Registered Nurse - Med Surg N Bordley

Registered Nurse – MO-SSM Health Saint Louis University Hospital

Job Summary: The Registered Nurse 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 using a patient/customer‑driven approach.

• Performs comprehensive nursing assessment/reassessment.
• Performs age‑appropriate admission or transfer assessment. Obtains input from family/guardian when appropriate.
• Accurately and completely documents findings.
• Performs assessment of post‑op/post‑invasive procedure patients.
• Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.
• Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status, diagnosis, response to care, procedures, etc., and standards of care.
• 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.
• Identifies short and long term goals based on patient care needs.
• Formulates nursing interventions to achieve desired patient outcome.
• Incorporates disease‑specific evidence‑based practice into nursing care plan and other documentation.
• Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.
• Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.
• Provides, coordinates, and communicates patient care, including accurate handoff communication reports.
• Administers and documents medications accurately according to policies and procedures.
• Monitors, maintains, and documents accurate IV fluids and parenteral nutrition per policies and procedures.
• Completes referrals as indicated by assessment data.
• Requests consultation for special needs, equipment, or information for patient and/or family.
• Provides patient/family education and discharge planning per documentation guidelines and protocol.
• Clarifies all physician orders as warranted.
• Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record.
• Assists physician with procedures/treatments as requested or delegates to care partner as appropriate.
• Documents "Readback" for all telephone/verbal orders.
• Takes telephone/verbal orders only in emergency situations.
• Recognizes changes in patient’s condition and takes appropriate nursing actions.
• Involves the family/guardian when providing care and decision‑making as appropriate.
• Recognizes risks for patient and takes appropriate action.
• Incorporates use of infection control practices in daily care.
• Documents and/or communicates nursing care and/or changes in patient condition.
• Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures.
• Evaluates and documents effectiveness of patient/family education.
• Evaluates plan of care and modifies as indicated.
• Recognizes significant changes in patient’s clinical parameters and reports immediately to physician and others as indicated.
• Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.
• Reports variation from care/treatment following the occurrence reporting policy and procedures.
• Provides specialized care to patients at high risk for injury.
• Restraint care: initiates/evaluates alternatives to restraint prior to application; applies restraints consistent with approved procedure; monitors and assesses patient’s response; provides specified patient care (toileting, skin care, hydration, feeding, etc.); provides consultation for peers; documents restraint use and associated care thoroughly.
• Pain management: assess patient for presence of pain; incorporate patient’s cultural/spiritual beliefs; implement pain management techniques; include patient and/or family members in developing a pain…