Assessment
1.     Assesses and collects health status data that is documented, retrievable, continuous and communicated to all health care team members, focusing on the emotional, physical, spiritual, educational, and pyschosocial needs of the patient/resident. 
    a. Interviews the patient/resident/family/significant others on admission, and as needed, and completes an appropriate, documented detailed patient/resident history (admission Database.)
    b. Identifies actual and/or potential discharge needs and initiates a plan in collaboration with physician(s), case manager, and other health care team members.
    c. Prioritizes data collection as determined by the patient’s/resident’s immediate condition or needs.
    d. Correlates findings from all body systems to determine additional signs/symptoms that should be assessed.
    e. Recognizes deviations in development/age-specific behaviors and plans interventions, as appropriate, towards a return in normalcy of the patient/resident.

2. Consistently and proficiently performs accurate patient/resident physical assessment, incorporating bio-psychosocial, age-specific, and spiritual needs, which are based upon clinical and theoretical knowledge.
   3. Interprets messages and subtle cues in patient/resident/family movements, gestures, physical appearances, facial expressions, etc., and validates their meaning with the individuals in a supportive/professional manner. 
   4. Identifies variables and relationships in data to assist in developing an individualized plan of care.
   5. Identifies effectiveness of patient’s/resident’s support systems. 

Nursing Diagnosis
1. Uses analytical and critical thinking skills to assess data, symptomatology, and age-specific needs related to pathophysiologic processes to formulate nursing diagnostic
hypothesis. 
 2. Formulates a plan of care within the established time frame to specific unit, based on the identified problems as documented on the plan of care for continuous individualized care.
 3. Nursing diagnoses are validated with patient/resident/significant others, and health care providers, when possible.

Planning
1. Develops a written individualized patient/resident plan of care using nursing diagnosis and establishes measurable expected outcomes in behavioral terms for planned nursing
interventions consistent with current scientific knowledge of disease, entities and human behavior.
2. Develops realistic short-term goals for each problem, involving patient/resident/family, significant others, and health care providers, when appropriate with understanding of the developmental (age-specific) needs of the patient/resident. 
3. Establishes priorities for care based on multi-disciplinary, teaching, discharge planning and age-specific needs.
4. Outcomes:
    a.Are realistic in relation to the patient’s/resident’s present and potential capabilities.
    b. Are attainable in relation to resources available to the patient/resident.
    c. Include a time estimate for attainment.
    d. Provide direction for continuing care.
     e. Are documented.

