Summary Manages individualized, outcome oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures
1 - ASSESSMENT/REASSESSMENT
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients by:
a - Initiating admission assessment within 8 hours of admission, identifies and documents patient/family/significant other teaching needs upon admission anf throughout hospitalization.
2 - PLAN OF CARE
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient, in collaboration with designated support persons in order to address all identified needs.
a - Develop, evaluate and update individualized plan of care for patients and documentsd outcomes.
b - Actively communicates plan of care with the primarynure assigned to care for the patient
c - Facilitates dischasrge/transfers by goal of 12:00 pm, communicating barriers utilizing the Chain of Command.
d - Documents all patient care follwoing the department of nursing policies, unit based standards and nurse sensitive indicators (falls, skin pain).
e - Assessess/re/assesses and documentsd patient's level of comfort utilizong the appropriate pan scale and the patient's response to each intervention both pharmacoligical and non-pharmacological per South Shore Hospital Policy.
f - Works on behalf of patient/family. Seeks help to repersent patient/family when they are unable to represent themselves.
g - Raises ethica questions and concerns with clinica team. Seeks available resources to help formulate and understand ethical decisions.
3 - MEDICATION ADMINISTRATION
a - *Demonstrates knowledge of and follows SSH policies and procedures for administering, transcribing, and recording medications.
b - Demonstrates proper porcedure for the documentation of narcotic withdrawal, administration, verifies count, wastes per policy and resolves narcotic discrepency.
c - Initiates and maintains IV access according to SSH policy and procedure.
6 - SAFETY
Fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.
a - Verifies patient identification with two idenitifiers prior to the start og any invasive procedure, including "time out", admisinstration og care, medications, labeleld specimens and documents confirming the correct patient, procedure, site, equipment and consent.
b - Complies with the current CDC hand hygiene guidelines through proper handwashing. Adheres t universal precautions, makes approriate use of personal protective equipment at all times and appropriately disposes of hazardous materials. Maintains awareness of MSDS sheets and how to access them.
c - Assesses each patient's risk for falling throughout hospitalization using appropriate interventions to prevent falls.
d - Ensures environment meets regulatory requirements at all times (ie: no cardboard boxes on floor, equipment cords are secured and plugged into foot of bed, etc. ).
e - Understands and is able to demonstrate individual roles and responsibilities in teh event of hospital codes/emergency preparedness.
f - Practices patient hand off utilizing the principles of SBAR - including walking rounds.
7 - PROFESSIONAL DEVELOPMENT
Assumes overall responsibility for own professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.
a - Obtains at least 5 contact hours per year in area of practice.
b - Practices within the legal boundaries of MA Nurse Practice Act. Directs other licensed and non-licensed personnel as ssigned.
c - Active participant in unit based initiatives and/or hospital committees.
d - Understands and demonstrates job responsibilities for charge nurse, preceptor and mentor role.
e - Analyzes cause of problems, identifies and evaluates alternative solutions, and selects appropriate solutions and communicates appropriately and effectively utilizing the proper Chain of Command.
f - Assumes and active role in keeping informed about changes in hospital policy, procedure and equipment.
g - Interacts with patient and families on a compassionate and humanistic manner - demonstrating empathy, sensitivity and patience.
8 - TECHNOLOGY
Embraces technological solutions to work processes and practices.
a - Access Lotus Notes to review e-mail, learning management and other resources as applicable to RN role.
b - Utilizes all Meditech applications required by department and unit standards (PCS,EMR, Order Entry, etc. )
ESSENTIAL FUNCTIONS (Cont. )
1 - Technology and Learning
a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.
JOB REQUIREMENTS
Minimum Education - Preferred
Graduate of an accredited School of Nursing
Minimum Work Experience
Previous Acute Care RN experience preferred
Required Licenses / Registrations
RN - Registered Nurse
Required Classes/Skills -
ACLS - Advanced Cardiac Life Support
CAP Education Verification Required
Required additional Knowledge, and Abilities
Demonstrated proficiency in acute care nursing, knowledge, and skills
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