Registered Nurse

Job Summary
:
Follows the nursing process from preoperative holding area to PACU; communicates with surgeon and anesthesia care provider about relevant patient medical/surgical history and medication allergies; pulls supplies, instruments, and equipment needed for surgical case; opens surgical case with scrub technologist, maintaining aseptic technique; counts with scrub technologist prior to incision; performs the Time Out; is at the patient’s side during induction and intubation and extubation;

safely positions patient with health care team; obtains additional supplies, instruments, and equipment as needed; performs final counts and makes sure they are correct; accurately documents and charges patient; gives report to PACU nurse with anesthesia care provider; performs biological testing for OR autoclaves, knowledgeable of immediate use steam sterilization policies and principles. Follows recommended practices of AORN.

Essential Functions
:

• The Perioperative Registered Nurse is responsible for providing quality nursing care utilizing the nursing process as reflected in AORN Standards of Perioperative Nursing Practice.
• Provides Safe and Appropriate Nursing Care to Patients Utilizing the Nursing Process and Demonstrates the Ability to Perform Clinical/Technical and Administrative Tasks
• Coordinates use of instruments, supplies and equipment for intraoperative phase based on patient’s needs and surgeon’s preference card
• Systematically assesses the health status of the patient and records health data
• Assesses knowledge level of patient preoperatively and provides basic teaching related to procedure and monitoring
• Is proactive in the Time Out process to be sure the patient’s procedure is performed on the correct site, side, and level
• Establishes nursing diagnoses; plans, implements, and evaluates nursing interventions – initiates changes when appropriate
• Protects the patient from injury caused by extraneous objects and chemical, electrical, laser, mechanical, and thermal sources
• Performs interventions to protect patient from surgical site infections
• Maintains patient’s normothermia
• Properly labels specimens and requisition forms
• Demonstrates flexibility and adaptability to changes as they occur
• Adheres to hospital policy for sponge counts, sharps, and instrument counts; protects patient from retained surgical items
• Provides education consistent with the patient/family’s learning abilities and preferences; evaluates outcomes

Effectively Communicates with Physicians, Co-workers, Patients, Families
:

• Reports pertinent observations regarding patients to physicians and other health care team members
• Hand-off report is given accurately and concisely; hand-off paperwork is completed
• Documentation on the patient’s medical record is accurate, complete and concise to ensure continuity in the provision and coordination of patient care
• Patient advocate – ethical and moral decision making per patient or family member’s wishes
• Uses problem solving and conflict resolution skills to foster effective work relationships with team members

Patient Safety
:

• Completes the Pre-Procedure form so that problems can be anticipated and corrected prior to the patient entering the OR
• Maintains National Patient Safety Goals, including participation in the Time Out process
• Verifies, coordinates and carries out physicians orders/preferences accurately
• Coordinates interdepartmental transfers smoothly and efficiently
• Coordinates interdepartmental activities related to SCIP measures to ensure timely efficient care
• Communicates and coordinates with coordinator and other nurses to ensure timely discharge, patient satisfaction, and quality care along the continuum of care
• Practices Standard Precautions
• Demonstrated knowledge of and practices department safety procedures, including safe handling of equipment and hazardous substances
• Responds to emergency situations to promote optimal patient outcomes by recognizing changes in the patient’s health status
• Initiates incident reports appropriately

Administers Medications in an Accurate and Timely Manner
:

• Follows the 5 “rights” when administering medications (patient, route, time, dose, med) after checking for allergies
• Uses 2 patient identifiers before administering medications
• Initiates and effectively maintains IV therapy

Participates in Quality Improvement
:

• Acts as a resource and mentor for others
• Verbalizes unit specific quality improvement projects
• Verbalizes hospital-wide quality improvement initiatives
• Collects, interprets or relays quality improvement data for the unit

Minimum Education/Certifications
:

• Graduate of an accredited school of nursing, preferably BSN program.
• Current NJ license or letter of permission from the New Jersey State Board of Nursing to practice in the state of New Jersey.
• CNOR and/or CRNFA preferred with maintenance of the required continuing education.
• One year experience preferred.
• American Heart Association (BLS)