Provide patient-centered nursing care in accordance with professional and regulatory standards. Assess and monitor patients, administer treatments, document care, operate equipment, and communicate changes to the healthcare team. Promote patient safety, education, advocacy, and continuity of care through effective collaboration.
Essential Functions
Assess patients’ conditions and record their medical histories and symptoms
Observe patients and record the observations and assessments in patient’s electronic health record (EHR)
Administer patients’ medications and treatments
Set up plans for patients’ care and contribute information to existing plans
Consult and collaborate with doctors and other healthcare professionals
Operate and monitor medical equipment and assist with diagnostic testing and analysis of results
Educate patients and their families on managing illnesses or injuries and following care instructions at home after treatment
May perform department tasks including one or more of the following:
Pre-Op:
· Check all charts (doctor’s orders) for the surgery day
· Check surgery schedule for surgery add-ons or cancellations
· Check all equipment including glucometer, O2 tanks, and suction
· Check Crash-cart to ensure all medications are in the appropriate place and stocked. Defibrillator and monitor tested and noted in log
· Count narcotics and document them
· Greet patients and properly identify patients per policy/procedure
· Orient and familiarize the patient with the surroundings
· Recheck charts to ensure all operative consents are signed and witnessed
· Take vitals and start IV’s
Operating Room:
· Assist with preparation of the operating room, including checking functionality of equipment and all necessary supplies are available
· Competently operate equipment in the operating room (OR)
· Be the patient advocate during surgery
· Ensure safety measures are carried out by the OR team (e.g., timeouts, counts, positioning, infection control)
· Document all pertinent information in patient EHR, and report information to team members, the surgeon, and anesthesia personnel
Post-Op:
· Receive handoff of patient from OR with reports from circulating nurse and anesthesia
· Assess patient’s respiratory function; take vitals, including pain score, and record all information, looking for any signs of post-op/anesthetic adverse reactions. Notify surgeon and anesthesia if applicable
· Record all care/assessment of patient in EHR including patient belongings
· Provide supportive reassurance to patients and caregivers
· Follow post-op orders requested from each surgeon
· Provide detailed post-op instructions to patients and caregivers about care after discharge
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