PRE-OP/PACU Charge Nurse in Peoria, Arizona at Mountain View Headache and Spine Institute PLLC
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Job Description
Job Description
| Job Title: | PRE-OP/PACU Charge Nurse | Department: | Clinical |
| Reports to: | Director of Nursing | Location: | Sonoran ASC |
The ASC Registered Nurse provides safe, efficient, patient-centered nursing care throughout the perioperative experience at Sonoran ASC. The RN also assists the Clinical Director with the daily clinical operations of the Pre-Op and PACU areas in accordance with applicable federal and state requirements, accreditation standards, and Center policies and procedures. This position participates in the development and implementation of Quality Assessment and Performance Improvement (QAPI) activities; maintains and produces monthly Pre-Op and PACU statistics and records; supports equipment maintenance; coordinates the authorized purchasing of medications and controlled substances; assists with Pre-Op and PACU staff orientation; and helps ensure the completeness and accuracy of medical records.
Supervisory ResponsibilitiesNone. The RN may provide clinical direction, task coordination, and real-time support to members of the perioperative team within the RN's scope and assigned responsibilities.Duties/ResponsibilitiesPreoperative Nursing Care
- Complete and document preoperative nursing assessments, including health history updates, medication reconciliation, allergies, baseline vital signs, pain assessment, fall risk, and other required screenings.
- Verify patient identity, procedure, site, provider orders, required consents, history and physical, diagnostic results, medication instructions, NPO status, allergies, and other readiness criteria before the procedure.
- Identify and promptly communicate abnormal findings, missing information, or changes in condition to the appropriate provider and perioperative team.
- Establish and maintain intravenous access as assigned; administer preoperative medications and therapies in accordance with orders, policy, and demonstrated competency.
- Provide patient and caregiver education regarding the procedure, expected course, pain management, discharge planning, and safety requirements.
Intraoperative and Circulating Responsibilities
- Serve as circulating nurse when assigned and competent, coordinating nursing care and supporting safe, efficient movement through the procedure room.
- Participate in the pre-procedure verification process, site verification, and time-out; immediately stop the process and escalate any discrepancy or safety concern.
- Maintain aseptic practice and monitor sterile technique, room traffic, positioning, equipment, supplies, medications, specimens, implants, and counts as applicable to the procedure.
- Assist with safe patient positioning, pressure-injury prevention, grounding-pad placement when applicable, skin preparation, transfer, and protection of patient dignity and privacy.
- Document intraoperative nursing care, personnel, medications, counts, specimens, equipment, positioning, events, interventions, and patient response accurately and in real time.
- Anticipate procedural needs and communicate effectively with the surgeon, anesthesia professional, scrub personnel, radiology staff, and other team members.
Post-Anesthesia Care and Discharge
- Receive a complete handoff and provide Phase I and Phase II recovery care when assigned and competent, including airway, respiratory, cardiovascular, neurological, pain, nausea, wound, and procedural-site assessment.
- Continuously monitor the patient at the level required by condition, anesthesia type, provider orders, and facility policy; recognize deterioration and initiate appropriate interventions without delay.
- Administer medications and treatments as ordered, evaluate effectiveness, and document the patient's response.
- Apply established discharge criteria, confirm provider discharge authorization when required, and ensure the patient has a responsible adult and safe transportation when applicable.
- Provide and document individualized written and verbal discharge instructions, including medication guidance, activity restrictions, warning signs, follow-up care, and emergency contact information.
- Complete post-discharge follow-up activities when assigned and report concerns through the appropriate clinical pathway.
Medication Safety and Emergency Response
- Maintain an active and unrestricted Arizona Registered Nurse license, required certifications, continuing education, and competency requirements as a condition of employment, and promptly disclose any restriction or change in status.
- Prepare, administer, and document medications and IV therapies in accordance with provider orders, applicable law, professional standards, and facility policy.
- Verify medication, dose, route, timing, allergies, expiration, labeling, and compatibility; obtain an independent double-check when required.
- Maintain controlled-substance accountability, wasting documentation, medication security, and chain-of-custody practices as assigned.
