Job Description
POSITION OVERVIEW
This position is responsible for providing nursing care in an ambulatory setting and teaching patients the skills necessary to care for themselves at home. This position must be able to meet patient needs effectively and efficiently in medical and surgical areas of nursing and provides direction to other staff members regarding patient care. ESSENTIAL FUNCTIONS OF JOB
: (other duties may be assigned) ASSESSMENT
Assess patient at least one day prior to endoscopic procedure by telephone Assess patient data and review physician orders. Call patient for pre procedure assessment. Complete med recon sheet. Notify patient of arrival and scheduled procedure time. Provide pre-procedure instructions and directions to patient or family. Review "to be admitted," outpatients, and endoscopy patients on the day of the surgery/diagnostic procedure. Confirm and document assessment data, ensure all documentation is complete. Identify patient problems and develop a plan of care, note physician orders. Provide pre-operative teaching to include the family/significant others. Ensure consents are signed properly, including procedure date and time; complete documentation. Accurately completes med recon sheet. PATIENT MONITORING
Monitor the patient post-operatively. Assess the patient upon return to Ambulatory Services Unit (ASU) and note the physician's post-operative orders; draw labs if needed Monitor patient per post-operative protocols. Maintain concise documentation of care provided. Evaluate patient response to interventions provided and notify the physicians of any change in condition. DISCHARGE
Prepare patients for discharge. Complete discharge instructions and discharge the patient when he/she has met the established discharge criteria. Notify physician if discharge criteria is not met. Explain discharge instructions to the patient and family/significant others. Monitor patient for any questions or concerns about the instructions given and gauge by successful return demonstration by patient. Provide any additional learning materials and make appropriate appointments. MEDICATION ADMINISTRATION
Administer medications/treatments. Assess patient needs. Provide medication as ordered by the physician following the ten patient rights. Immediately document administration of medication. Evaluate patient response to the medication given. Utilize bedside medication verification for all medication administration. Administer IV conscious sedation. Follow the physician's orders by administering medications following policy guidelines and maintain proper documentation of the drugs given. Monitor the patient's response and administer reversal agents if needed and note patient's response. Complete annual conscious sedation competency. PROCEDURES
Assist with diagnostic procedures such as endoscopy and other specialty procedures. Assess the patient prior to the procedure and ensure the proper consents are signed. Monitor the patient during the procedure in accordance with policy and notify the physician of any problems observed. Assist the physician during the procedure by obtaining specimens, labeling, documenting specimens. Uses order entry system for specimens. IV ADMINISTRATION
Administer intravenous blood and IV medications. Assess the patient before blood/medication is given and place the IV in accordance with the medication's requirements. Follow the physician orders by administering the drugs in accordance with the medication requirements and maintain proper documentation in PCS Monitor the patient during and after the treatment for side effects and document. Ensure proper disposal of tubing and IV bags. Complete annual IV competency. DEPARTMENTAL RESPONISIBILITIES
Assist with departmental evaluation and improvement of nursing practices. Participate in quality improvement, fire safety, infection control, etc. Support change to improve patient care through suggestions offered by patient response forms. Participate in departmental committees or projects. Maintain compliance with all Hospital policies and procedures. CLINICAL OVERSIGHT
Provide clinical oversight of the nursing care process. Serve as a resource for staff including the licensed practical nurses, nurse aides, and other ancillary staff. Delegate nursing care duties as appropriate for the scope of practice of assignee. Periodically serve as the charge nurse responsible for the overall functioning of the nursing unit. Observe staff with patient to ensure patient satisfaction. Demonstrates proper use of equipment and supervises staff in use of equipment. Direct staff as needed to ensure compliance with all hospital policies and procedures. Assist in orienting new staff and transferred staff when necessary. Schedules procedures in computer. Confirms name, DOB, procedure and Dr. Pre-procedure diagnosis. Confirms time is available for procedure. Confirms no conflict in order of cases. REGULATORY COMPLIANCE
Must remain up to date, knowledgeable and compliant on DOH and other applicable regulatory related to your department and area. Patient safety regulations and goals will be followed (i.e., using 2 patient identifiers, reporting critical values, medication reconciliation, etc.) Perform appropriate documentation regarding narcotics administration (i.e. second signature for count and waste, etc.) Follow the regulations regarding restraint and seclusion, sentinel event notification, etc. Attend appropriate educational programs related to regulatory standards, updates and new initiatives. OTHER DUTIES
(not all-inclusive): Provides after-shift coverage for ASU. Ensures availability for emergency endoscopy and specialty procedures. Respond to emergency codes as required. Perform limited computer operations such as placing orders, reviewing and printing lab and EKG results. Complete incident reports as necessary. Review procedures manual and write new procedures as necessary. Identify educational needs of the department. Perform other related duties as assigned or required. Follow standard precaution guidelines. Other duties as assigned. REPORTS TO
Director of Surgical Services SUPERVISION ADMINISTERED
: None MENTAL/PHYSICAL REQUIREMENTS OF JOB
: This position typically requires: Managing multiple projects/tasks, close attention to detail, adapt to a constantly changing work environment, meet frequent deadlines, establish own goals, work closely with others, high pressure for results, predictable work schedule and maintain high level of record-keeping/routine paperwork. The ability to constantly stand, walk, use both legs and hands, communicate orally and hear conversation is typically required. The ability to use specific visual requirements and rapid mental/muscular coordination, is also typically required. Depth perception is frequently required. The ability to occasionally sit, stoop, lift a maximum of 65 lbs. and use color vision is typically required. WORK ENVIRONMENT
: This position typically requires: Constant contact with patients, blood and bodily fluids. Frequent exposure to gases (i.e., oxygen, nitrous) and pharmaceutical drugs. Occasional contact with chemicals including housekeeping and laboratory chemicals. Frequent contact with formalin (chemical) in ASU and OR departments. Occasional work alone. PERSONAL PROTECTIVE EQUIPMENT
: This position typically requires: Frequent use of gloves and body protection and eye protection. Occasional use of respirator QUALIFICATIONS
: Education/Training/License/Certification :
Minimum Diploma of Nursing required. Current, valid Pennsylvania Registered Nurse License required. CPR / BLS, and Advanced Cardiac Life Support (ACLS) preferred at time of hire, required within 6 months of hire date or enrolled in next available course. Work Experience :
Six months to one year related experience and/or training preferred. KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED
: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to apply such concepts such as fractions, percentages, ratios, and proportions to practical situations. Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. Knowledge of state nursing guidelines and health standards. Effective oral and written communication skills and interpersonal skills. Knowledge of medication and calculation and ability to calculate medicine dosages. Excellent documentation and observation skills. Knowledge of phlebotomy. Knowledge of applicable federal and state guidelines and health standards. Knowledge of pharmacology principles. Knowledge of all equipment related to endoscopy/special procedures.
