Ambulatory Surgical Center

Job Description Summary

Manages individualized, outcome oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures

Job Description

1 - ASSESSMENT/REASSESSMENT
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients

a - Performs preaneasthesia assessment including history of the preanesthesia patient. Identifies factors impacting the patient's upcoming procedure.
1. Obtain Comprehensive patient health history.
2. Obtain a complete history including system review
3. Obtains all preoperative testing results.

b - Completes nursing assessment record according to guidelines/policy.

c - Assesses patients level of comfort utilizing approved pain scale for patients in a specific age category.

d - Determines testing based on specific clinical indicators and risk factors, such as age, pre-existing conditions and magnitude of surgical procedure.

2 - PLAN OF CARE
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient, in collaboration with each patient/family/significant other in order to address all identified needs.

a - Develops written plan of care for patient needs and documents care plan according to established guidelines including:
Problem/need assessment
Nursing interventions
Other needed services of healthcare team
Outcome criteria met/not met

b - Assists patients and families/significant others in developing health care goals which are part of the individualized plan of care

c - Develops patient/family/significant other teaching and discharge plan and documents according to policy

d - Identifies issues that may impact patient's surgical plan and communicates accordingly.

3 - MEDICATION ADMINISTRATION
Demonstrates the skills and judgement necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient.

a - Demonstrates knowledge of SSH policies and procedures for recording medications and completion of medication reconciliation intake form.

b - Demonstrates knowledge of commonly used medications: action, dose and side effects and uses resources to review new or unfamiliar medications as they pertain to the surgical procedure.

4 - DOCUMENTATION
Maintains up-to-date documentation of nursing care provided to assure the integration of information for use by the healthcare team, in order to assure quality care.

a - Discharge plan accurately reflects patient and/or significant other’s ability to manage care after discharge .

b - Referrals are made based on identified needs and communicated to the healthcare team according to policy

5 - DELEGATION
Directs other licensed and non-licensed personnel in the provision of care to patients as assigned.

6 - SAFETY
Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.

a - Follows approved procedure for verifying MD orders including a verbal readback to the licensed independent practitioner after receiving a telephone order.

b - Complies with the current CDC hand hygiene guidelines through proper handwashing , as observed by nurse manager and peers.

c - Assesses and periodically reassesses each patient's risk of falling utilizing the approval fall risk assessment tool, according to policy.

7 - PROFESSIONAL DEVELOPMENT
Assumes overall responsibility for professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.

a - Keeps current in all hospital and unit based education.

b - Incorporates knowledge gained from professional organizations and literature into practice.

c - Takes action to achieve goals identified in the evaluation process.

8 - COLLEGIALITY
The registered nurse interacts with, and contributes to the professional development of peers and colleagues.

a - Shares knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentation at formal or informal meetings.

b - Provides peers with constructive feedback regarding practice or role performance.

c - Interacts with peers and colleagues to enhance nurse's own professional practice or role performance.

d - Maintains compassionate and caring relationships with peers and colleagues.

e - Contributes to an environment that is conducive to education of healthcare providers.

9 - LEADERSHIP
The registered nurse provides leadership.

a - Works as a team player and team builder.

b - Teaches others to succeed by mentoring and other strategies and inspires loyalty by valuing people as the most precious asset in an organization.

c - Exhibits creativity and flexibility through times of change and demonstrates energy, excitement, and passion for work.

d - Willingly accepts mistakes by self and others, thereby creating a culture in which risk-taking is not only safe but expected.

e - Serves in key roles in the work setting by participating on committees, councils, and administrative teams.

ESSENTIAL FUNCTIONS (Cont.)

1 - Technology and Learning

a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

JOB REQUIREMENTS

Minimum Education - Preferred

Graduate of an accredited School of Nursing

Minimum Work Experience

Demonstrated proficiency in acute care nursing, knowledge and skills

Required Licenses / Registrations

RN - Registered Nurse

Required Classes/Skills -

BLS - Basic Life Support