Staff RN, Per Diem
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.
- 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.
- 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
· 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: