Staff Nurse - Medical/Surgical Orthopedics
Position Purpose
The registered nurse assumes principle responsibility under general supervision, for the total care, assessment, implementation and evaluation of each patient assigned to the nursing unit, either directly or through leadership of personnel. The RN develops and/or revises a plan of care for each patient, initiates health care training and education of the patient and/or patient family to facilitate recovery; utilizes principles of teaching and learning to assist patients, staff and self in the identification of the need for new knowledge and skills.
Role Specific Competencies
1. Administers all medications in accordance with policies and procedures (RN)
- Verifies physician orders against MAR for accuracy on each shift and on an ongoing basis.
- Maintains knowledge of all actions, indications, contraindications, adverse reactions, dosage and route of administrations on all drugs administered to patients.
- Assures that all medications are administered in accordance with Bedside Medication Verification Policy 100% of the time.
- Responds to pt requests in a timely manner, answering questions about medications to patient's satisfaction.
- Provides supervision and assistance to LPN with administration of IV push medications, and blood / blood product administration.
2. Completes comprehensive physical and psychosocial assessment of assigned patients (RN)
- Completes nursing databases and physical assessment within eight hours of admission, identifying care needs. Makes appropriate referrals based on assessment.
- Initiates a patient plan of care within 8 hours of admission. Establishes appropriate nursing diagnoses, interventions and measurable outcomes in collaboration with the physician, patient and family. C ommunicates plan of care to other healthcare team members.
- Documents evaluation of the patient's compliance and response to the therapeutic regimen as indicated.
- Updates patient plan of care to reflect changes in patient's condition.
- Communicates pertinent patient information to physician to obtain appropriate patient care orders.
- Reports pertinent patient care data to the Clinical Coordinator.
3. Demonstrates skills and knowledge necessary to provide quality care services for special age specific populations, such as, but not limited to pediatric and geriatric patients. (RN)
4. Implements and monitors appropriate nursing care to meet patient's needs. Evaluates patient response to care provided.(RN)
- Participates in nursing shift reports, giving accurate and complete information on each patient.
- Establishes priorities appropriately, delegates assignments and follows-up on completion of assigned work.
- Performs physical assessments for each assigned patient on every shift.
- Performs direct patient care and documents care, treatments, response to care/treatment and events occurring during shift.
- Identifies pertinent patient information and communicates as appropriate to physician including critical results, changes in patient condition, patient and family concerns, diagnostic results and clarification of orders.
- Responds appropriately to emergency situations.
- Accepts, accurately documents and ensures accurate transcription of physician verbal orders.
- Assures all orders are initiated by conducting periodic chart and meditech reviews throughout the shift.
- Demonstrates computer literacy and competency in O/E and chart review.
- Verifies and coordinates scheduling of tests and procedures.
- Maintains adherence to infection control measures, including wearing personal protective equipment per policy.
- Responds to patient requests in a timely manner, answering questions about patient condition as appropriate.
5. Participates at the unit level to support unit functioning. (RN)
- Participates in unit staff meetings.
- Successfully completes all required education courses as assigned within established deadlines.
- Adheres to attendance and tardiness policies.
- Conforms to hospital and departmental dress code.
- Always utilizes sign-in/sign-out documentation sheet for meals or breaks.
- Participates in unit based performance improvement data collection as needed and in unit based improvement efforts as assigned.
- Reviews unit and hospital communication on a routine basis to include electronic and paper formats.
- Assures that computer data entries are complete and accurate.
- Maintains confidentiality of all records (patient/employee.)
- Ensures appropriate use of equipment used in patient care; ensures that broken equipment is tagged for repair.
6. Participates in healthcare education needs of the patient and family. (RN)
- Assesses patient educational needs and utilizes educational programs for teaching.
- Documentation reflects implementation of teaching plan.
- Documents evaluation of patient and family understanding and areas of inadequate understanding.
- Revises education to reflect current patient status.
- Utilizes appropriate resource persons and documents referrals.
Qualifications and Experience
- Current C PR/BLS is required.
- Graduate of an accredited school of nursing and current RN licensure in the State of Maryland.
- One year previous experience in Med/Surg Nursing within the past five years.
Physical Requirements
- More than 75% of work time will involve pushing, pulling, stretching, bending and walking.
- Must be able to hear normal sounds with some background noise.
- Must have ability to use a standard computer keyboard, and be able to read a computer screen and differentiate colors.
- Routinely lifts objects under 50 pounds.
