Registered Nurse - Clinical Float - Critical Care - Days

Registered Nurse (RN), Medical Surgical Float Pool

It's more than a career, it's a calling.

MO-SSM Health Saint Louis University Hospital 1201 Grand

Worker Type: Regular

Job Summary: The Registered Nurse (RN), Medical Surgical Float Pool is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates care planning with other disciplines utilizing a patient/customer driven approach in a variety of Medical Surgical units. Must be highly energetic, flexible and motivated to support the success of Saint Louis University Hospital.

Job Responsibilities and Requirements:

POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA (% of time)

Essential Functions: The following are essential job accountabilities and performance criteria:

Position Accountabilities

1) Performs comprehensive nursing assessment/reassessment.

Criteria

A) Performs age-appropriate admission assessment or transfer assessment. Obtains input from family/guardian when appropriate.

B) Accurately and completely documents findings.

C) Performs assessment of post-op / post-invasive procedure patients.

D) Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.

E) Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and /or diagnosis, response to care, procedures, etc., and standards of care.

2) Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant.

Criteria

A) Identifies short and long term goals based on patient care needs.

B) Formulates nursing interventions to achieve desired patient outcome.

C) Incorporates disease specific evidenced based practice into nursing care plan and other documentation.

3) Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.

Criteria

A) Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.

B) Provides, coordinates and communicates patient care, including accurate Handoff Communication Reports i.e. Bedside shift report, ticket to ride, SBAR, daily huddles, Patient Care Conferences, etc.

C) Administers and documents medications accurately according to policies and procedures.

D) Monitors, maintains and documents accurate IV fluids, blood, blood products and parenteral nutrition according to policies and procedures.

E) Completes referrals as indicated by assessment data.

F) Requests consultation for special needs, equipment, or information for patient and/or family.

G) Restraint Care

1. Initiates/evaluates alternatives to restraint prior to application.

2. Applies restraints consistent with the approved procedure.

3. Monitors and assesses patient's response throughout the restraint period at the appropriate intervals.

4. Provides specified patient care (toileting, skin care, hydration, feeding, etc.) on a timely basis.

5. Provides consultation for peers to determine alternatives to restraints and 1:1 observation.

6. Documents restraint use and associated care thoroughly.

H) Provides patient/family education and discharge planning per documentation guidelines and protocol.

I) Pain Management

1. Assess patient for presence of pain on admission and during Assessments/reassessments.

2. Incorporates patient's cultural/spiritual beliefs regarding pain into pain management plan.

3. Implement pain management techniques. Focus on prevention rather than treatment.

4. Include patient and/or family members in developing a pain management plan.

5. Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy.

J) Abuse Assessment

1. Is aware of abuse recognition criteria and incorporates it into assessments.

2. Reports signs of possible abuse/neglect to the physician, Risk Management and Social Work.

3. Takes appropriate action to support patient safety when signs of abuse are noted.

K) Clarifies all physician orders as warranted.

L) Transcribes and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record.

M) Assists physician with procedures/ treatments as requested or delegates to Care Partner as appropriate.

N) Documents "Read back" for all telephone/verbal orders.

O) Takes telephone/verbal orders only in emergency situations.

P) Recognizes changes in patient's condition and takes appropriate nursing actions.

Q) Uses Chain of Command when indicated.

R) Involves the family/guardian when providing care and in decision-making as appropriate.

S) Recognizes risks for patient and takes appropriate action.

T) Completes and or incorporates use of Infection Control Bundles in daily care.

U) Implements and or works with Care Partner to assure that all interventions related to Fall and Skin Injury Prevention are in place.

1. Completes Fall and Skin Audits when indicated.

4) Documents and or communicates nursing care and or changes in patient condition.

Criteria

A) Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient's response to medications, treatments and procedures.

B) Evaluates and documents effectiveness of patient / family education.

C) Evaluates plan of care and modifies as indicated in "A" above.

D) Recognizes significant changes in patient's clinical parameters and reports immediately to physician and others as indicated.

E) Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.

F) Reports variation from care / treatment following the occurrence reporting policy and procedures.

5) Specialized Care: Provides specialized care to patients at high risk for injury.

Criteria

A) Restraint Care

1. Initiates/evaluates alternatives to restraint prior to application.

2. Applies restraints consistent with the approved procedure.

3. Monitors and assesses patient's response throughout the restraint period at the appropriate intervals.

4. Provides specified patient care (toileting, skin care, hydration, feeding, etc.) on a timely basis.

5. Provides consultation for peers to determine alternatives to restraints and 1:1 observation.

6. Documents restraint use and associated care thoroughly.

B) Pain Management

1. Assess patient for presence of pain on admission and during assessments/reassessments. 2/16/09

2. Incorporates patient's cultural/spiritual beliefs regarding pain into pain management plan.

3. Implement pain management techniques. Focus on prevention rather than treatment.

4. Include patient and/or family members in developing a pain management plan.

5. Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy.

C) Abuse Assessment

1. Is aware of abuse recognition criteria and incorporates it into assessments.

2. Reports signs of possible abuse/neglect to the physician, Risk Management and Social Work.

3. Takes appropriate action to support patient safety when signs of abuse are noted.

6) Demonstrates accountability for own professional practice.

Criteria

A) Adheres to all quality and performance standards, policies, procedures, protocols when implementing clinical and technical aspects of care.

1. Participates in learning experiences that increases professional competence.

B) Demonstrates appropriate technical and cognitive skills for area of practice.

C) Maintains currency in all hospital/unit information, communication, policies and procedures.

1. Attends staff meetings/reviews minutes when absent.

2. Participates in Committee(s), Shared Governance, Work Team(s), in a leadership and or in membership role.

3. Reviews