*STAFF NURSE II

Overview

The Staff Nurse is a professional caregiver who assumes responsibility and accountability for the assessment, nursing diagnosis, planning, implementation and evaluation of care for patients and their families in compliance with the standards for care at AHMC Seton Medical Center.

Responsibilities

POSITION SPECIFIC DUTIES (other duties may be assigned)

Clinical Practice: Nursing

 

Assesses, collects and documents health assessment data focusing on the physical, emotional, spiritual, psychosocial and educational needs of the patient considering the planned procedure for which the patient is scheduled

Interviews the patient/family/significant other to complete nursing assessment.

Reviews scheduled procedure, and physicians orders 

Identifies actual and potential needs and determines priority

Identifies barriers to learning.

Performs ongoing assessment as indicated by changes in status.

 

Plans nursing care, based on assessment, knowledge of the surgical planned procedure, data collection such as lab results and radiological exams.

Develops realistic goals for the pre and post care,including safety, infection control, pain control and temperature modulation.

Incorporates National Patient Safety Goals into the plan of care.

Plan demonstrates understanding of age-related needs of the patient.

 Collaborates with physicians, and post op nursing units to plan for discharge needs               

 

Implements the plan of care including prescribed procedures. 

Incorporate the National Patient Safety Goals in the implementation of the plan of care.

Organizes and prioritizes care based on individual patient needs, requirements of the procedure, and preferences of the cardiologist, surgeon and anesthesiologist.

Assesses for changes in patient’s condition and appropriateness of the plan.  

Initiates interventions using appropriate clinical expertise and knowledge.

As Primary Nurse, coordinates the activities of health care team members in completing diagnostic and therapeutic interventions.  

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Evaluates the effectiveness of nursing care delivered to reach the expected outcome.

a) Evaluates the plan of care according to the current condition and changing needs of the     patient. 

b) Accurately and concisely documents the patient’s status and response to the care               delivered. 

Clinical Practice:  PeriOperative Nursing

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Utilizing professional nursing knowledge and skills. Appropriately assesses for:

Physical and psychosocial-emotional needs.

Barriers to learning.

Educational/learning needs.

Discharge needs.

Age-related needs.

 

Analyzes patient related data, such as vital signs, medical history and physical exam findings, laboratory values and other information, including age-specific criteria, to determine appropriate care.  

 

Uses knowledge of the equipment, supplies instrumentation appropriate for the surgical procedure to prepare for appropriate care.

 

Guides and supervises members of the perioperative team in the preparation of the operating room for the intended surgical procedure.   

 

Coordinate effectively with the members of the team, including physicians, technicians, Charge Nurses and other departments to coordinate care.

 

Effectively performs procedures, such as initiation of IV catheters and administration of fluids and medication, within the scope of practice, and unit, department and Medical Center policies and procedures.  

   

Effectively performs other nursing procedures/skills, such as cardiac monitoring, rhythm interpretation, defibrillation, monitoring of conscious sedation, etc., based completed specialty training and scope of practice, and unit, department and Medical Center policies and procedures.

 

Appropriately recognizes and quickly responds to emergency medical situations.

a) Accurately assesses “C-A-Bs.” 

b) Initiates appropriate emergency treatment, i.e., CPR, O2, etc.

c) Communicates critical information to other team members.

 

d) Maintains competencies required by the department:

e) Extubation

f)  Removal of the sheath in post cath patients

g) Discharge of outpatients against criteria

 

Maintains all required credentials and training (CA RN license, BLS, ACLS, PALS). 

 

Remains current in practices/procedures through attendance at continuing education events, in-services and the review of professional literature.

 

Integrates/applies new knowledge from education and research into clinical practice.

 

Demonstrates knowledge of and competence in age-related patient care.