STATE REGISTERED NURSE, ENDOSCOPY-2 at KPJ Healthcare · Kuala…

GENERAL DESCRIPTION

• Responsible for rendering professional nursing care to patients within an assigned unit of the hospital. Such nursing care is an integral part of the individualized holistic patient care plan as directed by the Medical staff according to the Policies and Procedures of the hospital and in keeping with the generally accepted principles, policies and procedures of the Nursing Services.

JOB DESCRIPTION

ORGANIZATION AND MANAGEMENT

• Understands and carries out the nursing care in line with Vision and Mission Statements, Goals and Objectives that suit the scope of the Nursing Services.
• Works shift duties or as assigned by Unit Manager according to Unit’s Operational Hours.
• Informs Unit Manager when change occurs in circumstances which affect standards of care.
• Receives and handover report of patient, knows the case in detail as:
• Progress of the patient.
• Ensures all doctors’ orders are carried out before shift change and on taking over case.
• Any incident or problems encountered.
• Visits every patient in the unit together with the team members on taking over of duties to:
• Assess condition of patient, compare with report.
• Re-plan nursing care according to assessment or evaluation.
• Determines nursing priorities and plans patient care according to patient’s needs and staff availability.
• Provides individualized holistic care to patients using the Nursing Process approach with proper nursing documentation in patients files and that it is contemporaneous.
• Reports all abnormal findings and progress of patients to the relevant doctors / consultants.
• Conducts regular nursing rounds on all patients in the ward to ascertain for other additional needs; talk to patient/family members as an integral part of providing emotional support.
• Follows doctors / consultants ward round and assists them in doing procedures when required.
• Carries out orders of doctors / consultants pertaining to care of patients and delegates to other team members according to their assignments.
• Liaises and discusses with the relevant doctors / consultants with regards to care of patients in the unit / ward.
• Establishes and develops effective communication with all disciplines, patients and relatives, to achieve optimal patient’ satisfaction.
• Attends and participates in unit meetings, dialogue sessions and hospital’s activities.
• Participates in the health education of patients and their families in the ward.
• Assists the Unit Manager in the administration of the unit / wards when assigned as shift nurse in charge.
• Acts on behalf of the Unit Manager in setting standards and expectations in the quality of care.
• Carries out duties and responsibilities of the Unit Manager in her absence as directed.
• Ensure charges of equipment/consumable items into patient’s charges accordingly and checked for completeness.
• Responsible for checking and documenting supply of sterile packs from CSSS and weekly checking for integrity of packaging.
• Maintains and documents adequate supply of unit stock.
• Carries out assignments scheduled by Unit Manager and provide feedback.

HUMAN RESOURCES AND MANAGEMENT

• Participates in the development and maintenance of the nursing process when providing patient care as well as nursing documentation.
• Supports and assists the Unit Manager in effective and efficient utilization of staff, supplies and services.

POLICIES AND PROCEDURES

• Contributes suggestions in periodic revision and upgrading of Nursing Policies and Procedures and relevant work instructions.
• Checks DDA drugs with the off-going Nurse In-charge of the previous shift when in-charge of the present shift.
• Participates in the care, custody and administration of medications in accordance with Hospital Policies and Procedures.
• Checks daily and audits resuscitation trolley periodically as scheduled.
• Ensure all staff complies with Prevention and Control of Infection including implementation of surveillance activity in the unit and evidence of involvement.
• Maintain confidentiality of patient’s personal and medical history.

FACILITIES AND EQUIPMENT

• Operates / maintains specialized equipment assigned to the unit and provides assistance / guidance to new staff in their use.
• Assists the Unit Manager in keeping accurate records of equipment, medical supplies and drugs in the unit / ward.
• Checks that all equipment in the unit are functioning well and service according to PPM schedule.
• Report to Bio Medical personnel if any faulty and takes necessary action accordingly.
• Assists in maintenance of instruments and equipment by proper cleaning, handling, disinfect and utilizing as directed.

