General Statement of Job
This position provides safe and effective nursing care and treatment to patients in the Obstetrics Unit. The employee is part of a managed care team and works collaboratively with ancillary personnel in the provision of appropriate medical services and treatment. This position provides nursing care and services to neonatal and obstetric patients in accordance with established regulations, policies, nursing standards and medical instructions.Responsibilities
Provides nursing care to meet the needs of the patient population served as qualified; i.e., infant, adolescent, adult, and geriatric patients.
Delivers patient care within defined hospital and obstetrics standards for assessment, care planning, interventions, and reassessment, and delegates care appropriately to other team members and support staff.
Evaluates patient’s care status frequently. Reports variances in care and/or medication administration for quality improvement.
Maintains a working knowledge of infection control standards, department and hospital policies and procedures for the delivery of nursing care.
Communicates with physicians and ancillary care providers in the coordination of safe and effective patient care.
Performs duties with a clear understanding of the JCAHO Safety Goals and delivers care with patient safety as a goal. Follows hospital policies guiding compliance with National Patient Safety Goals.
Performs duties in accordance with pathogen transmission practices; i.e., follows hand washing procedures and utilizes protective equipment effectively.
Performs nursing care within the guidelines of the Relationship and Results Oriented Healthcare model utilizing the recommended bundles of best practice.
Assesses and charts patients’ vital signs and notifies physician of abnormal ranges as well as any significant changes.
Includes the patient and the family in the plan of care as appropriate.
Develops patient focused goals with the patient and family as appropriate, assuring patient understanding and involvement in their care.
Works as a team with other care providers; utilizing good communication skills, critical thinking, and checkpoints for team work.
Provides patient information timely and effectively during shift report and with patient’s hand offs.
Delegates and supervises patient care appropriately within the scope of the assigned staff’s skills and competency. Provides follow-up and feedback to ensure quality of care. Initiates appropriate actions as needed.
Assesses the neonate patient at time of delivery and performs neonatal resuscitation as needed.
Observes neonate patients’ fetal heart rate (FHR) patterns and treats appropriately.
Communicates effectively with other patient care providers and team members for efficiencies and safety of care through appropriate ordering procedures, preparing patients for surgery and other procedures, communicating fall potential and other risk identifiers.
Follows policies for administration of high risk drugs, patient identification, documentation and taking telephone orders with read back and communication of critical values/diagnostic results.
Conducts inventory checks, including all medications administered at the time of administration. Reconciles the count with oncoming nurse at the end of the shift.
Performs patient medical chart checks.
Participates in the review and development of department policies and procedures.
Develops plan of care and patient focused goals with the patient and family as appropriate, ensuring patient understanding and involvement in their care.
Delivers patient care in accordance with established infection control standards for patient placement, IV therapy, medication administration and the performance of all patient procedures; demonstrating adherence to hand washing policy.
Assists physicians with procedures in Labor and Delivery, Postpartum, Newborn Nursery and NICU within the scope of abilities and competencies.
Evaluates clinical/diagnostic reports and reports variances to the physician and documents same.
Follows guidelines for performance improvement and demonstrates understanding of participation in the Core Measures for Lakeside Medical Center, and for documentation review and restraint review process.
Utilizes patient care equipment and patient restraints appropriately and safely, following hospital policy and procedure. Reports any identified equipment breakdown or malfunction by hospital policy. Maintains cleanliness of equipment after use.
Works cooperatively with ancillary departments in ensuring the patient’s care is safe, following protocols as applicable.
Documents and maintains all patient care records and related required documentation. Maintains records and communications with respect to patient’s privacy.
Participates in department’s QI activities on a daily basis.
Participates in the orientation and mentoring of new staff members recognizing importance of bringing new staff into a friendly and supportive work environment.
Utilizes and ensures staff uses supplies efficiently, following infection control procedures, avoiding waste and follows patient charging procedures.
Follows ACLS protocol for patients as indicated.
Completes assessments and documentation of new admissions and discharges including the interim plan of care. Completes discharge instructions with information regarding food and drug interaction.
Applies, observes, and documents all patients requiring restraints according to hospital policy.
Documents the administration of medicines including dosage, medicine route, medicine site, and patient's response as required in the documentation system.
Maintains accurate and current record of patient’s care and response to care following the guidelines for appropriate electronic documentation.
Documents attendance of continuing education programs for maintenance of professional license per Florida State Law.
Serves as the facilitator of educational programs at staff meetings as needed.
Explains all procedures and treatments to patients and/or significant others as appropriate. Ensures patient and/or family are educated for appropriate health maintenance.
Provides teaching and training to staff members as needed.
Provides care for the patient both pre- and post-specialized procedure and assists physicians during procedure as needed.
Performs bedside blood glucose monitoring per physician order and/or hospital policy.
Obtains and transcribes physician’s orders in a timely and accurate manner, ensures all tests are ordered appropriately and efficiently.
Completes pre-operation check-list.
Obtains and witnesses consents for surgery, anesthesia and special procedures as per hospital policy.
Performs waived glucose testing in accordance with the hospital’s policies and procedures.
Determines at-risk patients and follows through with treatment accordingly.
Orders necessary supplies and equipment and initiates repair requisitions as needed. Ensures availability of age appropriate supplies and equipment.
Starts IVs and delivers IV medications to patients as needed. Runs and calculates IV drips.
Performs port flushes, injections and blood transfusions as needed.
Dresses patients’ wounds as needed.
Performs respiratory care assessments and specimen collections using the appropriate techniques.
Obtains and submits lab specimens from patients. Ensures correct dates, times, and initials are indicated on all specimens.
Conducts walking rounds at the start and the end of each shift, visually checking each patient and providing an end-of-shift report.
Interviews patients in preparation for surgery as needed.
Floats to other units as required.
Oversees the care of newborns in the nursery.
Performs specialized patient assessments as needed.
Helps with code assistance.
Transports patients to appropriate care locations.
Oversees newborn care in the NICU.
Receives and reviews patient reports from out going staff. Utilizing the RROHC approach to bedside reports, interviews, huddles and patient care.
Assists with emotional needs of patients.
Troubleshoots patient care equipment when necessary.
Performs monitor/defibrillator, code cart and emergency box checks every shift.
Serves as an example for team members in cost saving practices.
Assists manager and other staff members to maintain competence and skills for procedures assigned and assists in validation of skills and competence of new staff members prior to delegation of patient care.
Participates in the hospital Utilization Management Program by assisting with discharge planning, reporting to case managers, and keeping patient, family, physician, and other personnel informed.
Participates with team members and manager to identify opportunities for improvement in patient care processes.
Performs time out procedures on all invasive procedures at the bedside as needed.
Performs monitoring and recovery care to PACU patients per Operating Room Department protocol when necessary.
Maintains competencies and participates in required training and in-services for unit.
Demonstrates understanding and commitment to hospital’s mission, philosophy, standards, policies and procedures. Recognizes all staff, physicians and visitors, as well as, patients as customers and provides courteous and respectful service.
Documents and reports any complaints from patients, physicians and visitors to supervisor as guided by hospital policies and procedures.
Participates in the cleanliness of the work environment.
Demonstrates an understanding of responsibility of emergency plans and is available for patient care as needed or scheduled when hospital emergency preparedness plans are activated.
Ensures completion of continuing education requirements in subjects pertinent to critical care nursing or position related information.
Serves as a leader for change, positively promoting new systems and changes implemented which improves the hospital and the service provided to its patients.
Participates in hospital community activities and helps portray a positive image of the hospital in the community.
Defibrillates patients safely in accordance with regulations, policy and accepted procedure.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.