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RN- PACU
3 months ago
Job Summary
Responsible for the planning and delivery of patient care utilizing nursing processes. Oversees the plan of care for the patient in the immediate post-operative phase. Utilizes effective problem solving strategies and applies evidence based practices while supporting quality standards of a Magnet designated hospital. Practices under the supervision of the Nursing Manager/Director. Provides compassionate and family centered care for PACU patients.
Job Specific Duties
- Recovers patients and supports airway management in collaboration with Anesthesia during Phase I Post-Operative Care.
- Monitors surgical site and performs post-surgical site assessment checking for circulation, color, temperature, and movement.
- Monitors post-operative bleeding.
- Sets up all PCA pumps according to standards and initiates all transfusions of blood/blood products per policy to include cardiac, ICU, NICU, PICU, CICU patients.
- Administers direct patient care especially through the nursing process of assessment, recovery and vitals, intervention, and evaluation.
- Collaborates with the medical staff in review of all post op orders to minimize any delay of care.
- Completes all nursing multi-system assessment that includes head to toe, vitals, pain management, post anesthetic scores, and airway management.
- Communicates and documents the patient’s progress including critical findings, changes in patients' condition with the physician and/or disciplines involved in the care of the child.
- Implements and documents the plan of care in collaboration with other disciplines and services to assure safe and efficient care.
- Follows physician’s orders, administers and provides medications when needed. Adheres to six rights of medication administration per Medication Administration policy.
- Utilizes the EHR hand-off tool to initiate/accept handoff from the OR RN and Anesthesiologist and continue to provide airway management and pain management.
- Promotes family centered care by ensuring parental presence in the PACU. Educates patient and family on post-operative care and medications .
- Works collaboratively with all levels of the hospital interdisciplinary team and promotes the team concept within the department & hospital wide.
- Interacts with patients and families to review plan of care, creates a family-centered environment by requesting input and communicating any patient and family concerns to physician.
- Collaborates with the PGR Representatives to provide timely and effective communication to families.
- Actively participates in the performance review process through chart reviews and documentation of quality metrics and ensures timeliness of charting and all requirements are met.
- Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation in the patient’s electronic health record.
- Promotes a safe "error free" working environment by consistently adhering to infection prevention on their assigned shift.
- Participates in the Environment of Care rounds to ensure that rounds are completed.
- Demonstrates proper personal protective equipment (PPE) indication and use.
- Provides patient information and effectively completes the hand off process.
- Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner, & is accountable to regulatory, requirements of the DNV, CMS, DOH, & other accrediting agencies.