Interventions

1. Orients patients/residents/families to physical environment and routines, ensures the documentation and safety of belongings, sets basic care priorities accommodating to changing needs, provides physical care/comfort measures, and assists with activities of daily living. 
   2. Processes or ensures timely processing of physicians’ orders, protocols, prescribed tests, procedures and treatments.
   3. Schedules and coordinates patient/resident care services (i.e., tests, therapies, procedures, etc.) to avoid delays in hospitalization, waste of resources and duplication of services. 
   4. Organized and priorities care based on individual needs and the overall activity of the unit.
   5. Prescribes, implements, and/or delegates, appropriate interventions (actions) to achieve stated or written measurable, expected outcomes to the identified problems in the plan of care.  Delegation is based on consideration of health care team members competency, skills and abilities. 
   6. Coordinates the activities of team members in completing their diagnostic and therapeutic interventions. 
   7. Utilizes a variety of available resources (i.e. physicians, peers, other employees and administrative leaders), effectively and efficiently in providing care. 
   8. Performs general and specific nursing technical skills to individuals and groups of patients/residents utilizing equipment safely and properly and to avoid complications leading to additional services and/or prolonged hospitalization.
   9. Proficiently performs all procedures related to the area of practice. 
   10. Applies the principles of counseling, therapeutic communication, and teaching/learning in patient/resident interactions – demonstrating caring and compassionate behaviors. 
   11. Creates relationships that acknowledge and support patients’/residents’ rights to self-determination. 
   12. Identifies strategies in creating and maintaining positive patient/resident interactions while respecting their social/cultural values in therapy.
   13. Assess patients’/residents’ condition on an ongoing basis for changes and the appropriateness of the plan of care.
   14. Communicates significant changes in the patients’/residents’ condition to the appropriate health team members in a timely manner. 
   Patient/Resident/Family Teaching
   1. Assesses patient/resident (and family if appropriate) learning (age-specific) needs, abilities, and readiness to learn and gives consideration to the patients’/residents’ family, cultural, religious, emotional, motivational, psychosocial, physical, cognitive and language status. 
   2. Assesses patient/resident and family interpretations of health and illness, in order to develop and appropriate teaching plan aimed at facilitating adaptation to illness/injury/limitations. 
   3. Provides an interpretation of conditions and gives rationale for procedures to patients/resident including expected and/or potential changes.  
   4. Negotiates with patients/residents, families, and health care team members in planning patient/resident-teaching strategies and in formulating a realistic discharge plan.
   5. Collaborates with other health care team members to identify patient/resident and family needs for teaching to achieve expected outcomes. 
2. Uses support services/resources to provide education and discharge planning.  These include, but are not limited to: Social Services, Case Managers, Home Care, Wound Care, Diabetes Specialist, Dietician, Interpreters, Occupational Health, Physical Therapy, Infection Control Coordinator, Pharmacist, Community Resources, etc. 
   7. Records indicate that the patient’s/resident’s (and family’s if appropriate) learning needs concerning the following are identified and addressed:
   a. Safe use of medication
   b. Use of medical equipment
       c. Diet and nutrition
       d. Rehabilitation (if needed)
       e. Referral Services
       f. Follow-up care and how it’s obtained.
       g. The patient’s/resident’s and family’s responsibilities in the provision of care.
   8. Provides pre-operative/pre-procedure and post-operative/post-procedure teaching and documents
   responses and understanding of patient/resident and family.
   9. Assesses outcome data to determine effectiveness of education/counseling.
   10. Minimizes barriers to patient/resident education and/or health behavior changes by modifying
   teaching methodologies based on ongoing assessment of patient/resident comprehension of material. 
   Evaluation
   1. Evaluates the plan of care according to the current condition and changing needs of the patient/resident.  Involves the patient/resident, family’s significant others and health care provider in the evaluation process. 
   2. Accurately and concisely documents on the appropriate medical record forms, the patients’/residents’ status and responses, including age-specific responses, to interventions given by all health care team members in reaching expected outcomes. 
   3. Evaluates the plan of care for patients/residents on a 24-hour basis or more often as indicated.
   4. Modifies the plan of care as needed based on changing patient/resident needs as determined by continuing assessment.
   Leadership, Professionalism, Self-Development, Teaching
   1. Teaches in accordance with established policies and procedures and serves as a preceptor/resource for new staff, orientees, and students.
   2. Provides formal/informal in-service programs to staff, students, and faculty, e.g., demonstrates
   rationale and use of complex/new equipment and/or procedures.
   3. Alerts faculty and students to educational opportunities and experiences that become available. 
   4. Readily acknowledges limitations of knowledge/skills and seeks assistance from appropriate resources in self-development including new equipment and products used in performance of job.
   5. Demonstrates awareness of legal implications in matters of patient/resident care and unit operations
       a. Documentation is legible, timely, comprehensive, and accurate.
       b. Follow established written policies and procedures.
   6. Consults others for validation and guidance in decision making, as necessary.
   7. Takes control of crisis situations, e.g., acting out, combativeness, withdrawn/suicidal patient/resident behaviors; internal disaster situation sin department, etc.  Initiates appropriate actions and mobilizes others in situations of multiple and conflicting stimuli.
   8. Demonstrates appropriate leadership skills in the delegation of tasks and duties to other health care team members in order to promote quality patient/resident care. 
3. Identifies problems, offers solutions and uses sound judgement and ethical principles in their resolution.
   10. Gives constructive feedback to co-workers regarding care policies.
   11. Actively participates in achieving patient/resident, unit and Nursing Department goals/objectives. 
   12. Develops/updates/revises general teaching plans (as needed) for different patient/resident populations served.
   13. Demonstrates knowledge of the RN Scope of Practice and that of other team members, including the LVN Scope of Practice.
   14. Actively participates in ongoing performance improvement processes on the unit as well as the Nursing Department.  Participates in peer review where appropriate and in the development and/or revision of nursing standards.
   15. Uses CQIP process to document any all unusual occurrences appropriately (includes reporting of ADVERSE DRUG REACTIONS).

Interpersonal Relationships/Communication/Team Work
1. Conveys ideas, concepts, and facts in a logical, understandable, and concise manner.
2. Listens, comprehends and responds immediately to directions. 
3. Uses oral and written skills to effectively communicate to others health care team members, patients/residents, and families, including speaking English, as per the Language policy, as appropriate. 
4. Communicates verbally and non-verbally in a clear, caring and polite manner with all contacts; checks for understanding. 
5. Recognizes and utilizes appropriate lines of communication and seeks guidance, direction and assistance when needed.
6. Answers the telephone within 3 rings and patient/resident call system within 3 minutes courteously and relays calls or messages to the appropriate person in a timely manner.
7. Initiates collaborative interchange with members of the health care team and chooses appropriate location and environment for verbalization of concerns.
8. Facilitates the use of other professional/support roles in the delivery of patient/resident care.  Adapts to changing workloads.
9. Assigns and reassigns patient/resident care responsibilities considering skill/competency level of staff within the team in a timely, efficient manner to accommodate changes in patients’/residents’ needs. 
10. Uses a problem-solving approach to resolving job-related issues.
11. Directs and/or redirects criticisms to constructive discussion and minimizes role conflict and
territoriality.
12. Fosters a cooperative effort in meeting the goals of the team and sharing the workload.
13. Contributes to the team spirit of the department and positive interdepartmental relations.
14. Participate sin physician rounds and encourage fellow staff to do the same, as appropriate. 
15. Demonstrates awareness of unit (department) staff needs, provides feedback to Nurse Manager or designee and participates appropriately in providing staff.
16. Delegates appropriately to team members, evaluates performance of tasks delegated and provides constructive feedback to team members. 
17. Displays a caring, courteous attitude toward all patients, their families and visitors. 
18. Responds quickly to the needs of patients, their families and visitors.
19. Calls patients, their families and visitors by name, e.g., Mr. Or Mrs.
20. Treats patients, their families and visitors with dignity and respect.
21. Communicates effectively with angry or difficult patients, families, or visitors. 
22. Resolves all patients’ questions and concerns quickly; if unable to do so, refers the issue to the appropriate individual.
23. Demonstrates courtesy and respect for fellow employees, including volunteers and students.