SAFETY AND QUALITY IMPROVEMENT

• Fully receptive and supportive in the activities that contribute towards continuous improvement of nursing service e.g. Quality Assurance, Infection Control and Fire and Safety Program.
• Conduct investigation and root cause analysis in any incident in the services, takes appropriate action and ensure completion of incident reports within stipulated time frame.
• Carries out duties as an employee as stipulated in Occupational Safety and Health Act and Regulations 1994:-
• a. To take reasonable care at work for the safety of yourself and other persons;
• b. To co-operate with your employer or any other person in the discharge of any duty;
• c. To wear or use any protective equipment or clothing provided by the employer.
• d. To comply with any instruction or measure on occupational safety and health.
• Ensures compliance of Patient safety goals as safety improvement measures recommended by World Alliance for Patient Safety.
• Ensures the policies on Patient and Family’s Rights are addressed at all times
• Complies with the Baby Friendly Hospital Initiative Breastfeeding Policy, and protect, promote and support Baby Friendly Hospital activities.
• Participates in 5S activities and comply with the specified requirements.
• Ensures all staff adheres to Standard People Practice (SPP) at all times.

IN OPERATION THEATRE

Perioperative Nurse in general:

• Assists the Unit Manager in overseeing the smooth running of OT and CSSS daily.
• Checks the following: - Damp dusting has been done. - Gas supply in the anaesthetic machine cylinder.
• Prepares trolleys and standing by items to be used.
• Arranges with wards to prepare patients to arrive into OT according to the scheduled time
• Receives and greets patient, checks patient with ward staff from the ward in accordance to the checklist
• Notes for any abnormalities, refers to the surgeon and anaesthetist if necessary.
• Escorts patient into the Operating Rooms and ensures patient’s safety at all times.
• Enters particulars of all cases in the Operation Theatre Record Book.
• Ensures proper care and handling of all specimens after each case – properly labeled and recorded before they are sent to the laboratory or pathology department. If in doubt, always ask and confirm with the surgeon.

Anaesthesia Nurse:

• Supervises and prepares anaesthetic equipmentbefore anaesthesia and surgery
• Infection control:
• To maintain sterility of equipment and working environment
• Disinfection and cleanliness of the laryngoscopes, suction machine, masks, etc
• Cleanliness of the GA machine/ ventilator and circuits.
• Performs daily routine task, counter check:
• GA machine and ventilator;
• Adequate monitoring equipment and accessories.
• In the GA trolley, e.g. syringes, endotracheal tubes, stoppers, etc.
• Paediatric difficult intubation set 3.
• Reviews patient’s information:
• Age and weight.
• Surgical procedure to be performed.
• Type of anesthesia.
• Allergic and other sensitive reactions.
• Site marking at surgical site as needed
• Notes any potential anaesthetic risks, hazards and complication.
• Prepares and obtains the necessary drugs and accounts for the Dangerous and Psychotropic drugs used in the OT.
• Remains with the patient prior to and during the induction of anesthesia.
• Assists the anesthetist in monitoring the patient and as required throughout surgical procedure.
• Maintains anaesthetisia records with complete accurate and legible documentation.
• Observes safety measures in positioning the patient, paying particular attention to patient’s limitations.
• E.g.Positioning of limbs to facilitate adequate arterial and venous access and prevent nerve damage.
• Skin integrity and adequate protection of eyes and ears.
• Protection of patient’s airway.
• Secure cannula, catheters.
• Adequate co-ordination, communication and sufficient personnel to position patient.
• Passes over the patient with relevant information to the Recovery Unit.
• Maintains the cleanliness of the room, anaesthesia equipment and always ready for the use of next session.

