Operating Room Nurse Recent OR Experience Required

Summary

Manages individualized, outcome-oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures.
(Salary Range: $35.79-$69.09)

ESSENTIAL FUNCTIONS

1 - ASSESSMENTS/REASSESSMENT
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients
a - Provides ongoing assessment of nursing care needs of a defined group of patients
b - Completes nursing assessment record according to guidelines/policy
c - Documents assessment/reassessment data on medical record according to guidelines and standards
d - Conducts and initial and ongoing assessment to gather data relevant to the patient's individual needs
e - Recognizes the significance of abnormal laboratory values for patient's and takes appropriate action
f - Assesses patient's understanding of disease process.
g - * Assesses/reassesses and documents patient's level of comfort utilizing the approved pain scale for patients in a specific age category.
h - * Assesses/reassesses patient's response after each intervention both pharmacological and non pharmacological.

2 - UNIT SPECIFIC ASSESSMENTS
a - Pre-Op checklist is complete and signed. Consistently reviews and assures completeness.
b - *Consistently uses 2 patient identifiers.
c - *Assures that patient is marked before entering Operating Room.
d - Perioperative Nursing Assessment is complete, accurate, and signed.
e - Perioperative guidelines for Labs, EKG, H&P, and Medical Clearance are followed as per policy.

3 - PLAN OF CARE
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient, in collaboration with each patient/family/significant other in order to address all identified needs.
a - Develops written plan of care for patient needs and documents care plan according to established guidelines including:
Problem/need assessment
Nursing interventions
Other needed services of healthcare team
Outcome criteria met/not met
b - Based on reassessment, plan of care is modified to meet the patient/family/significant other's identified needs.
c - Develops patient/family/significant other teaching and discharge plan and documents according to policy.
d - Evaluates that the identified problems, care provided and patient's responses are reassessed in order to meet patient and family needs and documents outcomes according to policy/guidelines.

4 - UNIT SPECIFIC PLAN OF CARE:
a - Follows procedure for updating, revising, creating and deleting of Physicians Preference Cards.
b - *Assembles necessary instruments, supplies and equipment prior to the start of care.
c - * Checks for availability, proper conditions of equipment, instrumentation and implants.
d - Identifies priorities and executes nursing care accordingly.
e - Provides emotional support and comfort measures to patient and family
f - *Applies and monitors principles of aseptic technique throughout the intraoperative period.
g - Has the ability to scrub/circulate during the intraoperative phase.
h - Preps the surgical site using AORN standards of practice and proper aseptic technique.
i - *Confirms and contains sources of contamination.

5 - MEDICATION
Demonstrates the skills and judgement necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient.
a - Demonstrates knowledge of SSH policies and procedures for administering, and recording medications
b - Demonstrates knowledge of commonly used medications: action, dose and side effects and uses resources to review new or unfamiliar medications
c - *Observes the 5 R's for administering medications:
Right patient
Right drug
Right dose
Right method
Right time
d - * Performs narcotic count each time a narcotic medication is withdrawn from the Pyxis.
e - *Demonstrates proper procedure for documentation of narcotic administration and wasting, and follows the procedure for resolving narcotic discrepancy.
f - * Demonstrates procedure for the use of the override function in Pyxis
g - *Documents medication administration reflecting full signature and title, time given, reason for omission, and site for injection (if applicable)

6 - UNIT SPECIFIC MEDICATION
a - *All medications drawn up are labeled for procedures.
b - * All non-controlled medications removed by PYXIS are counted and amount properly recorded
c - * Unused medications are returned to PYXIS following policy.
d - * All narcotics are counted and signed off on a weekly basis.
e - * Antibiotic given by Anesthesia is recorded on intraopertive record by RN.
f - Initiates and maintains IV access according to SSH policy and procedure.
g - Completes medication reconciliation process per SSH Policy.
h - All medication that is used by the surgeon is documented on physician order set and signed by physician.

7 - DOCUMENTATION
Maintains up-to-date documentation of nursing care provided to assure the integration of information for use by the healthcare team, in order to assure quality care.
a - Patient medical record sheets are accurately signed with name and title.
b - Referrals are made based on identified needs and communicated to the healthcare team according to policy.
c - Nursing documentation is reflected in Integrated Progress Note with an entry made per standard and when reassessment of the patient requires.

8 - UNIT SPECIFIC DOCUMENTATION
a - Revises physician preference cards and communicates changes to appropriate personnel.
b - * Records are closed properly.
c - * Copy of on-line record is placed in patients chart.
d - All patient charges, including implants, are documented properly.
e - Accurately documents on-line intraoperative record including military time.
f - Assures accurate and complete documentation of the patient medical record.

9 - DELEGATION
Directs other licensed and non-licensed personnel in the provision of care to patients as assigned.
a - Based on patient care needs and skills of caregiver, delegates responsibilities accordingly.
b - Practices within the legal boundaries of the MA Nurse Practice Act and according to SSH Hospital policy and procedure.

10 - UNIT SPECIFIC DELEGATION
a - When assigned charge responsibilities manages staff and delegates assignments to staff with proper skill sets.

11 - SAFETY
Safety Awareness - Fosters a 'Culture of Safety' through personal ownership and commitment to a safe environment.
a - * Prior to the start of any invasive procedures, a final verification to confirm the correct patie.