UI Health - Staff Nurse I - Rotating Evening position (PACU)

Position Summary

The PACU Staff Nurse I is responsible for delivering comprehensive nursing care to all patients during all phases of the perioperative process. This role includes the management & care of post-surgical patients requiring extended recovery/admission to an appropriate level of care. The SNI provides direct patient care taking initiative to improve patient outcomes by integrating Shared Leadership, Evidence Based Practice, Relationship Based Care, & standards of nursing excellence into clinical practice. This position integrates professional practice model, current standards of practice & clinical experience to provide "quality" patient care as measured by established nursing quality standards & other governing/accrediting health care bodies. The Staff Nurse I engages & obtains information from patient and/or family to advocate for patients, develops an appropriate patient educational plan, and responds to patient changing needs while collaborating with others to provide effective care.

Duties & Responsibilities

• Provides safe, high-quality perioperative nursing care which encompasses preoperative intake, support for minor procedures, post-anesthesia recovery Phase I & Phase II, and recovery room boarders for all levels of care to include ICU for a diverse patient population spanning the continuum from pediatrics to geriatrics.

• Establishes an in-depth database by assessing the behavioral and physical status of a variety of pre-surgical patient populations, utilizing interview, observation, and physical examination. Interprets overt and subtle data to determine physiologic or psychosocial risk.

• Ensures the delivery of quality nursing care for patients undergoing surgical and non-invasive procedures in accordance with age-related and individual needs, physician's orders, hospital policy, standards of care and nursing practice.

• Responsible for assessing the needs of patients, planning nursing care to meet those needs, and ensuring that the plan of care is carried out and documented according to the principles defined in the nursing process.

• Provides patient with safe, therapeutic, and quality care by utilizing the nursing process and diagnosis in a timely manner, setting appropriate priorities.

• Evaluates patient’s responses to care based on the effectiveness of nursing interventions in relation to established outcomes and consults with the medical staff, Care Team Lead, and/or Nursing Supervisor.

• Demonstrates critical thinking by integrating theoretical knowledge and expertise to pose relevant clinical questions when evidence and practice differ.

• Recommends changes to the plan of care based on observed variances.

• Integrates nursing interventions into the multidisciplinary plan of care, incorporating appropriate standards of care and practice.

• Identifies learning needs with patients and families and teaches by adapting standard information to provide individualized and comprehensive learning.

• Incorporates discharge/home care planning into the multidisciplinary plan of care.

• Develops a therapeutic relationship by establishing trust and enabling the patient and/or family to verbalize the requirements for care comfortably.

• Supports and enhances the patient’s responsibility and self-determination in decision making concerning health, treatment, and well-being.

• Competent in all areas of PeriAnesthesia - Preop, Phase 1, and Phase 2 recovery areas, and extended care to boarder post-surgical patients requiring the appropriate level of care including ICU.

• Checking and updating patient files, charts, and medical records

• Assure that operative/informed consents are accurate and signed per policy

• Assess and instruct patient/family prior to surgery

• Engages and obtains information from patient and/or family to develop an appropriate patient educational plan

• Observing patients for side effects of anesthesia

• Monitoring and recording patient vital signs during the perianesthesia phases

•Monitoring patient’s level of consciousness throughout sedation recovery

•Performing post-operative tasks, such as administering medication or changing dressings

•Collaborating with surgeons, anesthesiologists, physicians, and other members of the patient’s care team

•Discern and execute provider orders per hospital policy, guidelines, or protocol

•Verifies and implements orders from providers, by performing interventions as prescribed by the provider and documenting accurately in the electronic medical record.

•Ability to administer a variety of treatments & medications, including all medications on the crash cart

•Collaborating with the medical team on post-operative patient care and facilitating timely specialized interventions.

•Treating pain, nausea, and other post-operative symptoms of anesthesia.

•Providing comfort and answering questions when patients wake from sedation

•Assure intake of patient is accurate through chart review, questioning using safe communication tactics outlined in learning modules

•Monitor and accurately document vital signs and assure patient meets discharge criteria

•Monitor patients’ condition and report and changes to the appropriate physicians

•Assure patient comfort, address, and resolve patient and care provider questions. Coordinate holistic care needs with the interprofessional team.

•Evaluates effectiveness of teaching interventions and the patient/family’s level of understanding.

•Educating patients and their families regarding post-surgery care at home

•Oversees tasks and delegates to support staff and promotes positive patient experience.

•Requires adherence to all policies and procedures, including but not limited to standards for safety, attendance, punctuality, and personal appearance.

•Other assigned duties that will assist with safety, quality, and efficiency

Organizational
•Adheres to UI Health’s Code of Conduct.

•Treats patients/families, staff, students and visitors with respect and dignity.

•Adheres to Nursing’s time, overtime, and attendance policies.

•Completes electronic learning modules and related programs as assigned by UI Health by established date

•Complies with University Health Services TB, flu compliance and fit-testing requirements

•Utilizes established communication channels/chain of command to escalate or resolve patient care problems.

•Identifies recurring clinical practice and/or related unit problems and participates in problem solving and resolution.

Education/Research
•Collaborates with other nurses to identify, promote, and provide positive learning experiences for staff and students

•Serves as preceptor and/or resource to other nursing staff and students.

•Accesses UI Health intranet/Outlook for relevant communication and to review and interpret changes in policy, procedure, and other information pertinent to practice

•Supports nursing and multidisciplinary research efforts conducted on the unit and UI Health.

•Takes responsibility for continued professional growth/development by identification of learning needs and initiates strategies to meet such needs.

•Be proactive in a committee or a process improvement project

Reporting Structure
•This person works independently within the scope of nursing practice. The Director/CNCII, acting as coach and mentor, provides direction, guidance, and feedback regarding practice and performance.

•The employee’s performance is evaluated annually in writing and more frequently if needed. The employee and Director meet on an as needed basis for coaching and mentoring where support, guidance and direction can be given. The Extra help Perianesthesia RN provides and receives input from peers regarding expected care and documentation.

•Engages support personnel by delegating appropriate tasks per the Illinois State Nurse Practice Act and provides support and feedback.

•Demonstrates a commitment to UI Health’s values through teamwork and effective communication in an effort to achieve quality outcomes, patient safety, customer satisfaction and a clean, safe, and therapeutic environment.