Scrub nurse: Prepares the operation room for operations:

• Assists in cleaning the Operation Rooms in the morning.
• Prepares and counter checks trolley, ensures all required items are available for the case.
• Equipment required for the case is available and functioning.
• Discusses with Surgeon the approach of surgery and any special preference.
• Verifies the correct patient identity, operative site and side and valid consent form.
• Reviews patient’s information and notes and communicates with team members potential surgical, anaesthesia risks, hazard and complication.
• Provides privacy, comfort measures and supportive care to patient.
• Scrubs well ahead of surgeon adhering to aseptic techniques of scrubbing, gowning and gloving.
• Conducts swabs, instruments, and sutures counts with circulating nurse prior to operation.
• Assists with draping patient.
• Attaches suction tubing and electrosurgical cord before knife is handed to surgeon.
• Participates in performing “Time-out” with the team before commencing the surgery. Anticipates and stays a step ahead of the surgeon. Asks quietly for additional supplies and avoid distracting the surgeon.
• Passes instruments decisively and positively that the surgeon knows he has it.
• Keeps instruments clean. Wipes blood and debris.
• Saves all specimens of tissues for laboratory examination.

Maintains sterile technique:

• Keeps hands at waist level when at rest, never below waist level.
• Keeps and confines herself to the sterile area after preparation and reduce traffic at all times.
• Never turn her back to the sterile field or to her colleagues.
• Does not reach behind the back of the operating team for instruments.
• Conducts counts on swabs and instruments before:-
• Closing of any cavity.
• Closing of skin.
• Communicates with surgeon after each counting.

In the event of incorrect count:

• Repeats the entire count and perform thorough search on and off the sterile field and in the wound is made immediately for the item.
• If the count is still incorrect, an x-ray must be take before the patient leaves the theatre. The incident must be reported to the Unit Manager immediately, an incident report and the appropriate documentation must be done.
• Passes over to circulating/recovery nurse the correct and relevant information about collection of specimens.
• Keeps voice down but loud enough to be heard.
• Maintains respect for both the patient and the people who works with her.
• Disposes sharps and used items safely into the appropriate container according to hospital policy to avoid accidental cuts, punctures, lacerations and prevent potential risks of infectious contamination.
• Cleans used instruments and passes over to the CSSS staff, accounting for each instrument that had been used.
• Documents the necessary information on the swab count form.
• Maintains cleanliness of the room and equipment, and ready for use of next surgery.

Circulating nurse:

• Prepares the operating room for the appropriate surgical procedures according to the operation list.
• Checks and records the temperature and humidity of the Operation Room daily. Reports to superior if abnormality found.
• Prepares:
• Equipment for its designed purpose; lotion, packs, sutures for standby, specimen bottle/Lab form, dressing available, lotions for warming.
• Checks:
• The potential hazards of operating table and its attachment.
• The mechanical adjuncts to the operating procedure such as electro-surgical unit, different electrode and radiological equipment for its safety.
• Recognizes safety policies, procedures and adhere to them by practice a “Time out” procedure.

Adheres to:

• Aseptic techniques that are being done by the surgical team.
• Infection control policies at all times.
• Conducts surgical counts with the scrub nurse in verifying accountable item (swab, needles, sutures and instruments). Records in the operating Swab Count Procedure chart.
• Co-operates and anticipates in getting items required for the surgery.
• Enters time on operation, start – when incision is performed. Ending time :- last stitch.
• Fills in peri-operative care form.
• Helps to position patient safely.
• Records or tags items that are used onto the patient charges form.
• Connects diathermy cable, suctions to the machine and ensure it is ready for use.
• Helps to adjust operating light, big focus light first, then only small satellite light.
• Ensures collection of specimens is labeled correctly according to hospital and Operating Theatre policy.
• Discards all the used linen, clinical waste, general waste into the designated bins and bags.
• Never leave the operating room, unless there is another unscrubbed person in OT.
• Maintains cleanliness of the room and equipment, ready for use for the next surgery.

