Job Description Summary
Manages individualized, outcome-oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures. (Salary Range: $35.79-$69.09)
Job Description
ESSENTIAL FUNCTIONS
1 - ASSESSMENTS/REASSESSMENT
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients
a - Provides ongoing assessment of nursing care needs of a defined group of patients
b - Completes nursing assessment record according to guidelines/policy
c - Documents assessment/reassessment data on medical record according to guidelines and standards
d - Conducts and initial and ongoing assessment to gather data relevant to the patient’s individual needs
e - Recognizes the significance of abnormal laboratory values for patient’s and takes appropriate action
f - Assesses patient’s understanding of disease process.
g - * Assesses/reassesses and documents patient’s level of comfort utilizing the approved pain scale for patients in a specific age category.
h - * Assesses/reassesses patient’s response after each intervention both pharmacological and non pharmacological.
2 - UNIT SPECIFIC ASSESSMENTS
a - Pre-Op checklist is complete and signed. Consistently reviews and assures completeness.
b - *Consistently uses 2 patient identifiers.
c - *Assures that patient is marked before entering Operating Room.
d - Perioperative Nursing Assessment is complete, accurate, and signed.
e - Perioperative guidelines for Labs, EKG, H&P, and Medical Clearance are followed as per policy.
3 - PLAN OF CARE
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient, in collaboration with each patient/family/significant other in order to address all identified needs.
a - Develops written plan of care for patient needs and documents care plan according to established guidelines including:
Problem/need assessment
Nursing interventions
Other needed services of healthcare team
Outcome criteria met/not met
b - Based on reassessment, plan of care is modified to meet the patient/family/significant other's identified needs.
c - Develops patient/family/significant other teaching and discharge plan and documents according to policy.
d - Evaluates that the identified problems, care provided and patient's responses are reassessed in order to meet patient and family needs and documents outcomes according to policy/guidelines.
4 - UNIT SPECIFIC PLAN OF CARE:
a - Follows procedure for updating, revising, creating and deleting of Physicians Preference Cards.
b - *Assembles necessary instruments, supplies and equipment prior to the start of care.
c - * Checks for availability, proper conditions of equipment, instrumentation and implants.
d - Identifies priorities and executes nursing care accordingly.
e - Provides emotional support and comfort measures to patient and family
f - *Applies and monitors principles of aseptic technique throughout the intraoperative period.
g - Has the ability to scrub/circulate during the intraoperative phase.
h - Preps the surgical site using AORN standards of practice and proper aseptic technique.
i - *Confirms and contains sources of contamination.
5 - MEDICATION
Demonstrates the skills and judgement necessary to implement medical plan of care, nursing interventions and procedures as necessary for the care of the patient.
a - Demonstrates knowledge of SSH policies and procedures for administering, and recording medications
b - Demonstrates knowledge of commonly used medications: action, dose and side effects and uses resources to review new or unfamiliar medications
c - *Observes the 5 R’s for administering medications:
Right patient
Right drug
Right dose
Right method
Right time
d - * Performs narcotic count each time a narcotic medication is withdrawn from the Pyxis.
e - *Demonstrates proper procedure for documentation of narcotic administration and wasting, and follows the procedure for resolving narcotic discrepancy.
f - * Demonstrates procedure for the use of the override function in Pyxis
g - *Documents medication administration reflecting full signature and title, time given, reason for omission, and site for injection (if applicable)
6 - UNIT SPECIFIC MEDICATION
a - *All medications drawn up are labeled for procedures.
b - * All non-controlled medications removed by PYXIS are counted and amount properly recorded
c - * Unused medications are returned to PYXIS following policy.
d - * All narcotics are counted and signed off on a weekly basis.
e - * Antibiotic given by Anesthesia is recorded on intraopertive record by RN.
f - Initiates and maintains IV access according to SSH policy and procedure.
g - Completes medication reconciliation process per SSH Policy.
h - All medication that is used by the surgeon is documented on physician order set and signed by physician.
7 - DOCUMENTATION
Maintains up-to-date documentation of nursing care provided to assure the integration of information for use by the healthcare team, in order to assure quality care.
a - Patient medical record sheets are accurately signed with name and title.
b - Referrals are made based on identified needs and communicated to the healthcare team according to policy.
c - Nursing documentation is reflected in Integrated Progress Note with an entry made per standard and when reassessment of the patient requires.
