Position Summary
The Staff Nurse I provides direct patient care and takes the initiative to improve patient outcomes by integrating Shared Leadership, Evidence Based Practice, Relationship Based Care, and standards of nursing excellence into clinical practice. This position integrates professional practice model, current standards of practice and clinical experience to provide "quality" patient care as measured by established nursing quality standards and other governing/accrediting health care bodies. The Staff Nurse I engages and obtains information from patient and/or family to advocate for the patient, develops an appropriate patient educational plan, and responds to patient''s changing needs while sharing information and collaborating with other members of the health care team to promote effective patient care. The Staff Nurse I participates in organizational, departmental, and shared leadership activities; supports department and unit goals in daily behavior.
Duties & Responsibilities
- Develops, implements, and updates the patient's plan of care based on on-going assessment of the patient and input from the patient's family.
- Shares information and collaborates with other members of the health care team to promote effective patient care.
- Verifies and implements orders from physician, physician assistant and/or advance practice nurse by performing interventions as prescribed by the provider and documenting accurately in the electronic medical record.
- Engages and obtains information from patient and/or family to develop an appropriate patient educational plan.
- Recognizes symptoms, establishes priorities, and responds to patient's changing needs.
- Engages support personnel by delegating appropriate tasks per the Illinois State Nurse Practice Act and provides support and feedback.
- Advocates for patients, families, and their significant others, the community, and the nursing profession.
- Integrates theoretical knowledge, evidence-based research, current standards of practice and clinical experience to provide "quality" patient care as measured by established nursing quality standards and other governing/accrediting health care bodies.
- Assumes role of Charge Nurse when assigned, utilizing appropriate resources and tools.
- Collaborates with other nurses to identify, promote, and provide positive learning experiences for staff and students.
- Serves as preceptor and/or resource to other nursing, support staff and students.
- Takes responsibility for continued professional growth/development by identification of learning needs and initiates strategies to meet such needs.
- Other duties as assigned.
- Assess, instruct & prepare patients prior to surgery
- Ensure that operative and informed consents are signed and correct
- Take and record vital statistics of patients to ensure readiness for surgical procedure
- Initiate IVs and ensure patients are informed about procedure
- Assess patients' post-operative condition
- Monitor vital signs and other measurements of progress, meeting discharge criteria
- Log all findings in patient files
- Answer patient questions and ensure patient comfort
- Monitor patients for condition changes, reporting any changes to physician
- Perform intervention duties during post-operative emergencies
- Establishes an in-depth database by assessing the behavioral and physical status of a variety of pre-surgical patient populations, utilizing interview, observation, and physical examination.
- Interprets overt and subtle data to determine physiologic or psychosocial risk.
- Evaluates patient's responses to care based on the effectiveness of nursing interventions in relation to established outcomes and consults with the medical staff, Care Team Lead, and/or Nursing Supervisor.
- Recommends changes to the plan of care based on observed variances.
- Integrates nursing interventions into the multidisciplinary plan of care, incorporating appropriate standards of care and
practice.
- Identifies learning needs with patients and families and teaches by adapting standard information to provide individualized
and comprehensive learning.
- Incorporates discharge/home care planning into the multidisciplinary plan of care.
- Develops a therapeutic relationship by establishing trust and enabling the patient and/or family to verbalize the
requirements for care comfortably.
- Supports and enhances the patient's responsibility and self-determination in decision making concerning health,
treatment, and wellbeing.
- Competent in all three areas of peri anesthesia- Preop, Phase 1, and Phase 2 recovery areas
- Evaluates effectiveness of teaching interventions and the patient/family's level of understanding.
- Assess and instruct patient/family prior to surgery
- Assure intake of patient is accurate through chart review, questioning using safe communication tactics outlined in
learning modules
- Assure that operative/informed consents are accurate and signed per policy
- Initiate orders from physicians
- Obtain and record vital signs
- Monitor and accurately document vital signs and assure patient meets discharge criteria before moving to next Job
Description
- Monitor patients' condition and report and changes to the appropriate physicians
- Assure patient comfort and answer patient questions
- Other assigned duties that will assist with safety, quality, and efficiency
Organizational
- Observing patients for side effects of anesthesia
- Monitoring and recording patient vital signs
- Monitoring patient's level of consciousness throughout sedation recovery
- Performing post-operative tasks, such as administering medication or changing dressings
- Checking and updating patient files, charts and medical records
- Collaborating with surgeons, anesthesiologists, physicians and other members of the patient's care team
- Providing comfort and answering questions when patients wake from sedation
- Educating patients and their families regarding post-surgery care at home
- Excellent communication and interpersonal skills
- Comfortable working in a high-pressure environment
- Good eye for detail while monitoring patients
- Ability to quickly notify medical personnel regarding abnormal side effects or changes in a patient's condition
- Proficiency with hospital management systems, such as Epic
Treating pain, nausea, and other post-operative symptoms of anesthesia.
- Updating charts, patient files, and medical records.
- Collaborating with the medical team on post-operative patient care and facilitating timely specialized interventions.
- Providing comfort and reassurance to distressed post-operative patients and concerned family members.
- Educating patients and their families on post-surgery care, as well as answering questions.
- Adheres to UI Health's Code of Conduct.
- Treats patients/families, staff, students and visitors with respect and dignity.
- Adheres to Nursing's time, overtime and attendance policies.
- Completes electronic learning modules and related programs as assigned by UI Health by established date
- Complies with University Health Services TB, flu compliance and fit-testing requirements
- Utilizes established communication channels/chain of command to escalate or resolve patient care problems.
- Identifies recurring clinical practice and/or related unit problems and participates in problem solving and resolution.
Education/Research
- Collaborates with other nurses to identify, promote and provide positive learning experiences for staff and students
- Serves as preceptor and/or resource to other nursing staff and students.
- Accesses UI Health intranet/Outlook for relevant communication and to review and interpret changes in policy, procedure
and other information pertinent to practice
- Supports nursing and multidisciplinary research efforts conducted on the unit and UI Health.
- Takes responsibility for continued professional growth/development by identification of learning needs and initiates
strategies to meet such needs.
- Be proactive in a committee or a process improvement project Reporting Structure