PACU Registered Nurse FLOAT - Ft. Carson

SUMMARY

Perform essentially the same duties as those required of any military or government civil service nurse of similar experience and in similar duty assignments.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Collect, interpret, record, and communicate pertinent patient data relevant to the patient's care before, during, and after surgery.
• Actively observes patients and takes appropriate action as indicated by problems.
• Correctly and thoroughly uses and adheres to established protocols in preparing patients for examination, specialized tests, and surgery.
• Formulate nursing diagnosis based upon health status data by accurately interpreting assessment data and identifying patient problem/nursing diagnosis pertinent to surgical procedure.
• Develop a plan of care that prescribes nursing actions to achieve patient goals by establishing priorities for nursing actions.
• Effectively ensure patient procedures, treatments and medications are administered in accordance with (IAW) physician orders, sound nursing judgment and applicable guidelines.
• Accurately administers medications orally, intramuscularly, sub-cutaneous, intravenously, topically, etc., including narcotics and prescribed intravenous therapy, and maintains awareness of the effects of the medications on patients.
• Regularly ensures a safe, clean work environment is maintained for patients and staff. Exercises the standard precautions set forth by the CDC when providing direct patient care.
• Provide for patient privacy through maintaining confidentiality and physical protection of patient information.
• Generate and maintain proper medical records on beneficiaries to whom treatment is provided in accordance with Air Force Instructions on Medical Record Administration. All records generated in the performance of the contract will remain the property of and subject to exclusive control of the Government.
• Facilitate collaboration with all levels of health care management to include outside agencies. Performs utilization management activities to optimize cost, quality, and access to care. Adhere to medical group operating instructions (operating instructions provided during orientation). Facilitate evidenced-based clinical practice. Provide comprehensive professional nursing care to normal and high-risk patients, documents actions.
• Ensure the appropriate equipment and supplies are available, based upon patient needs.
• Monitor and controls the environment to include temperature, sensory environment, and cleanliness.
• Accurately document procedures, results of medications, untoward effects from medical/surgical procedures and unusual occurrences as appropriate in the patient's medical record.
• Prepare accurate reports and statistics as required.
• Uses tact and diplomacy when interacting with all personnel/patients/family members.
• Conduct patient/family interview and completes preoperative documents, progress notes and teaching.
• Fax prescriptions to pharmacy and enters lab and radiology orders and other functions in Composite HealthCare System (CHCS).
• Assist with orientation and training of other staff assigned to the ASU/PACU and Preop Clinic.
• Ensure all equipment is properly cleaned and stored at the end of each work shift. Ensure preventive maintenance and routine cleaning are performed as directed.
• Ensure a safe work environment and employ safe work habits.
• Utilize available information management systems in daily practice for patient care and administrative duties.
• Coordinate and communicate with facility staff members to facilitate patient care.
• Accurately review and confirm completeness of patient chart and report any abnormalities to appropriate staff in a timely manner.
• Establish patient goals that are congruent with present and potential physical capabilities and behavioral patterns based on nursing diagnosis by developing outcome statements, criteria for measurement of goals and setting priorities for outcomes based on need.
• Effectively participate in planning care with other professional and nonprofessional personnel.
• Take appropriate action to prevent deterioration and alleviate discomfort in patients.
• Orient and serve as a preceptor of newly assigned nurses to these areas.
• Set up, operate, and monitor therapeutic and emergency equipment such as cardiac monitoring devices, EKG units, vital sign monitors, and oxygen saturation monitors.
• Ensure that patients are adequately prepared for surgery, both physically and emotionally.
• Maintain regular and punctual attendance.
• Perform all other duties as assigned.

SUPERVISORY RESPONSIBILITIES

None.