The PACU Registered Nurse is responsible for the provision of safe and effective care of the pre-operative patient. The RN applies knowledge of the principles of growth and development over a lifespan to identify patient and family requirements relative to age-specific needs. Provides comprehensive and collaborative nursing care for identified post-operative patients utilizing a multidisciplinary approach. Demonstrates sound critical thinking skills, effective communication skills and the ability to work effectively and in a fast-paced setting that relies on a team approach. Nursing care in the PACU is based on the nursing process and emphasizes the critical evaluation of the post-operative patients with the emphasis on anticipation and prevention of complications resulting from anesthesia or the operative procedure.

Assessment:

• Performs Appropriate nursing history and physical upon admission and on an ongoing basis.
• Collects and documents patient data.
• Interviews patients and significant others and completes a history documentation.
• Documents signs and symptoms that indicate actual and potential problems.
• Incorporates information in the written assessment from families/significant others and members of the health care team.
• Assesses safety of the patient care environment.
• Documents patient/family teaching needs in the patient care plan.

Planning:

• In conjunction with the patient and family, develops individualized patient care plan.
• Identifies short and long-term goals, including discharge planning consistent with established patient care.
• Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.
• Provides continuity of care by communicating the plan of care and diagnostic data through the shift report, in accordance with the unit's guidelines.
• Involves family members and other health care team members in the development of the plan of care as able and appropriate.
• Revises the initial patient care plan to the changing needs of the patient.

Implementation:

• Provides direct nursing care based on the plan of care and established priorities.
• Sets priorities and gives nursing care based on the patient's needs.
• Implements the medical care plan as delegated.
• Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).
• Writes patient discharge plan and makes appropriate referrals.
• Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.
• Coordinates the activities of other disciplines of the health team to implement the individual care plan.

Evaluation:

• Evaluated and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.
• Revises plan of care based on evaluation.
• Documents the response of the patient to the medical care plan.
• Documents the response of the patient to nursing interventions.
• Recognizes alterations in physiological and psychosocial status.
• Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.
• Documents revision of the goals and plan of care to meet the changing needs of the patient.

Customer Service:

• Consistently strives to implement the unit's customer service standards and to exceed the expectations of patients, families, physicians and visitors.
• Unit surveys consistently meet or exceed hospital benchmark.
• Demonstrates customer service commitment to patients by maintaining flexibility in relation to patient assignment, shift assignment and work schedule.
• All interactions are conducted in a professional manner.
• Verbal and written feedback from patients, family members/significant others, medical staff, visitors and co-workers indicates behavior conductive to positive guest relations.
• Consistently exhibits appropriate phone protocol, e.g., answers phones promptly and professionally, is courteous and helpful.
• Interacts with other departments for problem resolution and quality patient care.
• Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.
• Makes rounds to assigned patients; anticipates patients' needs and answers/responds to the patients' call lights or paging promptly.

Professional Conduct:

• Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the department or on an as-needed basis or as determined by management.
• Follows attendance and all other established hospital and departmental policies.
• Demonstrates the philosophy of the team concept.
• Participates in staff meetings with suggestions that enhance the work environment and increase productivity.
• Communicates well with supervisor, reporting problems with equipment, supplies or procedures.
• Requests assistance as appropriate.
• Complies with all safety and infection control standards.
• Maintains confidentiality as related to job responsibilities.
• Exhibits willingness to resolve problems as they arise.
• Consistently projects positive professional image through appearance and behavior.
• Attends 75% of staff meetings or reads and initials minutes.
• Completes assigned work within shift.
• Complies with time and attendance policy (i.e., Kronos).

Performance Improvement:

• Demonstrates WHMC's commitment to quality through the maximum individual effort of each employee.
• Consistently works to improve identified unit-specific problems.
• Consistently works to improve identified hospital-wide system problems.
• Uses established systems to document occurrences.

Professional Growth and Development:

• Completes Annual Updates and Ethics Training within established time frames.
• Completes general and departmental orientation within established time frames.
• Attends 80% of in-service programs.
• Maintains licensure/certification as appropriate.

• Minimum Education: Graduate of approved nursing program.
• Minimum Experience: 1 year acute care experience preferred.
• Required Certification/Registration: Current California License; BLS; ACLS; PALS; proficiency in both written and oral English.