Registered Nurse - Med Surg Vascular ENT - Nights

Registered Nurse - Med Surg Vascular ENT - Nights

Join to apply for the Registered Nurse - Med Surg Vascular ENT - Nights role at SSM Health

4 days ago Be among the first 25 applicants

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.

• Performs comprehensive nursing assessment/reassessment.
• Performs age‑appropriate admission or transfer assessment, obtaining input from family or guardian when appropriate.
• Accurately and completely documents findings.
• Performs assessment of post‑op/post‑invasive procedure patients.
• Assesses and documents education and discharge needs on admission and throughout hospitalization.
• Provides patient reassessment documenting pertinent observations per the 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 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 outcomes.
• Incorporates disease‑specific evidence‑based practice into the nursing care plan and documentation.
• Provides and documents nursing interventions based on assessed needs, plan of care and changes in patient status.
• Collaborates with health‑team members for daily plan of care coordination.
• 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 or family.
• Provides patient/family education and discharge planning per documentation guidelines and protocol.
• Clarifies all physician orders as warranted.
• Recognizes and implements physician orders accurately and timely, evidenced by documentation.
• Assists physician with procedures/treatments 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 condition and takes appropriate nursing actions.
• Involves family or guardian in care and decision‑making as appropriate.
• Recognizes risks for patient and takes appropriate action.
• Incorporates infection control practices daily.
• Documents and/or communicates nursing care and changes in patient condition.
• Performs ongoing evaluation of care effectiveness based on assessment data, interventions, and patient response to medications, treatments, and procedures.
• Evaluates and documents effectiveness of patient/family education.
• Evolves plan of care based on findings and modifies as indicated.
• Recognizes significant changes in patient parameters and reports immediately to physician and others as indicated.
• Identifies problems, gathers data, suggests solutions, communicates authority lines, and works toward resolution.
• Reports variation from care/treatment following occurrence reporting policy and procedures.
• Provides specialized care to high‑risk patients.
• Restraint care: initiates/evaluates alternatives before application; applies restraints per approved procedure; monitors response; provides timely toileting, skin care, hydration, feeding; consults peers for alternatives and 1:1 observation; documents restraint use thoroughly.
• Pain management: assess pain; incorporate cultural/spiritual beliefs; implement techniques focused on prevention; involve patient/family; use massage, repositioning, immobilization, music therapy.
• Abuse assessment: recognize criteria; report signs to appropriate authorities; take actions to support patient safety.
• Adheres to quality and performance standards, policies, procedures, protocols when…