RN/Registered Nurse Weekend - NIGHT SHIFT - Emergency Nursing

MO-SSM Health Saint Louis University Hospital The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach. POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA Essential Functions: The following are essential job accountabilities and performance criteria: 1) Performs comprehensive nursing assessment/reassessment. B) Accurately and completely documents findings. 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. 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. 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. C) Administers and documents medications accurately according to policies and procedures. D) Monitors, maintains and documents accurate IV fluids 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) Provides patient/family education and discharge planning per documentation guidelines and protocol. H) Clarifies all physician orders as warranted. I) Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record. J) Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate. K) Documents "Readback" for all telephone / verbal orders. L) Takes telephone / verbal orders only in emergency situations. M) Recognizes changes in patient's condition and takes appropriate nursing actions. N) Involves the family/guardian when providing care and in decision-making as appropriate. O) Recognizes risks for patient and takes appropriate action. P) Incorporates use of Infection Control practices in daily care. 4) Documents and or communicates nursing care and or changes in patient condition. A) Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient 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. A) Restraint Care Initiates/evaluates alternatives to restraint prior to application Provides specified patient care (toileting, skin care, hydration, feeding, etc.) Documents restraint use and associated care thoroughly. Incorporates patient's cultural/spiritual beliefs regarding pain into pain management plan. Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy. Reports signs of possible abuse/neglect to the Administrative Director of Behavioral Health, physician, Risk Management and Social Work. A) Adheres to all quality and performance standards, policies, procedures, protocols when implementing clinical and technical aspects of care. C) Maintains currency in all hospital/unit information, communication, policies and procedures. Reviews Hospital/Nursing publications Keeps up to date with policies and procedures Participates and or keeps up to date with Shared Governance and Unit Based Practice Council activities and information. Provides assistance and support to peers, co-workers and other team members C) Functions as a resource person to co-workers, patients/families, medical staff and other members of the health care team. D) Effectively assumes and delegates care and other activities to the appropriate team member. E) Redirects clinical staff when the medical plan of care is altered. F) Communicates the plan of care to be followed on each individual patient in a precise and professional manner. G) Responsible for the supervision and teaching of students/new staff nurses. 8) Safety/Infection Control: Performs job in accordance with safety and infection control policies. B) Maintains a safe, clean, comfortable, and therapeutic environment for patients/ families/employees in accordance to hospital standards. Follows hand hygiene procedures. Utilizes Safe Patient Handling techniques and equipment. Keeps personal conversations/background noise to a minimum. C) Reports risk management concerns using eSRM. Annual TB Screening and Influenza vaccination Annual Ethics Training (Initial Ethics, if new employee) Annual Safety Training Annual Blood Borne Pathogens training (if required) E) Reports variations from care/treatment following the occurrence reporting policy and procedure. Provides service excellence to the customers of Saint Louis University Hospital by delivering timely, high quality care in a courteous and respectful manner.