Under the direction of the Charge Nurse, Patient Care Manager, Director, and Vice President of Patient Care, the Clinical Nurse (I - V) administers individualized age-appropriate patient care to the neonate, pediatric, adolescent, geriatric and adult patient according to the established nursing standards and Nurse Practice Act of Missouri.
Assesses Clinical and Psychosocial Patient Needs
• Accurately and thoroughly completes assessments.
• Accurately reconciles and documents medications during care transitions.
• Uses health information from a variety of appropriate resources.
• Assesses safety needs based on age.
Establishes Patient Goals and Tracks Progress
• Provides problems for immediate attention.
• Collaborates/consults with other members of the health care team and ensures that a collaborative care plan is up-to-date and based on assessment.
• Documents patient progress toward goals/effectiveness of interventions.
Provides Patient-Centered, Outcomes-Focused Care
• Provides direct patient care within interpreted guidelines of the Practice Act of Missouri.
• Incorporates new technologies to provide safe care.
• Adheres to Medical Center policies/procedures for care.
• Evaluates age specific/appropriate motor skills and psychological development.
• Uses interview and communication techniques appropriate for age.
•Uses equipment appropriately based on age and size of patient.
• Identifies any unique physical and or emotional needs and determines what other support systems are required for care.
• Practices evidence based nursing.
• Is knowledgeable about the nursing quality scorecard and practice is based on understanding any initiatives/processes related to reach benchmarks.
• Actively participates in the time out and "WHO" checklist.
• Completes quarterly competency/education updates.
Educates and engages patients and their families
• Develops education plan based on patient/family knowledge deficits, diagnosis, treatment regimen and community support/resources.
• Communicates with family/significant other during the surgical procedure and upon completion of the procedure.
Coordinates care with inter-professional caregivers
• Participates in clarifying and communicating medical information to patients, family and staff.
• Is prepared and organized when discussing plan of care with the physician either by phone or in person.
Facilitates safe patient transition to next care setting
• Consistent with POC, plans for safe community transition in collaboration with appropriate inter-professionals.
• Provides for a thorough verbal handoff to receiving entity.
• Provide for accurate medication reconciliation.
Provides a Clean and Safe Patient Environment/Work Area
• OR Room organized, all equipment removed and stored in proper place to include x-ray aprons, positioning devices, etc.
• All equipment/instruments stored in appropriate places in center core.