RN Charge, PACU

General Summary Statement

Provides comprehensive, quality nursing care through application of the nursing process. Adheres to Nursing Policies and Procedures and Organizational Goals and Objectives.

Essential Duties and Responsibilities

Clinical Practice

1. Provides age appropriate care for the population served. Gives consideration to growth & developmental phase of life, to age related factors such as thermal regulation, nutrition, medication administration, nutrition, safety and functional needs of the patient.
2. Uses appropriate resources for patients with special needs such as language barriers, sensory problems, altered cognition, cultural and religious needs.
3. Ensures attention to patient’s physical, spiritual and emotional well-being.
4. Demonstrates competency in assessment and re-assessment skills of the Surgical, Endoscopy (ENDO), Interventional Radiology (IR), and Ambulatory Care Center (ACC) patient, plans and initiates care, and evaluates the effectiveness of interventions taking appropriate actions to move patient toward reaching goals of care.
5. Performs pain assessments and intervenes to optimally meet patient’s needs for comfort. Documents result within 1 hour after giving pain med.
6. Plans clinical care based on patient’s needs and uses available resources.
7. Performs clinical care in accordance with policy and procedure. Performs hourly rounding or as often as necessary.
8. Performs peripheral venipuncture and peripheral access care according to policy & procedure.
9. Follows Enhanced Recovery after surgery (ERAS) protocol.
10. Identifies situations that warrant patient rescue and takes appropriate action, e.g. Rapid Response, Code Blue/Pink/Green/Stroke Alert.
11. Adheres to the Universal protocol for patient Identification and Site Identification.
12. Integrates principles of infection prevention into practice.
13. Adheres to aseptic technique as appropriate.
14. Uses resources and references for reviewing policies and procedures, medications, and clinical information.
15. Prioritizes and organizes work effectively within assigned shift.
16. Identifies potential complications related to surgery and implements appropriate interventions.
17. Promotes restoration of function to optimal level at discharge by implementing surgical nursing measures.
18. Administers appropriate medications and infusions as ordered. Demonstrates current knowledge of pharmacology. Adheres to the rights of medication administration.
19. Collaborates with physicians/physician’s assistants/advance practice nurses about the care and treatment of the ACC, Prep/R, PACU, IR, and ENDO patient.
20. Demonstrates understanding of, use and functionality of bedside monitoring equipment, monitors, transport monitors, and emergency cart monitors. Adheres to Joint Commission Standards guidelines and core measures for the care of the patient.

Communication

1. Uses effective communication during hand-offs, huddles and schedule updates and overall collaboration regarding surgical patients. (e.g. Shift report, transfer report, daily operations etc.).
2. Organizes information into a meaningful format, such as Optime or SBAR.
3. Delegates appropriately to team members.
4. Communicates patient care information to the interdisciplinary care team.
5. Provides patient and family education in a manner that is understood and gives the patient and family handouts, brochures and resources that can be taken home for future reference.

Documentation

1. Demonstrates writing skills clearly that are appropriate for healthcare communication.
2. Documents patient care in an accurate, professional and timely manner using electronic medical record and paper documentation forms according to policy and procedure.
3. Documents patient care that is relevant to patient’s diagnosis, problems and reflects patient’s status.
4. Knows how to document critical labs.
5. Delegates appropriately to unlicensed personnel and team members.
6. Communicates patient care information to the interdisciplinary care team in a timely manner.
7. Provides patient and family education in a manner that is understood and gives the patient and family handouts, brochures and resources that can be taken home for future reference.
8. Demonstrates a cheerful, friendly manner while on duty.
9. Accepts assignments and performs as a team member to provide best outcomes for patients.
10. Introduces self to patient and explains procedures to patient and family.
11. Utilizes appropriate communication methods (e.g. SecureChat, text messaging, etc.)

