PACU RN – Registered Nurse at Bergan Mercy Surgery Center in Omaha, Nebraska

Job Description:

Postanesthesia Care (PACU) Registered Nurse

Last Revised: 10/7/2011

Position Purpose: The PACU Registered Nurse is responsible for assessing, planning, implementing and coordinating patient care from admission to discharge. The Registered Nurse is responsible for the achievement of patient outcomes in accordance with the mission, vision, and values of the facility.

Position Reports to: Clinical Leader

Position Supervises: Licensed Practical Nurse/Licensed Vocational Nurse, Patient Care Attendant, Patient Care Technician, Nurse's Aide, Medical Assistant

Degree of Supervision Provided to Position:

Medium, must be self-directed and works under direction of the Clinical Leader.

Education, Experience, and Licensure:

Graduate of an Accredited School of Nursing. At least one year of medical/surgical nursing experience preferred. Current state licensure to practice. Successful completion of Basic Life Support (BLS)/Basic Cardiac Life Support (BCLS) within 90 days of employment or documentation of current BLS/BCLS certification. Successful completion of ACLS Course within 90 days of employment or documentation of current ACLS certification. Successful completion of PALS Course within 90 days of employment or documentation or current PALS certification.
Internal Relationships (Works Closely With):
As a representative of Surgical Care Affiliates, all comments, attitudes, actions, and behaviors have a direct effect on the Facility's image and perceptions of quality service. Interaction with patients, families, physicians, referral sources, affiliating schools, visitors, volunteers, co-workers, supervisors, vendors, etc. must be in a manner that is friendly, supportive, courteous, respectful, cooperative, and professional. This behavior should promote an atmosphere of teamwork, which is congruent with Facility standards and guidelines to promote positive relations.
Job Requirements:

1. Skills and Abilities:

1. Ability to correlate clinical data with patient's medical and nursing care.
2. Ability to set priorities.
3. Ability to provide direction to others that is clear, concise and promotes efficiency throughout the clinical areas of the facility.
4. Ability to communicate well with patients, families, Teammates, physicians, other members of the healthcare team, etc.
5. Recognizes legal and policy limits of individual practice.

1. Clinical Quality:

1. Assesses, plans, evaluates and ensures the implementation of the patient's care to achieve identified outcomes and delivers safe patient care according to facility policy and procedure.

1. Assesses patient status on admission and on an ongoing basis.
2. Implements appropriate standards of care based on assessment data and patient's own goals. Goals are mutually set with the patient and family
3. Coordinates nursing interventions to enhance achievement of expected outcomes and to ensure readiness for discharge.
4. Ensures provision of patient care daily in an organized and timely manner.
5. Adheres to all facility policies and procedures when providing patient care.
6. Utilizes nursing care standards when planning and implementing patient care.
7. Demonstrates ability to direct and provide for patient care in emergency situations.
8. Assesses learning needs according to patient's level of understanding and readiness to learn.
9. Evaluates patient's progress toward outcome achievement on an ongoing basis.
10. Revises plan of care based on change in patient status and/or information gathered at change of shift
11. Documents patient's progress toward achievement of outcomes.
12. Directs others in the implementation of the teaching plan.

1. Assumes an active role in the provision of quality nursing care for patients receiving care.

1. Analyzes nursing care provided in the facility related to the established standards of care.
2. Participates in the monitoring and evaluation of nursing care provided.
3. Demonstrates ability to coordinate the nursing care provided in the facility.
4. Assigns patient care responsibilities based on patient needs and abilities of available staff.
5. Assumes charge nurse responsibility as assigned.
6. Demonstrates ability to make decisions concerning facility-based problems.
7. Participates on quality council to facilitate improvement of patient care.
8. Participates in the orientation of nursing staff.
9. Participates in developing standardized patient education programs, as requested.
10. Participates in team conferences on assigned patients.

1. Demonstrates continued competence in assessing, treating, and caring for individuals based upon age-specific needs utilizing a developmental perspective.

