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Operating Room Nurse
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Operating Room Registered Nurse Traveler
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RN- Operating Room
3 months ago
Job Summary
Responsible for the planning and delivery of care utilizing nursing processes, assessment, implementation and evaluation. Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practice. Supports and upholds quality standards of a Magnet designated Hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate, and family centered care for Surgical Services patients.
Job Specific Duties
- Ensures completion of surgical documentation requirements (consent, labs, H&P, patient history, etc.). Completes process accurately as per Universal Protocol and hospital policies and procedures.
- Greets family/patient and transports patient into OR. Acts as liaison to update family with procedure progress to ensure top tier patient and family satisfaction (SEI index).
- Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
- Provides nursing care that includes IV site monitoring, specimen collection, and assists medical team with specific procedures.
- Follows physician's orders, administers, and reconstitutes medications when needed. Adheres to six rights of medication administration per medication administration policy.
- Collaborates with a multi-disciplinary team in daily care planning, as appropriate, and fosters a Family Centered Care Environment.
- Ensures and monitors set up and maintenance of sterile field, performs all reconciliation, and counts of instruments per retained surgical site policy.
- Coordinates utilization of antibiotics per protocol and according the physician preference cards.
- Prepares all medication required for surgical field as determined by the procedure.
- Remains with the patient during emergence and extubation. Assists Anesthesia team as needed.
- Transports the patient to recovery room and completes the SOAR checklist for the procedure with transition of care performed with a hand-off to the PACU RN.
- Ensures advanced directives, secures blood consents, documents time-out procedures, ensures the correct site/side is marked, (when applicable) & admins antibiotics as per Universal Protocol.
- Performs reassessments as per policy and when there is a change in the plan of care, or when an intervention is performed.
- Accesses electronic health record (ERM) and performs charge reconciliation according to hospital policy and completes accurate and timely documentation in the patient's electronic health record.
- Communicates and documents critical lab results per hospital policy and procedures.
- Communicates with patients and families to review plan of care and solicits input and communicate any patient and family concerns to physician.
- Promotes an "error free" working environment by consistently providing high-quality safe care prompted as per the Universal Protocols Policy and Prevention of Retained Surgical Items Policy.
- Performs skin & structural assessment, takes measures to accommodate patient, and ensures safe care while ensuring no medication errors. Performs falls risk assessment & takes appropriate steps.
- Provides patient information and effectively completes the hand off process (SOAR document on hand off items) at and patient reassignments.
- Responsible for proper personal protective equipment (PPE) indication and use.
- Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH & other accrediting agencies.
- Accountable to optimize first case starts to prevent delay of patient care as per departmental goal.
- Promotes safety by actively practicing time-out. Documenting all implants and blood transfusion products per the Surgical Services Policy on blood transfusions, implants and time-out procedures.