Professional Role Development

1. Develops own nursing knowledge via practice, observation, professional literature, networking and attending continuing education programs.
2. Promotes best practice by demonstrating a commitment to quality patient care and the profession of nursing.
3. Promotes innovation and creativity in the practice environment.
4. Serves as a mentor for new employees. Mentors student nurses.
5. Accepts constructive feedback about performance or behaviors and shows evidence of change.
6. Adheres to the Department of Nursing Dress Code and maintains a professional appearance according to policy standards.
7. Maintains confidentiality.
8. Maintains good attendance/lateness standards in accordance with Hospital policy.

Department of Nursing and Organization Support

1. Attends assigned committee meetings and contributes to the committees. Reports back to staff.
2. Communicates support of organizational iCARE to BE values and strategies.
3. Supports the following organizational programs: Magnet®, Joint Commission Standards, Nursing Councils, and integrates their standards into clinical practice.
4. Reviews nursing quality data, (e.g. NDNQI, Press Ganey and OASCAHPS) and identifies how to apply best practice into own practice and mentor others towards meeting quality target goals.

Departmental Support

1. Maintains equipment in working order. Uses equipment appropriately, follows Department policies for equipment and supply use and maintenance.
2. Performs assigned duties to maintain unit in a state of survey readiness and maintain quality initiatives. For example, quality control measures, emergency equipment checks, medication preparation area cleanliness, monthly outdates, Environment of Care board, etc.
3. Adheres to unit programs to support patient care such as maintaining a quiet environment, hourly patient rounds, customer service, etc.
4. Keeps patient care area and work environment neat and organized.
5. Ensures the patient care area is cared for, maintained, clean, and secure for patients, visitors, and staff.
6. Assists the Director, Clinical Manager, and Assistant Clinical Manager with compliance for policies, procedures, regulations, and standards of care.
7. Coordinates and facilitates the patient flow process for admission, discharges, and transfers within established guidelines.
8. Integrates interdepartmental communication as evidenced by problem solving on the department level.
9. Collaborates with the Nursing Office Staffing Clerk and/or Assistant Clinical Manager/Manager/Director to effectively manage the schedule to meet the needs of the Nursing Department.
10. Assignments and coordination of care to support operations of the department.
11. Participates in QI/PI projects, staff evaluations, and Nursing Departmental projects.

Management Responsibilities:

1. Assists the management team with compliance for policies, procedures, regulations, and standards of care.
2. Coordinates and facilitates the patient flow process for admission, discharges, and transfers within established guidelines.
3. Integrates interdepartmental communication as evidenced by problem solving on the department level.
4. Collaborates with OR/ACC/Prep-Recovery/Endo/PACU/PPT regarding real time patient flow needs, schedule changes and throughput. Include other areas such as Cath lab, L+D, IR, etc.
5. Monitors arrivals, delays, and overall patient progression to ensure optimal patient throughput.
6. Collaborates with the Nursing Administrative Supervisor in maintaining staffing standards. Works with the Assistant Clinical Manager and/or Clinical Manager to maintain staffing schedules and assignments.
7. Assumes direct patient care as indicated by scheduling need.
8. Delegates assignments and coordination of care to support operations of the department.
9. Identifies performance and behaviors that may benefit from performance improvement strategies. Collaborate with management team.
10. Identifies and immediately performs service recovery and follows up as appropriate.

Education Training and Experience

Graduate of an accredited Nursing Program. BSN is required.

Two years Medical Surgical, or prior experience in PeriAnesthesia nursing is preferred. However, training and specialty specific education programs are provided during orientation and must be successfully completed as scheduled.

Basic computer skills: keyboard, mouse use. Ability to complete data entry on clinical documentation screens. Ability to use email and internet. Ability to successfully complete on the job training for CCH computer programs.

Ability to practice critical thinking and organizational skills.

Ability to speak, read, write and understand English.

Licensure/Certification

Current Pennsylvania RN License

CPR certification required

ACLS and PALS required

Certification in clinical specialty is preferred.