|Facility:||St. Joseph Regional Health Center (Bryan)|
|Department:||SJH OPERATING ROOM|
Plans, organizes, and administers comprehensive nursing care in accordance with department policies, procedures, and standards of care and directs nursing care activities of team members to ensure excellent care is provided to all guests.
- Assessment.Does admission and ongoing assessment of patient's condition to ensure that proper care is provided to the patient. Provides nursing care to meet the patient's physical, psychological and spiritual needs. Notifies doctor of changes in assessment that require attention. Implements falls prevention and wound assessment programs.
- Planning.Designs, directs, evaluates, and documents the plan of care, patient/family teaching and discharge planning to ensure that all aspects of the patient`s stay are tended to in a reverent manner. Uses multidisciplinary teaching (Social Services, Home Health, etc.) to ensure a safe environment for patient care and discharge.
- Implementation.Prepares patients physically, psychologically, and spiritually for treatments, operations, and diagnostic studies to relax patients and put them at ease. Knows patients' conditions and reports changes to Charge Nurse, Assistant Director of Nursing Service, or physician. Transcribes physician orders and is responsible for seeing these orders are carried out. Follows infection control policy for phlebotomy, catheterizations and wound care. Starts and maintains intravenous infusions, including the administration of IV medications. Administers medications and notes patients' reactions. Follows policy, procedure and standards of hospital and department. Floats to other areas as necessary for patient safety. Demonstrates understanding of department specific equipment (i.e., safe use, requisitions, trouble shooting).
- Evaluation.Documents response to treatments, medications, therapies and teaching to guarantee that patient's records are up-to-date.
- Documentation.Maintains accurate and complete records of nursing observations and care to ensure accurate documentation of said observations. Maintains accurate documentation of interventions and supplies used. Documents 12 hr chart checks.
- Report Skills.Provides an accurate and comprehensive report to the oncoming shift to help establish continuity of patient care. Takes report from off-going shift and delegates tasks as needed to provide continuity of care according to coworker's experience, abilities and the patient acuity.
- Supplies.Maintains accurate documentation of charges and supplies used to ensure efficient use of allocated funds.
- Time Management.Clocks in according to policy to ensure work is started and completed on time and to lead by example. Gets NM/AD approval before working overtime shifts.
- License. Maintains RN license to adhere to BNE Guidelines and serve the organization in a licensed capacity. Assists with the orientation of new employees and floated staff.
- Meeting/In-service Attendance. Attends in-services, workshops, and reads current journals to keep abreast of new developments in the medical and nursing fields. Also, attends 6 unit meetings per year, mandatory in-services, annual competency fair and team conferences.
- Patient Care:Identifies patient, operative procedure, site, surgeon, and consent form to ensure that the proper procedure is being performed. Evaluates patient status, understanding, perception of surgery, anxiety level, skin integrity, and disabilities. Verifies patient allergies, NPO status, H & P, and lab values. Develops a plan of care for nursing action to achieve the patient goals. Assists in assembling instruments, supplies, and equipment to help other team members. Implements nursing actions to support plan of care and preferences of the anesthesiologists and surgeons. Provides emotional support and comfort for the patient. Provides patient safety; assists anesthesia; provides for patient transfer and transport; performs counts according to policy; monitors aseptic technique and follows BSI protocol. Requests preference cards changes through the Team Leader to accommodate guests' needs. Documents implants, lot numbers, descriptions, sizes, etc. to ensure that records are kept according to protocol. Documents unusual occurrences, medical safety device issues, etc.
- Professional/Management:Demonstrates education, training, or an equivalent combination of both, consistent with standards for operating room nursing education and practice as defined by the AORN to serve the organization as a knowledgeable and trained healthcare professional.
- Performs other duties as assigned to meet the organization`s needs.