Position Accountabilities
1) Performs comprehensive nursing assessment / reassessment.
Criteria:
a) Performs age-appropriate assessments of new admissions or transfers immediately in the Critical Care areas and within one hour in Acute Care units which includes input from family / guardian. Behavioral, developmental, cognitive, educational, social and self-care are assessed as required by the patient's condition.
b) Documents patient assessment findings including the physical, psychosocial, spiritual, and cultural needs.
c) Performs an assessment of post-op / post-invasive procedure patients immediately.
d) Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.
e) Provides timely ongoing patient reassessment documenting pertinent observations according to the patient plan of care.
2) Establishes and coordinates a plan of care based on analysis on the initial assessment data, patient diagnosis, physician orders and established standards of care.
Criteria:
a) Identifies short and long term goals based on patient care needs.
b) Formulates nursing interventions to achieve desired patient outcome.
c) Identifies and initiates individualized educational and discharge plan.
3) Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient condition.
Criteria:
a) Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.
b) Provides, coordinates and communicates patient care, including accurate change of shift report.
c) Makes referrals when necessary.
d) Requests consultation for special needs, equipment, or information for patient and/or family.
e) Provides patient / family education and discharge planning per documentation guidelines and protocol.
f) Transcribes and implements physician orders in an accurate and timely manner.
g) Documents "Readback" for all telephone orders.
h) Takes telephone orders only in emergency situations.
i) Recognizes changes in patient's condition and takes appropriate nursing actions.
j) Involves the family / guardian when providing care and in decision-making as appropriate.
k) Recognizes the fall risk patient and takes appropriate action.
l) Identifies and implements alternatives to restraints.
4) Documents the effectiveness of nursing care and modifies plan of care as patient progresses toward expected outcomes.
Criteria:
a) Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures.
b) Evaluates and documents effectiveness of patient / family education per documentation guidelines.
c) Evaluates plan of care and modifies as indicated.
d) Recognizes significant changes in patients clinical parameters and reports immediately to physician and others as indicated.
e) Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.
Job Specifications
Minimum Education: RN licensure in the State of Missouri
Working Conditions: May be exposed to the risk of blood borne diseases. Exposure
to unpleasant elements (accidents, injuries, and illness). Subject
to varying and unpredictable situations. Handles emergency
and crisis situations. Subject to irregular hours.
Physical Requirements: Occasional prolonged standing/walking. Occasionally lifts,
positions, pushes and/or transfers patients. Occasional
reaching, stooping, bending, kneeling, crouching.