1. Demonstrates appropriate knowledge and competence of designated skills identified for position.
2. Displays an understanding of each patient's cognitive, physical, emotional, and chronological maturity in the assessments, treatment, and care undertaken based on age-specific criteria.
3. Appropriately modifies approach to the patient based upon patient age utilizing a developmental perspective.
4. Provides appropriate age-specific interventions related to safety issues.

1. Demonstrates appropriate knowledge and competence of designated skills identified for position in postanesthesia patient care duties.

Postanesthesia Care:

1. History and physical assessment of patient.
2. Completes review medical record.
3. Verifies surgical/procedure site with patient and according to surgical schedule and patient History and Physical.
4. Provides instructions according to patient need.
5. Communicates with members of healthcare team.
6. Verifies patient history and physical present on medical record prior to procedure,
7. Completes proper identification of patient according to policy and current clinical practice guidelines.
8. Receives report from OR nurse and anesthesia personnel.
9. Monitors vital signs, recognize emergencies and notify Anesthesiologist.
10. Maintains or improves circulatory function.
11. Maintains patient normothermia.
12. Promotes physical comfort and provide emotional support and safety for patient.
13. Checks dressings, drains, tubes and patency of catheters as appropriate.
14. Assures availability and proper function of equipment.
15. Carries out MD orders.
16. Protects patient rights to privacy.
17. Assists with preoperative and postoperative patient calls.
18. Provides emergency care according to physician and administrative policy.
19. Sets priorities to facilitate the flow of patient efficiently.
20. Cleans equipment according to procedure.
21. Assists with preoperative and postoperative patient calls.
22. Reviews charts for completeness and signatures of physicians.
23. Assists with cleaning of preoperative and recovery room areas according to policies and procedures.
24. Prepares and restocks area for following day.
25. Checks inventory and notifies appropriate staff member to re-order.
26. Notifies appropriate staff member to order non-drug supplies.
27. Initiates appropriate infection control measures.
28. Maintains an environment that promotes safety:

• Temperature range
• Electrical safety measures
• Oxygen and Suction Equipment
• Resuscitation Equipment
• Noise Control
• Traffic Control
• Control of Contamination

Discharge Care:

1. After stabilizing the patient, request Anesthesia exam and discharge order or discharge per criteria as appropriate.
2. Explain discharge instructions with patient, family, responsible adult.
3. Assist patient in dressing.
4. Transport patient to family using transportation safety.
5. Discharges patient upon order of anesthesiologist and/or attending physician in accordance with procedure.
6. Arranges transfer of patient to hospital, as needed, according to procedure as ordered by physicians.
7. Completes discharge Follow-Up per policy and current clinical practice guidelines.
8. Contacts each patient the next business day following the procedure to assist with any problems or questions that may have developed.

1. Teamwork/Accountability/Integrity:

1. Utilizes time effectively.
2. Follows established facility policies and procedures with regard to attendance.

1. Maintains attendance according to guidelines and policy established by facility.
2. Adheres to tardiness policy.
3. Provides notification for unscheduled absences or tardiness in accordance with established departmental procedures as noted by supervisor.
4. Requests scheduled time off according to procedure as noted by supervisor.

1. Completes all documentation to ensure the availability of accurate and up to date information in accordance with established standards.

1. Maintains accurate records of controlled substances.
2. Documents nursing care and physicians orders according to facility policy and best practice guidelines.

1. Adheres to established facility safety requirements and procedures to ensure a safe working environment.

1. Demonstrates to competent usage of proper body mechanics in all activities.
2. Identifies potentially unsafe situations and notifies supervisor.
3. Completes all Teammate/patient event and Variance documentation in a thorough and timely manner, as required by policy.
4. Demonstrates complete understanding of established emergency procedures for facility.
5. Practices infection control, standard precautions and universal precautions as instructed or trained.
6. Maintains work area and equipment in a neat, organized manner.

