The Staff Nurse is an individual who holds ultimate responsibility for direct and indirect nursing care through the utilization of the nursing process. The Staff Nurse provides individualized, goal-directed nursing care through use of the nursing process and practices within the guidelines of the Nurse Practice Act and the Standards, Policies and Procedures of Carney Hospital. He/she reports to the Clinical Manager or designee. ESSENTIAL FUNCTIONS- Assess and diagnoses patient and family problems in order to provide quality care to assigned patients.
· Completes patient assessment data within 8 hours of admission or in accordance with specific unit standard. · Identifies and documents nursing diagnosis/problem list on patient plan of care within 8 hours of admission. · Identifies and documents patient/family/significant other teaching needs upon admission. (including barriers/strategies/outcomes) · Identifies discharge planning needs of patient/family/significant other at time of admission. · Identifies and anticipates needs of patient/family as they move through the hospitalization process. - Develops discusses and communicates a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs/or in accordance with specific unit standards.
· Plan of care includes nursing diagnosis/problem list statement for each identified problem · Develops patient/family/significant other teaching and discharge plans that are driven by the needs of patient/family. - Demonstrates the skills and judgement necessary to implement medical plan of care, nursing interventions
and procedures as necessary for the care of the patient. · Demonstrates knowledge of Carney Hospital policies and procedures/protocols for administering, transcribing and recording medications. · Demonstrate knowledge of commonly used meds: action, dose and side effects · Observes 5 R’s for administering meds: - right patient - right drug - right dose - right method - right time · Demonstrated proper procedures in all methods of medication administration · Monitors patients response and intervenes appropriately · Provides effective pain management to include: - accurate assessment using 0-10 pain scale
- documentation of location, character and duration - timely appropriate interventions - timely reassessment and intervention
· Administers blood and blood products following Carney Hospital policy and procedures · Documents narcotics use according to Carney Hospital policy and procedure · Assess, maintains and documents IV access according to Carney Hospital policy and procedures · Identifies patients at risk for falls and implements fall prevention program as appropriate · Delivers culturally competent care being sensitive to issues related to culture, race, gender, sexual orientation, and socio-economic class · Provides emotional support to the patient/family · Considers patient’s spiritual needs and appropriately consults Spiritual Care Services · Effectively teaches the patient/family about the disease, disease process, procedures, medications, food drug interactions, activity progression and when to call M.D. - Re-evaluates the identified problems, care provided, and outcomes in order to meet patient and family needs and assure overall quality of care delivered.
- Reassessments of plan of care is done every 24 hours and as patient condition warrants/or at each patient visit.
- Assesses the patient/significant other’s response to teaching plan in order to evaluate the effectiveness of plan.
- Based on reassessment, plan of care remains the same or is modified to meet the patient/significant other’s identified needs.
- Contributes knowledge and information and is open to the knowledge and assessment of others, thus enabling the team to develop an integrated approach to patient care.
- Maintains up-to-date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team.
- Each identified problem is addressed using flow sheet or progress note every 24 hours
- Patient teaching record is completed to include barriers, teaching method and learning outcome
- Flow sheets and I&O sheets are accurate and signed with name and title each shift
- Medication administration record reflects full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable)
- Discharge plan accurately reflects patient and/or family’s ability to manage care after discharge
- Referrals are made based on identified needs
- Interagency communication referral forms (Pg. 2) are complete and accurate.
- Demonstrates ability to use critical thinking skills in all aspects of practice.
· Collates and integrates multiple sources of data · Recognizes the limits of clinical judgment and seeks interdisciplinary collaboration and consultation · Maintains a global grasp of situations, and utilizes nursing skills acquired through a process of integrating formal and experiential knowledge · Functions appropriately during medical emergencies. - Maintains current knowledge/certification/licensure.
- Practice within legal boundaries of nurse practice act and according to Carney Hospital policies and procedures
- Attends continuing education programs in order to maintain licensure
- Attends Carney Hospital sponsored skills programs as required by department.
- Functions as a role model for current and new staff.
- Facilitates problem resolution among peers as observed by Clinical Manager and peers
- Demonstrates a constructive approach towards the organization during all interactions with staff and nurse manager
- Role models the core values
- Seeks opportunities to act as preceptor/teacher/mentor.
- Performs competently in fulfilling job responsibilities as required by the Division.
- Maintains all unit based competencies
- Demonstrates knowledge of procedures/theories of PCA and epidural pain management modalities
- Demonstrates knowledge of procedures/theories of capillary blood glucose testing
- Demonstrates knowledge of Carney Hospital restraint policy
- Demonstrates ability to use computer system.
- Directs other licensed and non-licensed personnel in the provision of care to patients as assigned.
· Demonstrates willingness to assume charge nurse role as required · Delegates responsibility based on patient care needs, skills and competence of the caregiver. - Assumes all other duties and responsibilities as necessary.
· Identifies and/or assumes activities relative to the developmental needs of the unit and the nursing department · Demonstrates dependability/flexibility in meeting scheduling needs of the unit and Hospital - Maintains professional composure and confidence during stressful situations
- Maintains open communication using appropriate chain of command regarding issues
· Seeks opportunities to participate in decision making regarding standards, policies, practice and/or education · Demonstrates knowledge and principles of Performance Improvement works as a team member to achieve Performance Improvement · Participates in a minimum of 50% of staff meetings. - Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
1. Commits to recognize and respect cultural diversity for all customers (internal and external). 2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed. - Performs other duties as assigned
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