- Recognize and respond to adverse reactions, airway compromise, oversedation, hemodynamic instability, anaphylaxis, malignant hyperthermia, cardiac arrest, and other emergencies within training and competency.
- Participate in emergency drills and maintain familiarity with emergency equipment, medications, transfer procedures, and
Clinical Operations and Compliance
- Complete all nursing documentation related to the RN's role, including assessments, medications, monitoring, education, handoffs, interventions, communications, outcomes, and discharge. Documentation must be accurate, complete, timely, and entered under the RN's own credentials in the designated health record.
- Follow infection-prevention, hand-hygiene, aseptic-technique, environmental cleaning, sharps safety, exposure-control, and personal protective equipment requirements.
- Perform and document required checks of emergency carts, oxygen, suction, monitors, defibrillation equipment, medication storage, crash supplies, and procedure-room readiness as assigned.
- Maintain medication areas, clinical rooms, supplies, and equipment in a clean, secure, organized, and inspection-ready condition; promptly report deficiencies or safety concerns.
- Follow specimen handling, labeling, transport, and documentation requirements and immediately address any discrepancy.
- Support accurate counts, implant or device documentation, infection surveillance, quality reporting, incident reporting, and performance-improvement activities as applicable.
- Participate in orientation, competency validation, chart audits, peer review support, staff education, drills, and regulatory or accreditation survey preparation.
- Protect patient confidentiality and comply with HIPAA, OSHA, facility policies, medical staff rules, and all applicable federal and Arizona requirements.
- Perform other duties within the RN scope of practice and demonstrated competency as assigned.
Professional Expectations
- Maintain an active and unrestricted Arizona RN license or valid multistate privilege, required certifications, health clearances, continuing education, and competency requirements as a condition of employment.
- Promptly disclose any restriction, investigation, lapse, or change affecting licensure, certification, health clearance, or ability to perform assigned duties.
- Maintain dependable attendance, punctuality, and timely communication regarding availability, schedule changes, or potential coverage concerns.
- Demonstrate professionalism, sound clinical judgment, ethical conduct, teamwork, cultural sensitivity, and a consistent commitment to patient safety.
- Do not perform any task beyond authorized scope of practice, provider orders, facility policy, or demonstrated competency.
- Strong perioperative assessment, clinical judgment, medication administration, patient-monitoring, documentation, and emergency-response skills.
- Ability to function effectively in pre-op, circulating, procedure-room, and recovery assignments after orientation and competency validation.
- Knowledge of infection prevention, sterile technique, patient identification, surgical safety processes, and safe handoff communication.
- Ability to prioritize rapidly, remain calm during emergencies, and communicate clearly with patients, caregivers, providers, and team members.
- Ability to use electronic health records, medication administration systems, monitoring devices, and common ASC clinical equipment.
- Commitment to respectful patient care, confidentiality, teamwork, and continuous quality improvement.
- Associate Degree in Nursing or higher from an accredited nursing program; Bachelor of Science in Nursing preferred.
- Current, active, and unrestricted Arizona Registered Nurse license or valid multistate compact privilege authorizing practice in Arizona.
- Current Basic Life Support certification for healthcare professionals.
- Current Advanced Cardiovascular Life Support certification.
- Pediatric Advanced Life Support certification if required by the facility's patient population, services, or policy.
- At least one year of recent RN experience in an ambulatory surgery center, operating room, PACU, critical care, emergency care, procedural nursing, or a comparable setting; ASC and perioperative experience preferred.
- Successful completion of required background screening, health clearances, orientation, and role-specific competency validation.
- Ability to stand and walk for extended periods and to remain attentive while continuously observing patients.
- Ability to use hands for medication preparation, IV insertion, sterile or procedural tasks, equipment operation, and computer documentation.
- Ability to lift and carry up to 25 pounds routinely and to assist with patient transfer, positioning, or emergency response using appropriate equipment and assistance.
- Visual, auditory, and communication abilities sufficient to assess patients, read labels and monitors, distinguish alarms, and respond promptly.
- Regular exposure to blood, body fluids, potentially infectious materials, radiation environments, anesthetic agents, cleaning chemicals, and other clinical hazards, with required use of protective measures.
- Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position.