RN - PACU

Registered Nurse, Preop/PACU

This position assesses, plans, implements, evaluates, and documents nursing care of patients in accordance with organizational policies and standards of professional nursing practice. This position is accountable for the quality of nursing services delivered by self or others under their direction. Utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide, and evaluate care appropriate to the physical and developmental age of assigned patients.

Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural, and post-operative planning needs. Reviews patient history and physical with patient/family and ensures completion within the appropriate timeframe. Reviews available information obtained by other health care team members. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and as outlined in policy.

Formulates a plan of care, including the discharge plan, utilizing assessment data and input from the patient, family, and health team. Initiates a plan of care based on patient-specific needs, assessment data, and the medical plan of care. Goals for patients are realistic, measurable, and developed in conjunction with the patient/family. Considers physical, cultural, psychosocial, spiritual, age-specific, and educational needs of the patient in the plan of care.

Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patient's status. Implements the plan of care through direct patient care and coordination, delegation, and supervision of activities of the health care team. Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements.

Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided. Evaluates the patient's and family's response to care and teaching, revising the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient response and the effectiveness of patient teaching.

Documents assessment, planning, implementation, and evaluation in the patient record. Documentation is legible, timely, and in accordance with policy. Documentation reflects objective and subjective data, nursing interventions, and patient responses to treatment. Notes physician orders accurately and in a timely manner. Provides care based on the best evidence available and may participate in research activities within clinical practice. Participates in facility shared leadership and interacts in the education, role development, and orientation of facility personnel, patients, students, families, and visitors.

Promotes and supports the growth of others through precepting and mentoring when appropriate. Contributes to society through activities leading to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Actively participates in the improvement of national nursing quality indicators and outcomes. Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.

Provides all customers with an excellent service experience by consistently demonstrating core and leader behaviors. The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties.