SSM Health: Rn Trauma Icu
Company: SSM Health
Location: Saint Louis
Posted on: January 15, 2021
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Job Description:
Job DescriptionPOSITION ACCOUNTABILITIES AND PERFORMANCE
CRITERIA Essential Functions: The following are essential job
accountabilities and performance criteria: 1) Performs
comprehensive nursing assessment/reassessment. Criteria A) Performs
age-appropriate admission assessment or transfer assessment.
Obtains input from family/guardian when appropriate. B) Accurately
and completely documents findings. C) Performs assessment of
post-op/post-invasive procedure patients. D) Assesses and documents
education and discharge needs of patient and family on admission
and throughout hospitalization. E) Provides patient reassessment
documenting pertinent observations according to the patient plan of
care, changes in condition, status and/or diagnosis, response to
care, procedures, etc., and standards of care. 2) Establishes,
coordinates and evaluates a plan of care based on analysis of
assessment data, patient diagnosis, lab data, tests, procedures,
physician orders, protocols and standards of care and other
information as relevant. Criteria A)Identifies short and long term
goals based on patient care needs. B)Formulates nursing
interventions to achieve desired patient outcome. C) Incorporates
disease specific evidenced based practice into nursing care plan
and other documentation 3)Provides and documents nursing
interventions based on assessed patient needs, plan of care, and
changes in patient status. Criteria A) Collaborates with
appropriate health team members for coordination of daily plan of
care for assigned patients. B) Provides, coordinates and
communicates patient care, including accurate Handoff Communication
Reports. C) Administers and documents medications accurately
according to policies and procedures. D) Monitors, maintains and
documents accurate IV fluids and parenteral nutrition according to
policies and procedures. E) Completes referrals as indicated by
assessment data. F) Requests consultation for special needs,
equipment, or information for patient and/or family. G) Provides
patient/family education and discharge planning per documentation
guidelines and protocol. H) Clarifies all physician orders as
warranted. I) Acknowledges and implements physician orders in an
accurate and timely manner as evidenced by documentation in the
medical record. J) Assists physician with procedures/treatments as
requested or delegates to Care Partner as appropriate. K) Documents
" Readback" for all telephone / verbal orders. L) Takes telephone /
verbal orders only in emergency situations. M) Recognizes changes
in patient"s condition and takes appropriate nursing actions. N)
Involves the family/guardian when providing care and in
decision-making as appropriate. O) Recognizes risks for patient and
takes appropriate action. P) Incorporates use of Infection Control
practices in daily care. 4) Documents and or communicates nursing
care and or changes in patient condition. Criteria A) Performs and
documents ongoing evaluation of effectiveness of care based on
assessment data, nursing interventions, patient response to
medications, treatments and procedures. B) Evaluates and documents
effectiveness of patient/family education. C) Evaluates plan of
care and modifies as indicated in " A" above. D) Recognizes
significant changes in patient"s clinical parameters and reports
immediately to physician and others as indicated. E) Identifies
problems, gathers pertinent data, suggests solutions, communicates
using appropriate lines of authority, and works toward problem
resolution. F) Reports variation from care/treatment following the
occurrence reporting policy and procedures. 5)Specialized Care:
Provides specialized care to patients at high risk for injury.
Criteria A) Restraint Care 1. Initiates/evaluates alternatives to
restraint prior to application 2.Applies restraints consistent with
the approved procedure. 3. Monitors and assesses patient"s response
throughout the restraint period at the appropriate intervals. 4.
Provides specified patient care (toileting, skin care, hydration,
feeding, etc.) on a timely basis. 5. Provides consultation for
peers to determine alternatives to restraints and 1:1 observation.
6. Documents restraint use and associated care thoroughly. B) Pain
Management 1. Assess patient for presence of pain on admission and
during assessments/reassessments. 2. Incorporates patient"s
cultural/spiritual beliefs regarding pain into pain management
plan. 3. Implement pain management techniques. Focus on prevention
rather than treatment. 4. Include patient and/or family members in
developing a pain management plan. 5. Consider other methods of
pain control when developing plan of care: massage, repositioning,
immobilization, and music therapy. C) Abuse Assessment 1. Is aware
of abuse recognition criteria and incorporates it into assessments.
2. Reports signs of possible abuse/neglect to the Administrative
Director of Behavioral Health, physician, Risk Management and
Social Work. 3. Takes appropriate action to support patient safety
wh About SSM Health
Keywords: SSM Health, St. Louis , SSM Health: Rn Trauma Icu, Healthcare , Saint Louis, Missouri
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