patient assessments considering the physiological psychosocial spiritual cultural and developmental needs of patients and families. Serves as a resource in planning care for complex patients.
• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. Seeks opportunities to participate in developing revising standards of practice to meet changing patient population requirements.
• Coordinates care of assigned patient(s) preoperatively intraoperatively and/or postoperatively. Consistently demonstrates effective leadership behavior. Maintains patient privacy and confidentiality. Facilitates collaboration among other health team members fostering effective communication with other disciplines.
• Delivers nursing care to patients considering the current status of the patient and the plan of care and incorporating the principles of patient centered care.
• Evaluates the patient's response to treatment and progress toward identified goals and revises plan of care as appropriate.
• In collaboration with the patient family and other members of the health care team systematically develops revises and coordinates the patient's plan of care. Formulates nursing diagnosis as necessary. Assists others in developing revising and coordinating patient's plan of care.
• In coordinating the delivery of patient care delegates activities to unlicensed staff in accordance with Med Star/facility policies principles of Patient-Centered Care and the Maryland Nurse Practice Act. Supervises the performance of the delegated nursing task by the unlicensed staff. Assists staff in delegation/time management skills. Identifies ways to facilitate working relationships among all levels of staff.
• Initiates and monitors discharge planning activities in collaboration with other members of the health care team. Takes the lead in facilitating timely discharge.
• Maintains a safe and therapeutic environment of caring for patients and families. Provides basic patient comfort measures. When necessary provides environmental support to expedite timely patient admission or transfer. Ensures a safe supportive environment for staff and medical staff. Identifies and acts upon opportunities to improve the environment of care.
• Participates in multidisciplinary quality and service improvement teams.
• Performs other duties as assigned.

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