SSM Health: Rn Trauma Icu

Company: SSM Health
Location: Saint Louis
Posted on: January 15, 2021

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

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