Position Overview:

The Clinical Nurse assumes principal responsibility for the total nursing care, assessment, planning, implementation, evaluation of each assigned patient. The staff nurse initiates teaching and educates the patient and family/or significant other to attain optimal health. Access to all Patient Health Information for treatment purposes only.

Department Specific Duties:

• Obtains information and interpret information in terms of the patient�s needs.
  
• Demonstrates knowledge of growth and development.
  
• Understands the range of treatment needed as appropriate to the ages of the patients served.
  
• Independently cares for two critically ill patients.
  
• Assesses and recognizes change in condition and notifies the physician appropriately; report to physician is accurate and concise; documents completely including reassessments.
  
• Provides head to toe critical assessment and reports utilizing critical thinking skills; includes change in condition; treatment rendered and vasoactive medication dosages.
  
• Manages multiple drips and sedation.
  
• Assesses and cares for patients on ventilators and understands alarms and parameters of the patient.
  
• Understands hemodynamic status of the patient; correlates swan reading BP; UO to assess appropriately.
  
• Assists with bedside procedures- arterial line.
  
• Initiates interdisciplinary communications and incorporates recommendations.
  
• Consistently demonstrates the knowledge and skills necessary to provide care appropriate to the ages of the patients served on the assigned unit.
  
• Acts as a liaison between patient, physicians, family/significant other and other health disciplines.
  
• Develops, implements and updates an individualized teaching and discharge plan.
  
• Initiates and documents progressive patient and family/significant teaching.
  
• Facilitates the discharge process ensuring all goals are addressed prior to discharge.
  
• Utilizes current theories and knowledge for accurate assessments and evaluations.
  
• Completes acuity evaluation on all assigned patients according to unit protocol.
  
• Consistently performs proficiently on nursing unit. Including but not limited to: Manages an average caseload specific to unit.
• Adapts to altered work patterns, sets priorities, and modifies assignments to meet patient needs utilizing available resources and staff ability and availability.
  
• Administers medications prescribed by physicians according to policy, including IV�s, blood and blood products.
• Knows actions, indications, contraindications, precautions, adverse reactions, dosage and route of administration on all drugs before administering to patient
  
• Verifies against MAR for accuracy on an ongoing basis.
  
• Consistently recognizes, evaluates and intervenes appropriately in life-threatening situations.
  
• Consistently checks for new patient orders throughout the shift and implements them in an appropriate timeframe.
  
• Completes an end of shift review of physician orders.
  
• Consistently recognizes variances of diagnostic tests, vital signs and assessments.
• Notifies the physician in time appropriate to the variance.
  
• Functions as a charge nurse as assigned.
  
• Supports changes in clinical practice as evidenced by the plan of care for the patient and subsequent documentation.
  
• Functions as a resource to co-workers.
• Acts as preceptor, and other duties as assigned.
  
• Ensures compliance with Departmental policies and procedures.
• Assume responsibility for knowledge and implementation of policy, procedure, practice, CPG, changes.
  
• Maintains competence in nursing practice through in-services and participation in ongoing continuing education per year.
  
• Participates in the Quality Improvement Program.
  
• Follows appropriate chain of command for problem resolution approaching problem solving with a positive attitude and suggestions.
  
• Consistently demonstrates accountability for supervision and communication when assigned with students/orientates, and float personnel.
  
• Reports, documents, and takes appropriate action (by the end of shift) for incidents and or quality care issues that may affect the patient�s or staff well-being.
  
• Consistently assesses patients for risk of injury and takes appropriate action to reduce risk and promote safety.
  
• Uses restraints according to policy and consistently explores other options less restrictive.
• Accurate documentation demonstrated in medical record.
  
• Serves as advocate for patient/family by providing information and assists in utilization of available resources and or alternatives for making health care decisions (i.e. advanced directives, ethics consult etc.)
  
• Handles and disposes hazardous waste safely and appropriately
  
• Consistently handles oxygen safely
  
• Consistently practices hand washing and use of protective wear
  
• Establishes or assesses proper identification prior to delivery of care.
  
• Requests clarification of Physician orders as necessary.