Registered Nurse - Clinical - Medical​/Surgical

MO-SSM Health Saint Louis University Hospital

Worker Type:
Regular

The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

• Perform comprehensive nursing assessment/reassessment.
• Perform age‑appropriate admission or transfer assessment; obtain input from family/guardian when appropriate.
• Accurately and completely document findings.
• Assess post‑op/post‑invasive procedure patients.
• Assess and document education and discharge needs of patient and family on admission and throughout hospitalization.
• Provide patient reassessment documenting pertinent observations per patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc.
• Establish, coordinate and evaluate a plan of care based on assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care.
• Identify short and long term goals based on patient care needs.
• Formulate nursing interventions to achieve desired patient outcomes.
• Incorporate disease‑specific evidence‑based practice into nursing care plan and other documentation.
• Provide and document nursing interventions based on assessed patient needs, plan of care, and changes in patient status.
• Collaborate with health team members for coordination of daily plan of care for assigned patients.
• Provide, coordinate and communicate patient care, including accurate handoff communication reports.
• Administer and document medications accurately according to policies and procedures.
• Monitor, maintain and document accurate IV fluids and parenteral nutrition.
• Complete referrals as indicated by assessment data.
• Request consultation for special needs, equipment, or information for patient and/or family.
• Provide patient/family education and discharge planning per documentation guidelines and protocol.
• Clarify all physician orders as warranted and acknowledge and implement them accurately and timely.
• Assist physician with procedures/treatments as requested or delegate to Care Partner as appropriate.
• Document “Readback” for all telephone/verbal orders; take orders only in emergency situations.
• Recognize changes in patient's condition and take appropriate nursing actions.
• Involve family/guardian when providing care and in decision‑making as appropriate.
• Recognize risks for patient and take appropriate action.
• Incorporate use of infection control practices in daily care.
• Document and/or communicate nursing care and changes in patient condition.
• Perform ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures.
• Evaluate effectiveness of patient/family education.
• Evaluate plan of care and modify as indicated.
• Recognize significant changes in patient's clinical parameters and report immediately to physician and others as indicated.
• Identify problems, gather pertinent data, suggest solutions, communicate using appropriate lines of authority, and work toward problem resolution.
• Report variations from care/treatment following the occurrence reporting policy and procedures.
• Specialized care:
  Provide specialized care to patients at high risk for injury, including restraint care, pain management, and abuse assessment as described.
• Adhere to all quality and performance standards, policies, procedures, and protocols when implementing clinical and technical aspects of care.
• Participate in learning experiences that increase professional competence and acquire relevant skills.
• Maintain currency in all hospital/unit information, communication, policies, and procedures.
• Attend staff meetings and reviews; participate in committees, shared governance, and work teams.
• Review hospital and nursing publications and stay updated on policies and procedures.
• Adapt positively to changes in work demands and workload.
• Assist in orienting/precepting new employees and maintain a collaborative team approach.
• Serve as a resource person to co‑workers, patients/families, medical…