1. Assists with housekeeping tasks as necessary to provide a safe environment for patient's, teammates, physicians, and guests.
2. Performs all other duties as assigned by manager.

1. Continuous Improvement:

1. Maintains and evaluates own clinical expertise and clinical practice.

1. Attends 75% of unit based staff meetings and demonstrates review of minutes for any meetings missed.
2. Provides in-services as requested by management
3. Participates in scheduled performance appraisals and demonstrates dedication to ongoing performance improvement.

1. Responsibly demonstrates and the importance of continuing education to the performance of facility responsibilities and growth in profession.

1. Maintains and displays appropriate knowledge of professional developments through printed material or other sources.
2. Attends professional training seminars when appropriate for job development and shares information with other Teammates.
3. Attends and participates in all applicable facility training and development workshops scheduled by the facility
4. Maintains work area and equipment in an organized and clean manner
5. Maintains dress and appearance according to standards as observed by management
6. Maintains up-to-date knowledge of job description, role, and responsibilities through continuing education activities
7. Maintains certification requirements and submits required evidence of certification to facility management for teammate file
8. Strives to be professional, courteous, helpful and cooperative.

1. Performs all other duties as assigned by management.

1. Compliance:

1. Upholds and practices the principles and policies of the SCA Compliance program.
2. Demonstrates the safe operation of equipment and machinery and follows procedures for reporting and correcting an unsafe situation.

1. Service Excellence:

1. Communicates patient information to assure confidentiality and continuity of care.

1. Documents all patient information according to established standards of care, policies and procedures.
2. Provides hand-off reports to other teammates that are accurate, concise and pertinent to the patient's condition and response to care.
3. Provides pertinent patient information to the physician, family, teammates and other members of the multidisciplinary team.
4. Discusses patient information with other health team members in an appropriate environment.
5. Documents patient's/significant other's response to teaching interventions.

1. Interacts with all patients, families, visitors and fellow employees in a mature, responsible manner to ensure a positive and professional facility environment.

1. Displays a caring and responsive attitude and conducts all activities respecting patient, family and employee rights and expectations.
2. Maintains confidentiality of all facility and patient information as required by facility policy.

1. Fosters a positive and professional facility environment by interacting with all persons in a considerate, helpful and courteous manner and by participating as a team member.

1. Diffuses/resolves conflict by appropriately communicating with those involved.
2. Accepts constructive criticism and gives suggestions in a professional manner.
3. Considers age specific needs in communication.

1. Maintains dress and appearance according to standards as observed by management.
2. Demonstrates the safe operation of equipment and machinery and follows procedures for reporting and correcting an unsafe situation.
3. Demonstrates understanding and puts into practice the SCA value of Service Excellence.

1. Financial Skill:

1. Completes appropriate financial management responsibilities.

1. Provides input re: equipment needs/supply needs.
2. Completes patient charges in accordance with facility procedure.
3. Demonstrates sound cost containment techniques.
4. Participates in periodic inventory count as assigned by management.

1. Proficiency or Productivity Standards

ENVIRONMENTAL CONDITIONS: Indoors in climate controlled environment. Patient care environment with potential exposure to unpleasant odors, to blood and body fluids which may carry infection, to infectious disease, and to chemical and electrical hazards. Occasional exposure to outdoor climate.

PHYSICAL REQUIREMENTS: Good visual acuity, accurate color vision. Ability to lift/transfer patients in excess of 100 pounds, which may require pushing, pulling and essentially utilizing a full range of body movement. Ability to stand, walk, stoop, kneel, crouch and/or crawl. Ability to reach, grasp, use fine finger movement and feel fine sensation to discern temperature, texture, size and shape. Ability to speak and hear.

MACHINES/EQUIPMENT USED: Clinical equipment used for patient care, i.e., suction machine, patient diagnostic equipment, patient monitoring equipment, office equipment: computer, Xerox machine, addressograph.

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