Staff Nurse - 2 East Medical/Surgical Observation

Position Purpose

Responsible for assessing, planning, implementing and evaluating the care of the immediate post-anesthetic/post-operative patient. Accurate and complete documentation, reflecting implementation of the nursing process.

Role Specific Competencies

1. Actively participates in the development and / or administration of continuing education for the Registered Nurse.

2. Adheres to professionalism standards.

• Serves as a role model/resource for other team members and exhibits flexibility and adaptability to change in department practices.
• Identifies strengths and development needs of self.
• Identifies active/potential problems and seeks appropriate solutions to those problems, and assumes responsibility and accountability for "judgments" and actions.
• Appearance consistently complies with department policy.
• Participates in orientation and training of new personnel.
• Utilizes work time productively.
• Willingness to cover varying shifts as requested.

3. Adheres to the standards of the American Society of PeriAnesthesia Nurses Practice (ASPAN), The Joint Commission and other regulatory agencies.

4. Delivers quality nursing care to surgical patients during the immediate post-anesthesia phase that is consistent with published standards for nursing practice.

• Assessments and interventions are accurately and legibly recorded, timed, dated and signature affixed.
• Identified patient problems are documented in appropriate nurses note form.
• Changes in patient status are reported immediately to anesthesia, attending physician, Surgeon, and Radiologist that results in appropriate medical intervention.
• Documentation reflects implementation of the nursing process in PAC U.
• Nursing interventions meet standards and result in no injury or harm to patients.
• Develops, documents, implements and revises plan of care that meets patient's current needs and results in appropriate nursing interventions.
• Reviews and carries out a discharge plan for teaching self care required to outpatients and/or family members.
• Documents patient's responses to interventions.
• Orients new personnel as assigned to policies and procedures, resulting in no errors on part of orientee during probationary period.
• Promotes and maintains a comfortable and therapeutic environment.
• Provides pain control and other comfort measures.
• Demonstrates appropriate critical thinking and clinical judgment which promotes optimal outcomes.
• Supervises and delegates duties to the Patient C are Techs, Patient Escorts and the Unit C lerks as needed to promote optimum patient care.
• Ensures use of a complete and systematic approach to hand-off process and transfer of care.
• Maintains patient rights and dignity.

5. Demonstrates skills and knowledge necessary to provide quality care services for special age specific populations, such as, but not limited to, pediatrics and geriatrics patients. (Attach current skills inventory and/or skills check list; any current age specific certifications; departmental testing; etc.)

6. Knowledge and skill levels are maintained to ensure clinical competency that ensures safe patient care.

• Clinical competency checklist is maintained and completed prior to annual evaluation.
• Attends 80% of continuing education programs offered within the department.
• Assumes responsibility for maintaining a safe work environment that promotes patient care activities.
• Complies with and enforces relevant hospital/departmental policies and procedures.
• Participates in professional development / continuing education.
• Maintains personal accountability for professional competency.

7. Organizes nursing activities efficiently and safely which expedite patient care in a cost effective manner, within unique PAC U environs.

• Completes assignments within allotted time frames that reflect appropriate priority setting.
• Priorities established and implemented result in no delay to appropriate intervention.
• Able to problem-solve independently seeking assistance appropriately.
• Utilizes equipment and supplies as intended resulting in cost containment.
• Identifies co-workers' needs for assistance and responds appropriately.
• Consults, collaborates and cooperates with peers and other healthcare providers to improve quality, effectiveness and efficiency of patient care.
• Performs all other duties as assigned.

8. Participates and supports unit level functioning.

• Attends and participates in staff meetings.
• Participates in discussion of Quality Improvement Measures.
• Successfully completes all hospital and unit-based required education courses as scheduled.
• Adheres to attendance and tardiness policy.
• Participates in unit based and hospital Performance Improvement efforts and data collection as directed.

Qualifications and Experience

• Current AC LS is required.
• Current C PR/BLS is required.
• Current RN licensure in the State of Maryland.
• Hospital certification in Defibrillation, IV insertion blood glucose monitoring (Accucheck).
• Knowledge of anesthesia drugs and patient-expected response.
• Recent PACU experience or one year critical care experience, or two years Telemetry experience plus must attend Critical Care course given at an accredited institution.
• RN graduate from an accredited school of nursing.

Physical Requirements

• Concentrates on moderate to fine detail for extended periods of time with irregular telephone and other interruptions.
• Engages in frequent verbal and written communication using acceptable medical terminology.
• Must be able to function in an environment where background noises are a usual occurrence.
• Remembers schedules, tasks to be completed, where activities left off, etc.
• Routinely lifts objects over 50 lbs with good body mechanics.