• | Establishes an in-depth database by assessing the behavioral and physiologic status of the perioperative patient population by utilizing interviews, observations, and physical examinations. |
• | Utilizes resources to complete assessments of patients with unfamiliar or complex problems. |
• | Interprets overt and subtle data to determine patient’s current physiological or psychosocial risk. |
• | Develops, modifies, and integrates an individual care plan which incorporates the medical plan of care, key elements from the plans of other disciplines, and standards of care and practice. |
• | Establishes individualized, measurable patient goals in consultation with the patient, family, and health care team. |
• | Plans for individual operative needs (i.e. specialty implants, cell saver, irrigation solution, room temperature). |
• | Incorporates continuity of care planning. Coordinates and communicates continuity of care issues with other nursing units pre-and-post-operatively. Communicates operating room activities to facilitate efficiency in the surgical case progression and turnover between cases. |
• | Implements safe, competent, and efficient patient and family care within policies, procedures, and standards of care plan to the perioperative patient’s level of complexity. |
• | Recognizes potential problems and responds to general information/data indicating urgent and/or emergent risk to the patient. |
• | Assumes responsibility and accountability for effectively managing the care of a specialty patient population. |
• | Documents components of the nursing process that lead to insights, responses, and/or solutions to patient problems. |
• | Evaluates patient’s responses to care based on effectiveness of nursing interventions/actions in relationship to established goals. |
• | Initiates changes in the interdisciplinary care plan based on this evaluation. Problem solves with the specialty team to improve patient outcomes. |
• | Identifies learning needs of patients/families and teaches by adapting standard information based on needs. |
• | Ensures that the patient/family demonstrates knowledge, within the abilities of the patient, of the related surgical experience. |
• | Communicates with patient and family to identify their needs and includes them in the plan of care. Acknowledges and supports determinations by the patient and/or family concerning treatment. |
• | Assumes responsibility for meeting own learning needs and assesses the learning needs of the unit. |
• | Serves as a preceptor/mentor and works directly with new employees to fulfill planned orientation to the unit. Assists in the orientation, instruction, direction, and evaluation of students assigned to the unit. |
• | Identifies learning experience to gain or maintain competency. |
• | Makes sound judgments in the decisions involved in coordinating multiple, increasingly complex patient care demands. |
• | Supervises delegated care based on abilities of nursing staff and patient acuity. |
• | Plans, directs, and evaluates unit activities as a trauma/triage charge nurse as warranted. |
• | Participates in and facilitates the change process to enable continued growth and improvement in patient care. |
• | Assumes responsibility for the professional development of self, Registered Nurses, and other nursing staff. Supports a culture of continuous improvement. |
• | Participates in the development of the Surgical Services Department goals. |
• | Participates in committees/meetings as delegated. |
• | Participates in data collection for quality assurance activities. |
• | Identifies recurring practice problems in specialty areas and their impact on nursing care activities. |
• | Demonstrates knowledge of research findings related to clinical specialty. Communicates research and quality assurance findings to peers. |
• | Participates in interpreting data from quality assurance studies that are relevant to the clinical specialty. |
• | Contributes to development or implementation of methods to improve quality care in areas identified as deficient by quality assurance studies. |
• | Documents information which leads to insights or solutions of patient problems, including information about the response to and the outcome of care provided. |
• | Completes occurrence screens. |