The staff nurse is a graduate of an approved school of nursing and is currently licensed to practice as a professional nurse in the state of Kentucky. The Staff Nurse, under supervision of the House Supervisor and Director of Nursing, is responsible for the nursing care of the patients assigned to him/her and as a team leader, directs others in patient care. He/she should have a thorough knowledge of nursing principles and procedures, knowledge and skill in techniques of good patient care.
PRIMARY RESPONSIBILITIES & AUTHORITIES:
A. Assess physical and mental status, plans, supervises, and evaluates the care of all patients assigned.
1. Able to correctly assess the patient’s physical and mental condition and identify the patient’s needs.
2. Completes assessment of patient on admission and a nursing admission note is recorded on the patient’s record.
3. Initiates on admission a written patient care plan including identified problems/action and discharge plan.
4. Recognizes and interprets signs and symptoms by continually assessing the patient’s condition. This is done both by observation and data collection. Pertinent information must be documented in the patient’s medical record and reported to the physician.
B. Functions as assigned team leader.
1. Responsible for providing care within established standards and policies. Assist with orientation of new personnel.
2. Instructs, guides and assists other nursing personnel in documentation of care to ensure satisfactory nursing practice. Provides instruction and supervision as needed by team members. Must be technically capable of performing and supervising procedures as described in the Nursing Practice Guideline Manual.
3. Assumes responsibility for care of all patients assigned. Closely supervises, assists, and/or cares for the acutely ill patient. Is willing and does as is required in all nursing functions.
a. Uses good judgment in assigning the care of the more acutely ill patients to the most qualified nursing team member.
b. Plans work, sets priorities and delegates nursing functions so that work is equitably assigned.
4. Plans, implements and documents patient and family teaching programs.
5. Prepares the patient physically and psychologically for treatments, surgical procedures and diagnostic studies.
6. Assists the physician with examinations and treatments.
7. Make patient rounds with physician.
8. Following instructions initiates I. V. infusions (including blood), administers I. V. medications, does daily I. V. care and follows hospital policy in regard to changing I. V. needles and tubing. Accurately monitors I. V. infusion rates.
9.. Reports pertinent information at the end of the shift to oncoming shift.
10. Administers medication (including I. V. meds), following the Nursing Practice Guidelines in the Nursing Practice Guidelines Manual.
11. Performs and supervises extra duty assignments to see that they are completed.
12. Performs extra duties as assigned by House Supervisor/Charge Nurse or Director of Nursing.
C. Interprets, transcribes, and carries out physicians orders.
1. Physician’s orders are interpreted and transcribed accurately to the MedAct and Medication Administration Record.
2. Initiates all new orders promptly, either personally or by delegating function. All STAT orders are to be initiated immediately.
D. Responsible for accurate documentation and maintaining completed records.
1. Must assess and summarize each patient’s status at least once each twelve hours.
a. Summarization must include statement relevant to progress on status of admission disease process.
2. Documentation includes other health problems relative to care.
a. Treatments, diagnostic studies, and medications are documented with results and responses.
1. When documenting dressing change include condition of skin, wound, type and amount of drainage and any odor.
2. Use specific descriptive terms in documentation.
b. Oxygen therapy must be documented each twelve hours.
c. Decubitus care treatment and response each twelve hours.
d. Mental status, restraints, bed rails when applicable.
f. Discharge Planning
3. Complete Discharge Instruction Sheet, when patient is discharged and document all patient teaching.
OTHER DUTIES AND RESPONSIBILITIES:
A. Job conduct, professional responsibility, dress, in-service, committee activity, and continuing education.
1. Serves as a role model for all team members by setting an example of high standards in dress, conduct, attitude and performance.
2. Is emotionally mature and stable. Accepts responsibility for own and team member’s actions and omissions.
3. Observes confidentiality and safe guards all patient-related information.
4. Observes personal hygiene and dress code as outlined in the Employee Handbook and Nursing Department Dress Code.
5. Attends all mandatory in-services. (Fire, Safety, CPR, Competency etc.)
6. Attends all but 2 Nursing staff meetings per year unless excused by Nursing Administration. PRN staff are only required to attend 2 per year.
7. Accepts responsibility for regular attendance and reporting to work on time.
8. Earns 14 hours of Continuing Education every year as required to maintain a current active nursing license per Kentucky Board of Nursing Guidelines.
9. Willing to work extra shifts to meet the needs of patient, unit, and hospital.
10. Investigates and reports to the Director of Nursing any problems relating to patient care, unit and/or personnel.
B. Initiation of Incident Reports and Investigation of all incidents.
1. Any accident, lost article or unusual occurrence is investigated with the proper report initiated.
2. The House Supervisor/Charge Nurse is to be notified of such incidents.
C. Maintains quiet, clean, safe physical surroundings.
1. Must speak quietly and supervise conduct of other employees and correct when indicated.
2. Assists in keeping patient rooms clean, neat, equipment in place, old or unused articles discarded, clothing in closet, trash emptied as needed.
3. Instructs personnel in good body mechanics and safety rules, when observed in non-compliance.
Lifting varied weights, pulling, and standing for long periods of time. Stressful environment due to multiple tasks and working with multiple departments.
Work areas are often cramped around patient’s beds, equipment use required. Frequently required to use personal protective equipment to prevent exposure to body, blood and other potentially hazardous body fluids.