JOB SUMMARY: The DSU RN is accountable directly to the DSU Charge Nurse, the Perioperative Services Clinical Supervisor and the Director of Perioperative Services, and indirectly to the House Supervisor. The Registered Nurse is responsible for the delivery of patient care through the nursing process of assessment, planning, implementation, and evaluation for all patients within the DSU scope of services. The Registered Nurse also coordinates the post-operative care of the patient with the surgeon and anesthesiologist, directs and guides other personnel while maintaining standards of care in the DSU. He/She communicates with the physician about changes in the patient's clinical condition including hemodynamic monitoring, results of diagnostic studies and abnormal results and symptomatology. Works with other departments and co-workers to provide quality patient care across the continuum, efficient patient flow and unit maintenance and organization. Responsible for adherence to regulations, standards and hospital or unit policies and procedures. Responsible for participation in Performance Improvement activities, unit meetings and in-services. Acts as a resource for other personnel as appropriate.
EDUCATION, EXPERIENCE, TRAINING
1. Current and valid state RN License.
2. Current BLS (AHA) certificate or must be obtained within 30 days.
3. ACLS (AHA) certificate within 6 months of hire date and maintained current.
4. PALS (AHA) certificate within 6 months of hire date and maintained current.
5. Previous DSU experience preferred or minimum of one year on the job training.
6. Certified Ambulatory Perianesthesia Nurse (CAPA) preferred.
7. Bachelor of Science in Nursing (BSN) preferred.
DUTIES AND RESPONSIBILITIES
1. Promotes and demonstrates vision, mission and values of the organization.
2. Reviews and implements physician orders and keeps physicians informed of patient's status. Accurately records and/or processes orders in a timely manner.
3. Implements care in a safe, knowledgeable, skillful, consistent and continuous manner, using nursing skills specific to the needs of the patient recovering from anesthesia and/or invasive surgical procedures.
4. Documents evidence of nursing care on the patient's medical record, based upon the nursing process in a legible, concise, timely and complete manner.
5. Uses two patient identifiers consistently when accepting patients, administering medicating, drawing labs or performing procedures on a patient.
6. Does not use unacceptable abbreviations in documentation and uses read back on all telephone orders. Reviews and transcribes all telephone orders. Follows telephone read back policy.
7. Initiates discharge and patient/family education planning with proper documentation in patient medical record.
8. Assures consistently that all clinical alarms, i.e., vital sign monitors, IV pumps etc. are set with the appropriate parameters for the patient and are audible at all times.
9. Ensures Crash Cart and Defibrillator function have been checked per protocol and after each use appropriate items are immediately replaced and indicated by signature on the crash cart checklist.
10. Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling.
11. Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to:
1) Appropriate use of lifting devices and equipment.
2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation.
3) Use of lifting devices to handle patients safely.
12. Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
13. Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines) and demonstrates appropriate use of personal protective equipment (e.g., gloves, gown, masks, and goggles) and hand hygiene techniques.
14. Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e. suction and oxygen immediately available when needed.
15. Completes pain assessment and reassessment consistently with the time frame after giving pain medications and upon discharge or transfer of patients.
16. Detects and reports medication errors and ADR's according to hospital policy. Safely and accurately administers medications and documents properly on the Medication Administration Record (MAR) in a timely manner.
17. Complies with all regulatory requirements for clinical pathways, clinical assessments, interventions and documentation
18. Maintains regular attendance.
19. Performs all other duties as assigned or required.