Surgery

## Description

CASS REGIONAL MEDICAL CENTER

Department Name: Surgery

Title: Surgery RN

EEOC Classification: Professional/Non-Exempt

**PART ONE: Dimension and Description**

**Primary Purpose:** To assess, plan, implement, and evaluate the care of all patients assigned to the operating room, recovery room, and outpatient surgery, as well as to manage the supplies and equipment in the OR/RR/ASU, and to provide pre and post-op education.

**Formal Policy-Setting Responsibilities**: Formally responsible for providing input into policies associated with the job’s purpose and essential responsibilities.

**Routine Decision Making**: If pre-op lab and results are sufficient; surgical case schedule; if patient meets criteria for discharge from PACU/ASU.

**Formal Supervisory Responsibility**: No formal supervisory responsibility.

**Required Knowledge**: A&P; disease process; sterile technique; standards set by Association of Operating Room Nurses Association (AORN); functions and mechanism of multiple operating room equipment.

**Required Skills and Ability:** Computer skills; good communication skills; good organizational skills.

**Unusual Working Conditions:** Risk of blood, body fluid contamination.

**Education and Certification/ Registration required for the Position:** Two to four-year RN degree; currently licensed in the state of Missouri; ACLS/BLS required; PALS preferred.

**Age Specific Competencies:** Provides care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

**PART TWO: Essential Responsibilities and Tasks**

**Assesses, Plans, implements and evaluates patients receiving high risk specialty procedures. (40% of time)**

• 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 patient education. (15% of time)**

• 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.

**Maintains a safe and comfortable environment. (25% of time)**

• 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.
• 8. Accurately records, handles and labels specimens; demonstrates care of specimens.
• 9. Ensures alarms on any assigned area are audible to alert staff.
• 10. Assists with the cleaning and care of surgical instrument.
• 11. 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. (10% of the time)**

• 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. (5% of the time)**

• 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 w