The registered nurse will use the nursing process to provide pre and post procedural care to patients in Ambulatory Care Services (ACS) as well as the post anesthesia recovery unit (PACU). Staff will coordinate care activities with other professionals during the perioperative period and provide direction to nursing assistive personnel. Delegates nursing care according to legal and regulatory guidelines/statutes and organizational policies. Utilizes reasonable judgment in carrying out prescribed medical orders of a practitioner. Functions as primary nurse/total patient caregiver. Serves as resource nurse. Acts as preceptor and takes charge duties as assigned.

• Utilizes nursing process to deliver safe patient care based on AORN and ASPAN standards during the surgical care continuum.


• Assessment:
  
  
  
  • Demonstrates a systematic ongoing process of data collection.
  
  
  • Recognizes pertinent data and prioritizes relevance to the operative or invasive procedure.
  
  
  
  


• Diagnosis:
  
  
  
  • Identifies nursing diagnoses consistent with the assessment.
  
  
  
  


• Outcome ID:
  
  
  
  • Identifies expected outcomes unique to the patient setting priorities and timeline.
  
  
  • Communicates expected and attained outcomes to healthcare provider (HCP) for continuity of care.
  
  
  
  


• Planning:
  
  
  
  • Develops an individualized plan of care to attain outcomes.
  
  
  • Communicates the plan with the patient and/ or support person, and HCP.
  
  
  • Obtains and demonstrates the skills and knowledge needed to provide age- appropriate care to patients and families through education, training, and experience. 
  
  
  • Utilizes knowledge of procedures to plan for appropriate set up of equipment and supplies required.
  
  
  
  


• Implementation:
  
  
  
  • Implements nursing interventions consistent with the plan in collaboration with the patient.
  
  
  • Modifies and incorporates new knowledge.
  
  
  • Documents interventions to promote continuity of care.
  
  
  
  


• Coordination of Care:
  
  
  
  • Coordinates patient care continually throughout the patients.
  
  
  • Perioperative experience. Delegates tasks and functions based on scope and competency.
  
  
  • Organizes nursing activities in an efficient manner.
  
  
  
  


• Consultation:
  
  
  
  • Seeks specialized dialogue appropriate to the patient.
  
  
  • Facilitates communication between health care professionals to enhance patient outcomes.
  
  
  
  


• Evaluation:
  
  
  
  • Evaluates patient progress toward attaining outcomes.
  
  
  • Conducts systematic ongoing evaluation measuring the effectiveness of the interventions.
  
  
  • Monitors the patient progress in person or by telephone triage, documents the progress, and disseminates as appropriate.
  
  
  
  


• Safety:
  
  
  
  • Identifies Emergency situations and institutes appropriate measures in an emergency situation according to unit policy and procedures based on ACLS/PALS AHA guidelines.
  
  
  
  


• Medication Safety:
  
  
  
  • Demonstrates awareness of appropriate medication use and follows all policies concerning medication administration.
  
  
  • Demonstrates proficiency in the care of patients receiving conscious sedation.
  
  
  • Performs assessment and reassessment of patient's response to medications.
  
  
  
  


• Safe Environment:
  
  
  
  • Perioperative nurse will follow safe patient handling and movement in the perioperative setting using correct body alignment in positioning and transferring patients.
  
  
  • Follows the fire prevention and management plan per policy/procedure. 
  
  
  • Demonstrates proper use of equipment and supplies used within the perioperative setting.
  
  
  
  


• Safe Culture:
  
  
  
  • Actively participates in communication that promotes safe care including but not limited to SBAR, pre-op briefing, and time out.
  
  
  • Follow specimen handling and documentation procedures.
  
  
  
  


• Infection Control:
  
  
  
  • Complies with all infection control policies and procedures to include standard precautions, hand hygiene, principles of aseptic technique, and appropriate use of personal protective equipment.
  
  
  • Accepts responsibility as assigned to include charge responsibilities.
  
  
  • Initiates and facilitates room turnovers: light housekeeping duties, procurement of equipment, restocking of unused supplies and equipment, participates in economical utilization of supplies, cleaning of instruments, reprocessing and storage.
  
  
  • Performs other duties and accepts responsibility as assigned within the scope of their practice.
  
  
  • May be assigned to another cost center; that may include other work locations on a shift-by-shift basis to meet patient care requirements.
  
  
  • Incorporates the Maui Health Nursing Vision, Model and Values throughout their Nursing Practice.