RN, Surgery Unit, 2nd shift

MO-SSM Health Saint Louis University Hospital 1201 Grand

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

• 1) Performs comprehensive nursing assessment/reassessment.
  • Accurately and completely documents findings.
  • 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 and/or diagnosis, response to care, procedures, etc., and standards of care.
• 2) 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 and other information as relevant.
  • Identifies short and long term goals based on patient care needs.
  • Formulates nursing interventions to achieve desired patient outcome.
  • Incorporates disease specific evidenced based practice into nursing care plan and other documentation
• 3) 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 according to 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 in decision-making as appropriate.
  • Recognizes risks for patient and takes appropriate action.
  • Incorporates use of Infection Control practices in daily care.
• 4) 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 in ‘A‘ above.
  • 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.
• 5) Specialized Care: Provides specialized care to patients at high risk for injury.
  • A) Restraint Care Initiates/evaluates alternatives to restraint prior to application Provides specified patient care (toileting, skin care, hydration, feeding, etc.) Documents restraint use and associated care thoroughly. Incorporates patient‘s cultural/spiritual beliefs regarding pain into pain management plan. Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy. Reports signs of possible abuse/neglect to the Administrative Director of Behavioral Health, physician, Risk Management and Social Work.
  • A) Adheres to all quality and…