Job Description

Location: Carney Hospital
Posted Date: 3/2/2020
Internal 3.2.20-3.9.20

The Staff Nurse is an individual who holds ultimate responsibility for direct and indirect nursing care through the utilization of the nursing process. The Staff Nurse provides individualized, goal-directed nursing care through use of the nursing process and practices within the guidelines of the Nurse Practice Act and the Standards, Policies and Procedures of Carney Hospital. He/she reports to the Clinical Manager or designee.

  1. Assess and diagnoses patient and family problems in order to provide quality care to assigned patients.

· Completes patient assessment data within 8 hours of admission or in accordance with specific unit standard.

· Identifies and documents nursing diagnosis/problem list on patient plan of care within 8 hours of admission.

· Identifies and documents patient/family/significant other teaching needs upon admission. (including barriers/strategies/outcomes)

· Identifies discharge planning needs of patient/family/significant other at time of admission.

right patient

- right drug

- right dose

- right method

- right time

· Demonstrated proper procedures in all methods of medication administration

· Monitors patients response and intervenes appropriately

· Provides effective pain management to include:

  • accurate assessment using 0-10 pain scale

- documentation of location, character and duration

- timely appropriate interventions

  • timely reassessment and intervention

· Administers blood and blood products following Carney Hospital policy and procedures

· Documents narcotics use according to Carney Hospital policy and procedure

· Assess, maintains and documents IV access according to Carney Hospital policy and procedures

· Identifies patients at risk for falls and implements fall prevention program as appropriate

· Delivers culturally competent care being sensitive to issues related to culture, race, gender, sexual orientation, and socio-economic class

· Provides emotional support to the patient/family

· Considers patient’s spiritual needs and appropriately consults Spiritual Care Services

· Effectively teaches the patient/family about the disease, disease process, procedures, medications, food drug interactions, activity progression and when to call M.D.

  1. Re-evaluates the identified problems, care provided, and outcomes in order to meet patient and family needs and assure overall quality of care delivered.
  • Reassessments of plan of care is done every 24 hours and as patient condition warrants/or at each patient visit.
  • Assesses the patient/significant other’s response to teaching plan in order to evaluate the effectiveness of plan.
  • Based on reassessment, plan of care remains the same or is modified to meet the patient/significant other’s identified needs.
  • Contributes knowledge and information and is open to the knowledge and assessment of others, thus enabling the team to develop an integrated approach to patient care.

  1. Maintains up-to-date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team.
  • Each identified problem is addressed using flow sheet or progress note every 24 hours
  • Patient teaching record is completed to include barriers, teaching method and learning outcome
  • Flow sheets and I&O sheets are accurate and signed with name and title each shift
  • Medication administration record reflects full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable)
  • Discharge plan accurately reflects patient and/or family’s ability to manage care after discharge
  • Referrals are made based on identified needs
  • Interagency communication referral forms (Pg. 2) are complete and accurate.

  1. Demonstrates ability to use critical thinking skills in all aspects of practice.

· Collates and integrates multiple sources of data

· Recognizes the limits of clinical judgment and seeks interdisciplinary collaboration and

· Identifies and anticipates needs of patient/family as they move through the hospitalization process.

  1. Develops discusses and communicates a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs/or in accordance with specific unit standards.

· Plan of care includes nursing diagnosis/problem list statement for each identified problem

· Develops patient/family/significant other teaching and discharge plans that are driven by the needs of patient/family.

  1. Demonstrates the skills and judgement necessary to implement medical plan of care, nursing interventions

and procedures as necessary for the care of the patient.

· Demonstrates knowledge of Carney Hospital policies and procedures/protocols for administering, transcribing and recording medications.

· Demonstrate knowledge of commonly used meds: action, dose and side effects

· Observes 5 R’s for administering meds:


  1. Education: Graduate of an accredited School of Nursing
  2. Experience: Demonstrated proficiency in acute care nursing, knowledge and skills
  3. Certification/Licensure: Current registration in the Commonwealth of Massachusetts
  4. Software/Hardware:
  5. Other:

Application Instructions

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