RN PreopPACU

JOB TITLE Registered Nurse Preop/PACU POSITION
SUMMARY This position assesses plans implements evaluates and documents nursing care of patients in accordance with organizational policies and in accordance with standards of professional nursing practice utilizing the framework for professional nursing practice and development. This position is accountable for the quality of nursing services delivered by self or others who are under their direction. This position utilizes specialized knowledge judgment and nursing skills necessary to assess data and plan provide and evaluate care appropriate to the physical and developmental age of assigned patients.
ESSENTIAL FUNCTIONS

• Assesses patient physical psychological social spiritual educational developmental cultural and post operative planning needs. Reviews patient history and physical with patient/family and assures completion within appropriate timeframe. Reviews available information obtained by other health care team members. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and as outlined in policy.
• Formulates a plan of care including the discharge plan utilizing assessment data and patient family and health team input. Initiates a plan of care based on patient-specific needs assessment data and the medical plan of care. Goals for patient are realistic measurable and developed in conjunction with the patient/family. Considers the physical cultural psychosocial spiritual age specific and educational needs of the patient in the plan of care. Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patients status.
• Implements the plan of care through direct patient care coordination delegation and supervision of the activities of the health care team. Provides care based on physician orders and the nursing plan of care in compliance with policies and procedures standards of care and regulatory agency requirements. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
  Evaluates the patients and familys response to care and teaching and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patients response and the effectiveness of patient teaching.
  Documents assessment planning implementation and evaluation in the patient record. Documentation is legible timely and in accordance with policy. Documentation reflects objective/subjective data nursing interventions and patients response to treatment. Notes physician orders accurately and in a timely manner.
  Provides care based on the best evidence available and may participate in research activities within clinical practice. Participates in facility shared leadership. Interacts and participates in the education role development and orientation of facility personnel patients students families and visitors. Promotes/supports growth of others through precepting and mentoring when appropriate.
  Contributes to society through activities that lead to excellent patient outcomes through timely effective efficient equitable and safe care. Actively participates in the improvement of national nursing quality indicators and outcomes. Such activities may include participating in professional organizations.
• In some locations this position may provide relief charge for staff and work flow of the department.