- Identifies in the admission nursing assessment progress notes the relationship between data collected from the nursing history, systems assessment, and self-care needs within eight (8) hours of admission.
- Initiates a Master Problem List/ Patient are Plan within eight (8) hours of admission, establishing appropriate nursing diagnoses, interventions and measurable outcomes in collaboration, as possible, with the physician.
- Documents implementation of the medical/nursing plan of care in each Nursing Progress Note.
- Documents an evaluation of the patient's compliance and response to the therapeutic regimen in each Nursing Progress Note.
- Revises as necessary the Master Problem List/Patient Care Plan to reflect resolution of problems, new nursing diagnoses and/or revisions in patient/nurse actions.
- Includes preparation for transfer in the Patient Care Plan or Nursing Progress Note as appropriate.
- Communicates routinely with the physician to provide and gain information which will facilitate patient care.
- Documents learning needs, readiness to learn and motivation of patient and family in Education Care Plan after initial assessment.
- Documents all teaching/learning plans on the Patient Care Plan and/or nursing Progress Notes.
- Selects teaching tools consistent with the patient's ability to learn.
- Documents implementation of teaching/learning plans on teaching records or Nursing Progress Notes.
- Documents patient's behavioral response to teaching with each instruction.
- Revises teaching/learning plans in response to patient's need.
- Attends and signs the attendance sheet with the daily Huddle that is presented each day prior to the beginning of your shift.
- Makes at least one suggestion for investigation to unit representatives of appropriate nursing/hospital committees.
- Participates in the process of nursing quality assessment and improvement measures at least once per month.
- Demonstrates responsibility for maintaining certification in C PR and defibrillation and for review in Isolation, Fire/Safety and Electrical
- Safety as designed in nursing policy.
- Attends at least one continuing education program annually and attends unit in-services when presented when patient care allows.
- C ompletion of the Basic Knowledge Assessment Tool (BKAT) within three (3) months of employment to determine educational needs.
- Completion of IV therapy and Critical Care Skills Inventories within three (3) months of employment.
- Attends at least 75% of staff meetings per year.
- Demonstrates compliance with information presented at staff meetings, through email, huddle and other forms of communication.
- All Registered Nurses with one or more years of experience will achieve and maintain ACLS Certification.
- Completes nursing activities within established timeframe, establishing priorities appropriately and with consideration of patient
- desires.
- Collaborates as necessary with other members of the health team to establish priorities of patient care.
- In emergency situations: Recognizes potentially life-threatening clinical situations and intervenes appropriately to prevent
- complications. Functions effectively in clinical emergencies, demonstrating an ability to implement Emergency Cardiac Orders
- appropriately. Seeks assistance, if necessary, in order to accomplish immediate priorities without loss of control. Identifies stress
- producing situations and modifies behavior appropriately.
- All Registered Nurses with one or more years experience in Critical Care may be rotated to Charge following orientation to the Charge
- role: As Acting Charge RN, assigns nursing activities to those qualified to perform them. As Acting Charge RN, determines priorities of
- unit activity and utilizes appropriate resources. As Acting Charge RN, or preceptor, assesses learning needs of nursing personnel and
- makes recommendations for and/or provides instruction.
- Consistently participates in-group process, facilitating communications. Reads and initials the unit communication book and all posted
- hospital memos.
- Uses equipment and supplies as intended. Reports missing or mal-functioning equipment appropriately.
- Demonstrates knowledge and skill while performing those technical skills indicated on the Skill Inventory Checklist, which must be completed within three (3) months of employment.
- Accepts assignment in like units and functions effectively and efficiently to ensure that patient needs
- Current ACLS is required.
- Current CPR/BLS is required.
- Current registration in the State of Maryland.
- Graduate from an accredited School of Nursing.
- Concentrates on moderate to fine detail for extended periods of time.
- Must be able to hear normal sounds with some background noise.
- Remembers schedules, tasks to be completed, where activities left off, etc.
- Routinely lifts objects under 50 pounds.
- Understands and can operate from the conceptual basis of tasks and activities.
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Description
Staff Nurse - IMC/ICUPosition Objective
The Registered Nurse is responsible for assessing the self-care needs of each patient in his/her care and for planning with the patient/ family the actions of both nurse and patient necessary to meet those self-care needs which may be physiological, psychological, social or spiritual.
Once planned, the Registered Nurse is responsible for implementing the plan of care directly and/or through leadership of unit personnel. The Registered Nurse 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. Adheres to the purpose and objectives of nursing practice of the Department of Nursing Services, utilizing the nursing process to assist patients in meeting their self-care needs
testing; etc.)
3. Organizes and carries out a plan for teaching the self-care required to patient and/or family.
Includes patient and family while assessing learning needs and establishing teaching goals.