Nurse Practitioner

4 weeks ago

St Louis, Missouri, United States SSM Health Full time
Job Summary

The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

Job Responsibilities and Requirements
  • Essential Functions:
    • 1. Performs comprehensive nursing assessment/reassessment.
      • A. Performs age-appropriate admission assessment or transfer assessment.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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 when signs of abuse are noted.
      • 6. Demonstrates accountability for own professional practice.
        • .
      Specialized Care
      • 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.
      • 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.
      • 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 when signs of abuse are noted.

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