Under the direction of the Clinical Manager and the Nurse Coordinator, this position assesses plans, organizes and evaluates all aspects of patient care for assigned unit/patients.
Reports to: Nurse Coordinator/Nurse in Charge
Essential Job Functions
- Utilizes the nursing process to provide quality patient care according to established standards of care which includes planning, implementing, evaluating and adjusting plan of care, and discharge planning based on expected patient outcomes.
- Admits, transfers, and discharges patients.
- Completes ongoing patient assessment and documents according to policy.
- Completes nursing assessment within 2 hours of admission, or designates reason for incompleteness. Reviews database and nutrition screen.
- Participates in the development of patient plan of care to include patient problems, goals, evaluations and interventions.
- Reports symptoms and significant changes in patient’s condition to appropriate personnel.
- Assesses, collaborates and coordinates patient’s discharge planning needs and readiness for discharge with other members of the care team.
2. Demonstrates appropriate application of age specific standards, policies and procedures and guidelines in caring for adolescent, adult, and geriatric patients.
- Follows age specific standards in administering medications based on patient’s age.
- Follows age specific standards of care during altered states of consciousness related to analgesia, conscious sedation or anesthesia.
- Uses age specific standards, policies and procedures and guidelines to perform treatments and procedures that are routine for unit/clinic based on patient’s age.
- Incorporates cultural and developmental needs into plan of care.
- In collaboration with the patient/family, and in a developmentally and culturally appropriate manner, implements the plan of care.
- Demonstrates competency in the provision of nursing care according to established standards of nursing practice and in a developmentally appropriate manner.
- Demonstrates critical thinking skills, ability to provide and delegate activities to staff based on patient assessment and the requirements to deliver care in a safe efficient manner maximizing positive outcomes for the patient.
- Provides documentation of patient care in the patient record according to established standards of nursing care.
- Collaborates and works cooperatively with physicians and other members of the multidisciplinary health care team in formal and informal teaching of patients and/or family about his or her disease process and wellness promotion plan and discharge planning.
- Assesses patient/family learning needs, abilities, preferences, and readiness to learn.
- Utilizes a collaborative interdisciplinary process to provide appropriate patient/family education.
- Utilizes available information to evaluate the effectiveness of teaching in producing the desired patient outcomes and makes adjustments in teaching as indicated.
- Participates in performance improvement activities which include collecting, analyzing data to identify quantifiable measures to maintain quality and the promotion of desired outcomes. Also includes participation in development of patient care delivery systems, standards, policy and procedures, and problem solving teams.
- Demonstrates an awareness and relevance of research in nursing. Evaluates practices to identify areas for improvement or opportunities for research.
- Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
- Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.
- Maintains and protects confidentiality regarding all aspects of patient care, personnel and strategic issues. Adheres to Confidentiality Policy.
- Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s Guidelines for Appropriate Conduct in the HR Manual.
- Displays honesty and mutual respect when communicating with peers and other departments.
- Follows through on problems that may compromise effective job performance by using appropriate chain of command.
10. Post Anesthesia Care Unit Phase I specific duties include unit functions
addressing the nursing process aspects of assessment, planning,
implementation and evaluation as well as the nursing functions of teaching,
risk management, time management and communication as indicated in the
10.1 Receives patient from the operating room with report of pertinent history
and procedure (surgery performed, medications, fluids, complications,
anesthetic/sedation/reversal agents, emotional status pre-procedure.)
10.2 Obtains baseline pre-procedure vital signs.
10.3 Performs physical exam and vital signs per facility protocol.
10.4 Proficient in basic dysrhythmia interpretation.
10.5 Obtains diagnostic studies appropriate to patient diagnosis and
10.6 Utilizes clinical experience, knowledge and data to collaborate with
physicians and other health care providers to ensure appropriate follow
10.7 Plans patient care based on identified assessment analysis and
established standards, policies and procedures.
10.8 Includes patient, family/significant other, legal guardian whenever possible
in plan of care action development during PACU admission.
10.9 Documents all findings appropriately and in a timely manner.
10.10 Demonstrates proficiency in all unit specific competencies.
10.11 Evaluates patient care goals, quality and appropriateness of care
provided and patient outcomes.
10.12 Effectively explains rationale for care provided to patient and/or family,
significant other or legal guardian.
Education: Graduation from accredited school of nursing; Bachelor of Science in Nursing is preferred.
Certification, Licensure: Current state license as a registered nurse; current CPR certification; ACLS certification required within 6 months of employment.
Experience, Training, Knowledge: One (1) to three (3) years experience as an RN. Experience in orthopedic, neurosurgical, pain management specialties preferred.