Registered Nurse OR
Job Summary
Follows the nursing process from preoperative holding area to PACU; communicates with surgeon and anesthesia care provider about relevant patient medical/surgical history and medication allergies; pulls supplies, instruments, and equipment needed for surgical case; opens surgical case with scrub technologist, maintaining aseptic technique; counts with scrub technologist prior to incision; performs the Time Out; is at the patient’s side during induction and intubation and extubation; safely positions patient with health care team; obtains additional supplies, instruments, and equipment as needed; performs final counts and makes sure they are correct; accurately documents and charges patient; gives report to PACU nurse with anesthesia care provider; performs biological testing for OR autoclaves, knowledgeable of immediate use steam sterilization policies and principles. Follows recommended practices of AORN.
Essential Functions
- Provides Safe and Appropriate Nursing Care to Patients Utilizing the Nursing Process and Demonstrates the Ability to Perform Clinical/Technical and Administrative Tasks
- Captures the attention of the patient and family to obtain informed consent
- Coordinates use of instruments, supplies and equipment for intraoperative phase based on patient’s needs and surgeon’s preference card
- Systematically assesses the health status of the patient and records health data
- Absorbs knowledge level of patient preoperatively and provides basic teaching related to procedure and monitoring
- Is proactive in the Time Out process to be sure the patient’s procedure is performed on the correct site, side, and level
- Establishes nursing diagnoses; plans, implements, and evaluates nursing interventions – initiates changes when appropriate
- Protects the patient from injury caused by extraneous objects and chemical, electrical, laser, mechanical, and thermal sources
- Performs interventions to protect patient from surgical site infections
- Maintains patient’s normothermia
- Properly labels specimens and requisition forms
- Demonstrates flexibility and adaptability to changes as they occur
- Adheres to hospital policy for sponge counts, sharps, and instrument counts; protects patient from retained surgical items
- Provides education consistent with the patient/family’s learning abilities and preferences; evaluates outcomes
- Effectively Communicates with Physicians, Co-workers, Patients, Families
- Reports pertinent observations regarding patients to physicians and other health care team members
- Hand-off report is given accurately and concisely; hand-off paperwork is completed
- Documentation on the patient’s medical record is accurate, complete and concise to ensure continuity in the provision and coordination of patient care
- Patient advocate – ethical and moral decision making per patient or family member’s wishes
- Uses problem solving and conflict resolution skills to foster effective work relationships with team members
- Patient Safety
- Completes the Pre-Procedure form so that problems can be anticipated and corrected prior to the patient entering the OR
- Maintains National Patient Safety Goals, including participation in the Time Out process
- Verifies, coordinates and carries out physicians orders/preferences accurately
- Coordinates interdepartmental transfers smoothly and efficiently
- Coordinates interdepartmental activities related to SCIP measures to ensure timely efficient care
- Communicates and coordinates with coordinator and other nurses to ensure timely discharge, patient satisfaction, and quality care along the continuum of care
- Practices Standard Precautions
- Demonstrated knowledge of and practices department safety procedures, including safe handling of equipment and hazardous substances
- Responds to emergency situations to promote optimal patient outcomes by recognizing changes in the patient’s health status
- Initiates incident reports appropriately
- Administers Medications in an Accurate and Timely Manner
- Follows the 5 “rights” when administering medications (patient, route, time, dose, med) after checking for allergies
- Uses 2 patient identifiers before administering medications
- Initiates and effectively maintains IV therapy
- Participates in Quality Improvement
- Acts as a resource and mentor for others
- Verbalizes unit specific quality improvement projects
- Verbalizes hospital-wide quality improvement initiatives
- Collects, interprets or relays quality improvement data for the unit
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.