24. Identifies self and department on the telephone.
    25. Speaks in a polite and courteous manner on the telephone.
    26. On the telephone, offers assistance or takes a message. 

Accountability
1. Demonstrates the ability to document pertinent information in the medical record using appropriate forms in an accurate, legible, timely, clear, and concise manner following established policy, for all assigned patients/residents. 
2. Demonstrates competency in using the Nursing Process.
3. Delivers care in a nonjudgmental and nondiscriminatory manner.  In accordance with the mission, philosophy, and values of the organization, it provides patient/resident care consistent with the standards of Seton Medical Center, the community and regulatory agencies.
4. Demonstrates competency as documented on the Nursing Skills/Competency Checklist, Standardized Procedures and other certifications on an annual basis.
5. Identifies conflicting medical orders and nursing interventions and tasks appropriate actions to resolve them.
6. Demonstrates poise and proficiency in managing emergency situations under established protocols.
    a. Demonstrates appropriate prompt action in “Code Blue.”
    b. Demonstrates appropriate prompt action in “Code Red.”
    c. Rapidly recognizes and acts upon conditions which threaten the patient's/resident’s physical and emotional well-being.
7. Demonstrates safety-conscious behavior including using proper body mechanics and principles in moving objects, consistent with the hospital's safety program, infection control policies/procedures, including universal precautions, hazardous waste management program and all policies and procedures.
8. Notifies Manager or designee or any injury (completes Employee/Volunteer Accident Report), unusual occurrence, situation or compliant; necessary repairs, etc., in a timely manner.
9. Safeguards the patient’s/resident’s rights as delineated in the “Patient Bill of Rights.”
    a. Assists patient/resident/family in decision making process by making pertinent factual information available and assists them in comprehending data as necessary. 
    b. Obtains documented consent for procedures requiring it. 
    c. Maintains confidentiality of all patient/resident information and their records. 
    d. Assists patients/residents in maintaining dignity and treats all patients/residents with respect.
    e. Properly applies and monitors safety restraints per policy.
    f. Utilizes the Ethics Committee as necessary.
10. Accepts responsibility and accountability for assignment and the quality of care provided by self and health care team.
11. Actively contributes to cost containment in supply usage, staff utilization, proper use of equipment, etc.  Evaluates factors related to safety, effectiveness, and cost when two or more practice options would result in the same expected outcome. 
12. Maintains a professional attitude and appearance; wears a picture ID badge.  Follows departmental dress code.
13. Takes appropriate amount of time for breaks and ensures coverage of patients/residents, by other health care team members while on break.
14. Complies to the sick time policy and arrives punctually and ready to work.
15.  Checks with and obtains approval from Manager or designee before using overtime.
16. Maintains proof of current license(s), certification(s), and special training, e.g., BCLS, ACLS, PALS, etc., as required per area of practice.
17. Membership and participation in professional and/or specialty nursing organizations is highly encouraged.

18. Actively participates at staff meetings. 
    Age-Specific
    1. Assesses for age-related physical limitations and common age-associated conditions.
    2. Assess for age-related safety needs.
    3. Considers age-related variances when analyzing vital signs and lab values.
    4. Provides for age-related nutritional, psychosocial and functional needs.
    5. Communicates verbally and non-verbally effectively with specific age-related or cultural populations served. 
    6. Varies communication technique and teaching style based on age-related and/or cultural background. 
    7. Develops a plan of care that incorporates identified pertinent age-related needs.
    8. Evaluates patient response to medications based on age-related pharmacokinetics and weights. 
    9. Evaluates patient response to treatment based on age-related physiological and/or psychosocial factors.

EDUCATION: 

∙ Graduation from an accredited school of nursing.

EXPERIENCE:
∙ Experience and training as a perioperative nurse.
∙ 3-5 years of genral, cardiac, vascular, and thoracic operating room experience. 
∙  Scrub tech preferred. Circulating Nurse preferred.

CERTIFICATIONS/LICENSURE:
∙ Licensure as a Registered Nurse by the State of California required
∙ AHA Provider BLS, ACLS
∙ Membership in AORN desirable
∙ Certification as a Perioperative Nurse encouraged