Staff Nurse Level 2 - PACU

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Summary:

* The Registered Nurse (RN) operates as a key member of the health care team using the nursing process, clinical skills and leadership to direct, provide and evaluate age/population specific patient care according to the department's scope of service. Analyze patient health problems and needs, develop and implement nursing care plans, and maintain medical records. Responsibilities:
1. Monitor, record, and report symptoms and changes in patients' condition: a. collects patient data *

orders, interprets, and evaluates diagnostic tests to assists to determine plan of care
* identifies expected outcomes
* implements and modifies interventions identified in the patient plan of care
* evaluates the patient's progress towards outcomes and modifies patient treatment plans as indicated by patient response and condition
* prepares patients for, and assists with, examinations and treatments
* accurately prepares and administers medications according to polices and procedures *

• Documents nursing process in nursing assessment, nursing care plan (NCP), and nurses notes as outlined in policy and procedure. Diagnosis is valid for patient, interventions are appropriate and outcomes evaluated. Changes in the plan of care are made as the patient progresses.
  2. Systematically evaluates the quality and effectiveness of their nursing practice. *
• Identifies practices to improve job or department performance
  * Monitors job and department activities
  * Participates in department CQI by: *
• uses the results to initiate changes in practice.
  * uses the results to initiate system changes.
  3. Acquires and maintains current knowledge in nursing practice. *
• participates in ongoing educational activities.
  * seeks experiences to maintain skills.
  * seeks knowledge; displays skills appropriate to setting.
  * consistently seeks educational tools in order to broaden knowledge base of various age groups, diseases, and best practices.
  * Completes mandatory training each year, plus additional 16 minimal hours for staff development.
  * Remains up-to-date of new equipment, policies, and procedures.
  4. Contributes to the professional development of peers, colleagues and others. *
• shares knowledge with colleagues and others
  * provides constructive feedback.
  * directs and supervises less skilled nursing or health care personnel; may act as a charge nurse of a particular unit, and may work as a preceptor after attending preceptor workshop
  * adheres to unit specific standards of patient interaction and customer service.
  * Participates in staff development model, serves as a preceptor for new staff and students. Provides constructive feedback to peers.
  * holds staff members accountable for results
  * ensures adequate adherence to policies and procedures
  * informs and trains new team members of procedures and policies
  * Makes decisions and takes actions on the behalf of patients in an ethical manner.
  * Maintains confidentiality. Acts as a patient advocate. Delivers care in a non-judgmental and non-discriminatory manner that is sensitive to patient diversity.
  6. Collaborates with patient, significant others and health care providers in providing care. *
• consults and coordinates with health care team members to assess, plan, implement and evaluate patient care plans
  * makes referrals for continuity of care.
  * educates patients, families and other groups on topics such as health education, disease prevention, and health improvement programs
  * Involves the multidisciplinary teams as needed and is evident in the nurse documentation.
  * Informs patient and family members of actions being taken, status of activities, estimated time involved, and reason for changes or delays.
  7. Uses research findings in their practice. *
• uses interventions substantiated by research.
  * participates in research as appropriate to the nurse's position.
  * Interventions identified in the patient's plan of care are substantiated by research. Participates in improvement/redesign processes.
  * Implements findings from departmental and performance improvement activities into daily tasks.
  8. Considers factors related to safety, effectiveness and cost in planning and delivering patient care. *
• evaluates factors related to safety, effectiveness and cost when two or more practice options would result in the same outcomes.
  * assists patient in identifying and secure appropriate services available to address health related needs.
  * adheres to standard precautions
  * Demonstrates awareness of appropriate safety precautions in the environment for patients and significant others. Accesses resources to get necessary services to continue care post discharge.
  * Adheres to personal protective equipment requirements. Utilizes appropriate Safe Patient-Handling equipment, where indicated, to ensure personal and patient safety. Other Information…