Recovery Nurse:

• Receives patient and report from Operation Room, carries out post-anaesthesia care:
• Maintenance of airway.
• Check level of consciousness.
• Administers oxygen as ordered.
• Checks and records vital signs (blood pressure, pulse, respiration on Recovery Chart/GA chart).
• Checks and sees whether blood transfusion and / or intravenous drip is running as ordered.
• Carries out specific post-operative instructions as ordered.
• Informs ward staff to fetch patient when patient is ready for discharge from the Recovery Room
• Passes over correct and relevant information and reads out the Post-Operative order for patient clearly to the receiving Registered Nurse.
• Ensures the recoding of :
• Documentation is complete and accurate.
• Time of arrival and departure of patient.
• Nursing care is recorded in such a manner as to allow for easy retrieval communication, measurement and evaluation of patient care.
• Maintains general cleanliness of the room and always ready for next patient.
• Responsible for record, issue and indent of Dangerous Drug.

Coordinator Nurse:

• Assists the Unit Manager in overseeing the smooth running of OT and CSSS daily by allocation of the staff assignment.
• Arranging and ensure the vendor set required for surgery are available.
• Liaise with Anaesthetist for emergency cases.
• Receiving any booking case from ward staff and Consultant through phone.
• Arrangement of scheduled list, liaise with Anesthetist before calling the patient down to OT.
• Record all monitoring parameters such as cancellation, postpone, any departure of best practice and quality objective data.
• Check OT list before issue out to others services.

IN THE CENTRAL STERILIZING SUPPLY SERVICE

• CSSS staffs are tasked with the proper handling, cleaning, assembly, testing and packaging of many kinds of medical instruments.
• Decontamination Room -
• Maintains the cleanliness of the working area.
• Receives and checks used sets from the wards/operation theatre/clinics.
• Prepares disinfected solution for cleaning processes.
• Cleans and disinfects all instruments/ sets manually or using mechanical machine. Pays special attention to delicate instruments and power motorized instruments.
• Operates and maintains equipment such as ultrasonic machines, washers, dryers, etc.
• Records any monitoring parameter data.

Packing and sterilizing

• 1. Maintains cleanliness of the working area and equipment.
• 2. Checks to ensure that instruments are in good condition, functioning and sets are complete upon assemble.
• 3. Rejects instruments that are not clean properly.
• 4. Packs and labels the sets before sending for sterilization.
• 5. Records monitoring parameter data.

Storage and Distribution

• 1. Maintains cleanliness of the sterile store and shelves
• 2. Checks and records Temperature and Relative Humidity of the sterile store as per schedule. Reports to superior if any abnormality.
• 3. Maintains the integrity of sterile sets/items in storage.
• 4. Follow the “First-In First-Out” system in issuing the sterile instruments and sets.
• 5. Assist in inventory of instruments every week in sterile store and quarterly for other nursing services

Autoclave Operator

• 1. Cleans the autoclave chambers and records in the autoclave cleaning book.
• 2. Carries out test of autoclave machine efficiency by doing the Chemical test, Biological test and Leak test before running the autoclave machine.

DECISION MAKING

• This post requires adequate level of knowledge in operation theatre and central sterilizing supply practicesmakes decision related to patient care and ensure compliance of Nursing policies and procedures.
• Decision may impact the quality of service to the patient.

PERSONAL ATTRIBUTES

• Has good communication, counseling and interpersonal skills.
• Able to guide nursing staff, student nurse and non nursing staff.
• Has the ability to improve knowledge and skill in teaching and supervision in the clinical areas.
• Possess the attitude to make the patient care the primary concern, treating every patient compassionately, demonstrating and an aspiration to altruism.
• Strive to provide high quality nursing care; maintain patient’s dignity, privacy, autonomy and confidentiality.
• Prepared to work as a team member in the best possible manner.

QUALIFICATIONS REQUIRED

• Diploma/Certificate in Nursing.
• Post Basic qualification in related field.
• Peri-operative Nursing qualification.
• Bachelor of Nursing.
• Registered with Nursing Board of Malaysia with a valid license to practice as a Registered Nurse.
• Registered Nurse with at least one year experience.
• Able to write and communicate in Bahasa Malaysia and English Language.
• Strong interpersonal and communication skills.
• Caring, honest and responsible worker.
• Willingness to work on scheduled hours, shift, and weekends, public holidays, on-call and anytime when called during emergency.
• Microsoft office literacy.