*STAFF NURSE II

Overview --------

The Staff Nurse is a professional caregiver who assumes responsibility and accountability for the assessment, nursing diagnosis, planning, implementation, and evaluation of care for patients and their families in compliance with the standards for care at AHMC Seton Medical Center.

Responsibilities ----------------

### Position Specific Duties

#### Clinical Practice

• Nursing Assesses, collects, and documents health assessment data focusing on the physical, emotional, spiritual, psychosocial, and educational needs of the patient considering the planned procedure for which the patient is scheduled.
• Interviews the patient/family/significant other to complete nursing assessment.
• Reviews scheduled procedure, and physicians orders.
• Identifies actual and potential needs and determines priority.
• Identifies barriers to learning.
• Performs ongoing assessment as indicated by changes in status.
• Plans nursing care, based on assessment, knowledge of the surgical planned procedure, data collection such as lab results and radiological exams.
• Develops realistic goals for the pre and post care, including safety, infection control, pain control, and temperature modulation.
• Incorporates National Patient Safety Goals into the plan of care.
• Plan demonstrates understanding of age-related needs of the patient.
• Collaborates with physicians, and post-op nursing units to plan for discharge needs.
• Implements the plan of care including prescribed procedures.
• Incorporate the National Patient Safety Goals in the implementation of the plan of care.
• Organizes and prioritizes care based on individual patient needs, requirements of the procedure, and preferences of the cardiologist, surgeon, and anesthesiologist.
• Assesses for changes in patients condition and appropriateness of the plan.
• Initiates interventions using appropriate clinical expertise and knowledge.
• As Primary Nurse, coordinates the activities of health care team members in completing diagnostic and therapeutic interventions.
• Evaluates the effectiveness of nursing care delivered to reach the expected outcome.
• Evaluates the plan of care according to the current condition and changing needs of the patient.
• Accurately and concisely documents the patients status and response to the care delivered.

#### Clinical Practice: PeriOperative Nursing

• Utilizing professional nursing knowledge and skills.
• Appropriately assesses for:
• Physical and psychosocial-emotional needs.
• Barriers to learning.
• Educational/learning needs.
• Discharge needs.
• Age-related needs.
• Analyzes patient-related data, such as vital signs, medical history, and physical exam findings, laboratory values, and other information, including age-specific criteria, to determine appropriate care.
• Uses knowledge of the equipment, supplies, instrumentation, appropriate for the surgical procedure to prepare for appropriate care.
• Guides and supervises members of the perioperative team in the preparation of the operating room for the intended surgical procedure.
• Coordinates effectively with the members of the team, including physicians, technicians, Charge Nurses, and other departments to coordinate care.
• Effectively performs procedures, such as initiation of IV catheters and administration of fluids and medication, within the scope of practice, and unit, department, and Medical Center policies and procedures.
• Effectively performs other nursing procedures/skills, such as cardiac monitoring, rhythm interpretation, defibrillation, monitoring of conscious sedation, etc., based on completed specialty training and scope of practice, and unit, department, and Medical Center policies and procedures.
• Appropriately recognizes and quickly responds to emergency medical situations.
• Accurately assesses "C-A-Bs."
• Initiates appropriate emergency treatment, i.e., CPR, O2, etc.
• Communicates critical information to other team members.
• Maintains competencies required by the department.
• Extubation.
• Removal of the sheath in post cath patients.
• Discharge of outpatients against criteria.
• Maintains all required credentials and training (CA RN license, BLS, ACLS, PALS).
• Remains current in practices/procedures through attendance at continuing education events, in-services, and the review of professional literature.
• Integrates/applies new knowledge from education and research into clinical practice.
• Demonstrates knowledge of and competence in age-related patient care.
• Consistently demonstrates knowledge of state and federal regulations, such as Title XXII.
• Follows all TJC, CMS, CDPH guidelines.
• Consistently completes required documentation of the perioperative visit.
• Consistently demonstrates caring and compassion through behaviors and interactions in performance of all duties, recognizing the inherent worth and dignity of patients, families, other staff, and physicians.

Qualifications ------------

### Education

• Graduated from an accredited school of nursing.
• BSN preferred

### Experience

• Experience and training as an ICU nurse

### Certifications/Licenses

• Licensure as a Registered Nurse by the State of California required
• Current BLS certification by American Heart Association
• Current ACLS certification by American Heart Association

### Other Skills, Abilities & Knowledge

• Training and skills in specific to post anesthesia care
• Ability to perform the duties of the pre-op nurse
• Ability to perform the duties of the pre-assessment nurse
• Ability to administer moderate sedation according to policy under the direction of the physician