Shift: 6am - 6pm
Position Goal
The Registered Nurse (RN) performs the functions of assessing, planning, implementing, and evaluating the care for the assigned patients on the unit during a shift. The RN is responsible for meeting the Standards of Practice, which includes managing all assigned personnel, supplies, and equipment on the unit, and for the promoting collaboration with all members of the health care team. The individual demonstrates personal and professional responsibility, participates in creating an atmosphere of teamwork and coordination and assumes responsibility for their own professional development.
NURSING PROCESS
CARE ASSESSMENT:
- Includes appropriate interviewing techniques, systematic physical assessment and interpretation of available data including: past medical history, current medical status, vital signs, lab work, x-rays and other diagnostic tests. It should encompass the financial, spiritual, psychological, physiological, social, and age appropriate needs of the patient.
- Consistently, independently conducts a thorough admission interview and systematic physical assessment.
- Consistently, independently collects and interprets all appropriate patient data and reviews pertinent findings with anesthesia.
- Assesses the need for services of other health care professionals to facilitate the delivery of care.
PLANNING:
- Includes the development of a written plan of care that utilizes the data collected in the assessment process, incorporates the medical plan of care, demonstrates knowledge of resources available, sets priorities and establishes realistic outcomes and discharge planning.
- Independently develops/revises an appropriate age specific patient care plan
- Attends and participates in patient care conferences, when applicable
- Initiates and coordinates patient care conferences, when applicable
IMPLEMENTATION:
- Includes, prioritization and implementation of a safe therapeutic patient care regimen, recognizing the dynamics of changes that may occur and adjusting the plan of care to accommodate organization those changes. In addition, demonstrates an understanding of medication administration i.e. right patient, drug, route, dose, time, indications, drug interactions and side effects. Also demonstrates knowledge of the proper use, troubleshooting, and maintenance of all equipment utilized to carry out the patient care regimen.
- Independently organizes and implements a safe, therapeutic and efficient patient care regimen at all levels of acuity.
- Sets appropriate priorities and completes assignment independently
- Is aware of changing clinical status, anticipates problems and independently adapts plan of care to meet patient needs as clinical status changes and reviews pertinent findings with anesthesia.
- Demonstrates knowledge of location, operation and care of all equipment/implants (e.g. tourniquets, cauteries, drills, etc.) necessary to function on the unit independently. Can trouble shoot minor equipment problems
EVALUATION:
- Includes a review of the effectiveness of a patient plan of care, based on patient progress, changing clinical status and appropriateness of expected outcomes. As a result of this review, the plan of care is continued; revised or expected outcomes are adjusted.
- Evaluates effectiveness of plan of care, based on patient progress versus expected outcomes, and
independently revises plan or adjusts expected outcomes.
PATIENT SAFETY:
- Complies with surgical site verification and time out policies.
- Reviews the planned procedure and verifies the surgical consent with the patient.
- Verifies surgeon privileges as well as the need for surgical assistant.
- Verifies all equipment is functioning and inspects for safety prior to use.
- Implements appropriate patient positioning while maintaining proper body alignment for all types of surgical procedures.
- Completes all counts accurately.
- Verifies the sterility of all items prior to introduction onto the sterile field.
- Provides appropriate shielding for both the patient and the surgical team when using X-ray.
- Monitors the sterile field for any breaks or potential breaks in sterility.
DOCUMENTATION:
- Reflects the changes in patient condition, care given and response to care given. It should demonstrate an awareness of responsibility of medical/legal implications through content and legibility requirements as needed.
- Electronically documents on admission assessment, nursing care plan, flow sheets, medication administration record and nurses notes all pertinent information, in a manner that is concise, thorough, legible and accurately reflects patient condition, care provided, response to care and conforms to JHMH policy and procedure on charting
- Assists others in developing accurate and thorough documentation skills
PROFESSIONAL KNOWLEDGE/GROWTH
DISEASE PROCESS, MEDICATIONS AND TREATMENTS:
- Demonstrates advanced knowledge of disease processes, medications and treatments through sound nursing practice and appropriate use of resources independently.
PROFESSIONAL KNOWLEDGE GROWTH:
- Actively pursues appropriate continuing education and certifications.
- Attends and actively participates in unit in-services, patient conferences, and/or workshops annually
- Attends mandated in-services.
- Applies acquired knowledge in patient care practice.
- Attends 50% of department staff meetings, and signs minutes of meetings not attended.
- Maintains up-to-date CPR, safety training, and TB testing.
- Completes annual/critical competencies identified for assigned department.
- Demonstrates awareness of changes and advances in field.
- Takes responsibility for determining learning needs and seeks out opportunities for such.
LEADERSHIP/ CREDIBILITY:
- Performs charge duties effectively and independently, when applicable
- Makes decisions and solves problems using decisiveness, and judgment, and demonstrates effectiveness of decisions.
- Effectively handles crisis situations.
- Effectively distinguishes between activities and results; recognizes outcomes
- Demonstrates technical skills and knowledge in routine situations and serves as a resource person to support staff, patients and families.
- Demonstrates knowledge and technical skills in difficult situations and assists peers, other health care professionals, patients and family.
PROFESSIONAL ROLE MODEL:
- Meets basic professional appearance and behavioral standards; understands and maintains professional boundaries.
- Recognized as a professional role model by personnel and managers on assigned unit with active participation in unit activities.
- Acts as a mentor or preceptor.
- Actively participates in QI activities as evidenced by departmental data collection and active participation in completing monitors (e.g. crash cart checks), cost containment initiatives, new product/equipment evaluations, and failed equipment reporting.
COMMUNICATION
INTERPERSONAL RELATIONSHIPS:
- Performs duties with minimal personnel or patient conflict documented.
- Enhances hospital image internally and externally
- Initiates problem-solving of interdepartmental issues.
REPORTING:
- Accurate, thorough and timely in reporting patient condition to peers, charge nurse, daily nursing supervisor (if applicable) and other health care professionals involved in patient care using Hand Off communication that includes: patient, assessment, situation and safety)..
- Is accurate, thorough and timely in reporting patient condition to physicians
PRODUCTIVITY:
- Utilizes time wisely to revise plans of care, provide for unit equipment organization or maintenance or other tasks that facilitate unit workflow.
- Demonstrates enhanced time management skills as evidenced by completion of assignment in a timely manner and ability to assist others.
Experience: At least 1 year of Orthopedic OR Nursing/Spine experience preferred. Scrubbing experience preferred.
Education: Current Alabama or Multi-State RN License required.
Special Qualifications:
Required:
- Current Alabama or Multi-State License required or the ability to obtain.
- BLS required
The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.
