Surgery

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 waste.
• Participates in planning ways to solve problems and make improvements in the department as needed.
• Represents the organization in a positive and professional manner.

Other duties as directed. (5% of the time)

ESSENTIAL PHYSICAL REQUIREMENTS

x Heavy Work: Lifting 100# maximum with frequent lifting and/or carrying of objects weighing up to 50#.

Very Heavy Lifting: Lifting objects in excess of 100# with frequent lifting and/or carrying of objects weighing 50# or more.

PHYSICAL DEMANDS

x Lifting: Raising or lowering an object from one level to another (includes upward pulling).

x Carrying: Transporting an object, usually holding it in hands or arms or on the shoulders.

x Pushing: Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).

x Pulling: Exerting force upon an object so that the object moves toward the force (includes jerking).

x Hearing: Ability to determine audible communication.

x Stooping: Bending the body downward and forward by bending the spine at the waist.

x Kneeling: Bending the legs at the knees to come to rest on the knee or knees.

x Crouching: Bending the body downward and forward by bending the legs and spine.

x Crawling: Moving about on the hands and knees or hands and feet.

x Reaching: Extending the hands and arms in any direction.

x Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).

x Fingering: Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).

x Feeling: Perceiving such attributes of objects and materials as size, shape, temperature, or texture by means of receptors in the skin, particularly those of the finger tips.

x Speaking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

x Seeing: Obtaining impressions through the eyes of the shape, size, distance, motion, color or other characteristics of objects.

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.