Surgery

CASS REGIONAL MEDICAL CENTER•Harrisonville, MO

1d•Onsite

About The Position

The Primary Purpose of this role is to assess, plan, implement, and evaluate the care of all patients assigned to the operating room, recovery room, and outpatient surgery. This includes managing supplies and equipment in the OR/RR/ASU, and providing pre and post-operative education. The role involves providing input into policies associated with the job's purpose and essential responsibilities. Routine decision-making includes determining if pre-op lab results are sufficient, managing the surgical case schedule, and assessing if a patient meets criteria for discharge from PACU/ASU. There is no formal supervisory responsibility. Required knowledge includes A&P, disease process, sterile technique, standards set by the Association of Operating Room Nurses Association (AORN), and the functions and mechanisms of multiple operating room equipment. Required skills include computer proficiency, good communication, and good organizational skills. The working conditions involve a risk of blood and body fluid contamination.

Requirements

Two to four-year RN degree
Currently licensed in the state of Missouri
ACLS/BLS required
Computer skills
Good communication skills
Good organizational skills

Nice To Haves

PALS preferred

Responsibilities

Assesses, Plans, implements and evaluates patients receiving high risk specialty procedures.
Performs pre-procedure interviews per paper/computer correctly on all patients, evaluates the information obtained, and formulates a plan of care prior to the patient procedure.
Identifies the patients using two patient identifiers prior to the procedure 100% of the time.
Performs a comprehensive nursing assessment on patients and documents completely including appropriate signatures, times and dates.
Revises plan of care as indicated from the assessment.
Interprets physiological information from technical equipment, on each patient and applies this information to the plan of care.
Documents the findings from all assessments, evaluations and implementations on the patient record where, when, and how daily.
Reports all critical abnormal assessments and lab values to the physician, per hospital policy and implements further orders immediately and documents details on the patient record.
Adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.
Utilizes AIDET (acknowledge, introduce, duration, explain and thank) initiatives to include managing up with each patient.
Utilizes only approved abbreviations in patient documentation.
Provides pre-operative and post-operative teaching to all patients.
Evaluates patient learning ability and motivational levels.
Implements alternative learning measures, as evidenced by patient or caregiver verbalization or return demonstrations, as documented on the patient record i.e.; effectively communicates.
Effectively communicates discharge instructions to patient and responsible party at the time of discharge, per departmental discharge policy.
Explains all procedures and medications to patients prior to implementation.
Removes malfunctioning equipment from unit immediately upon discovering problem.
Complete requisition for repair or malfunctioning equipment by the end of shift.
Cleans and stocks supplies within the department, as needed.
Effectively communicates the plan of care on each patient to ancillary departments, case management and pharmacy staff as indicated by the orders received, patient diagnosis or condition.
Ensures all required documents are on the chart prior to going into the procedure room (H&P, informed consent, test results if applicable).
Evaluates the effectiveness of the communication, as evidenced by the preparedness of the patient and takes appropriate actions, including notifying performing physician.
Demonstrates thorough knowledge of location, care and operation of all departmental equipment.
Accurately records, handles and labels specimens; demonstrates care of specimens.
Ensures alarms on any assigned area are audible to alert staff.
Assists with the cleaning and care of surgical instrument.
Assists with terminally cleaning of OR rooms and documents on cleaning schedule.
Positions patients on operating table to facilitate surgical approach and to ensure patient safety for each case.
Uses padding on any boney prominences for each patient and documents on operating room record.
Applies cautery pads on muscular areas close to surgical site and away from any implants on each patient and documents on record.
Applies safety belt to each patient having surgery and documents on record.
Checks code blue carts each shift and upon using the cart, ensuring it has an intact tag attached.
If assigned as the scrub nurse, is fully responsible for care of instruments prior to, during and after the surgical case including appropriate transporting to decontamination.
Follows manufactures instructions for the sterilization equipment; knows responsibilities and the necessity for biological/chemical monitoring.
Able to accurately see and read color changes to biological and chemical monitors.
Demonstrates utilization of the nursing process through planning for patient care.
Pulls supplies for next day’s cases daily from departmental supplies according to physicians’ preference cards.
Orders special equipment as requested by physician or on preference card to have prior to surgery start time.
Updates preference cards to meet physician’s preferences so surgeon does not need to ask more than once.
Develops and promotes hospital/unit initiatives and professional relations.
Establishes and maintains effective communication and good working relationship with co-workers for the patients benefit.
Utilizes initiatives; strives to maintain steady level of productivity; self-motivated; manages activity and time; does not waste.
Participates in planning ways to solve problems and make improvements in the department as needed.
Represents the organization in a positive and professional manner.
Other duties as directed.