8 - UNIT SPECIFIC DOCUMENTATION
a - Revises physician preference cards and communicates changes to appropriate personnel.
b - * Records are closed properly.
c - * Copy of on-line record is placed in patients chart.
d - All patient charges, including implants, are documented properly.
e - Accurately documents on-line intraoperative record including military time.
f - Assures accurate and complete documentation of the patient medical record.
9 - DELEGATION
Directs other licensed and non-licensed personnel in the provision of care to patients as assigned.
a - Based on patient care needs and skills of caregiver, delegates responsibilities accordingly.
b - Practices within the legal boundaries of the MA Nurse Practice Act and according to SSH Hospital policy and procedure.
10 - UNIT SPECIFIC DELEGATION
a - When assigned charge responsibilities manages staff and delegates assignments to staff with proper skill sets.
11 - SAFETY
Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.
a - * Prior to the start of any invasive procedures, a final verification to confirm the correct patient, procedure, site, and information is done.
b - * Abbreviations on the hospital DO NOT USE list are adhered to, an evidence through ongoing concurrent medical record review.
c - * Prior to the use of any intravenous infusion pump assures free flow protection is in place.
d - * Follows telephone order policy and procedure. Writes order down then reads back to the prescriber.
e - Complies with the current CDC hand hygiene guidelines through proper hand washing , as observed by nurse manager and peers.
f - * Assures bio-medical equipment alarms are activated with appropriate settings and are sufficiently audible.
g - Adheres to universal precautions, makes use of personal protective equipment at all times and appropriately disposes of hazardous materials.
h - * Verifies patient identification with two patient identifiers according to policy prior to administration of care/procedures/medications.
i - Assesses and periodically reassesses each patient’s risk of falling.
j - Utilizes the Chain of Command to communicate any potential or actual patient or staff safety risks.
12 - UNIT SPECIFIC SAFETY AWARENESS
a - *Time Out is called prior to the incision or start of procedure in all cases. Circulating nurse assures that surgeon, anesthesiologist, CRNA, and scrub person all participate and all are in agreement.
b - * Uses 2 patient identifiers when identifying patient.
c - * Sponge, needle and instrument counts are done according to policy and procedure, Policy OR 1.A
d - Correctly collects and accurately labels specimens.
e - * Ensures safety of patients during the use of electrical equipment.
f - * Ensures safe transfer/transport of patient.
g - * Assures that surgical site is marked before transfer patient to OR from Pre-op area. Policy OR-2X.
h - Follows SSH procedure for patient hand-off.
13 - PROFESSIONAL DEVELOPMENT
Assumes overall responsibility for professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.
a - Attends continuing education programs in order to maintain licensure. Obtains at least five contact hours per year in area of practice.
b - Attends hospital sponsored training programs as required by the department.
c - Accepts role of preceptor for new staff members or mentor as required.
d - Demonstrates a constructive approach during all interactions with staff and Nurse Manager towards the Organization.
14 - UNIT SPECIFIC PROFESSIONAL DEVELOPMENT
a - Maintains current knowledge/certification/licensure. Pursues professional growth and development.
b - * Completes all mandatories assigned by manager in a timely manner.
c - Works on special projects,( ie glucometer inservice and PI activities and initiatives).
d - Has achieved and maintained speciality certification.
e - Has participated as Champion for hospital initiatives, or as a Shared Leadership Council member.
f - Supports the hospital's mission by attendance and participation on Committee meetings.
g - Functions as a role model for current and new staff.
h - Facilitates problem resolution among peers and management.
i - Participates in staff meetings.
15 - TECHNOLOGY
Embraces technological solutions to work processes and practices.
a - Utilizes Workday to access email, learning management database and other resources as applicable to RN role.
b - Demonstrates competence in using all clinical applications required by the department and unit standards.
c - Uses web based incident reporting system as indicated.
d - *Is able to access payroll and manage personal clockings and calendar in Time PC application.
e - Demonstrates required telephone, office equipment, biomedical equipment competencies.
JOB REQUIREMENTS
Minimum Education
Graduate of an accredited School of Nursing as validated through the Massachusetts Board of Registration in Nursing
Minimum Work Experience
Demonstrated proficiency in acute care nursing, knowledge and skills
Required Licenses / Registrations
RN - Registered Nurse
Required Classes/Certifications -
ACLS - Advanced Cardiac Life Support
