Job Description of a Staff Nurse

A. Morning/Afternoon

Duties and Responsibilities

1. Receives the endorsement from the outgoing nurse. Makes self updated
by new directions, memos and reminders received in the unit
2. Receives assignment from the head nurse-patient assignment making 24
hour condition report, checking I and O, IV level etc.

3. Makes rounds with the head nurse and other staff. Sees each patient and
takes notes of the following:

a.) Greets patient, establishes rapport. Observes for general condition of the
patient, especially level of sensorium
b.) Checks for preparation if patient has laboratory test, x-ray, ultrasound etc.
c.) Sees to it that there is a measuring cup, I and O sheet of bedside if patient
is for I and O
d.) Check drainage for catheters, Levin tube and abd/. Tube if draining
properly, notes the character of the drainage and documents in the nurses
notes and refer if necessary
e.) Checks IV site including IV fluids being infused

4. Plans and organizes work for the day as affected by the number and type
of patient’s assigned
5. Checks patient’s individual medicine boxes and order medicines good for
one day use by encoding it into the computer (afternoon duty)
6. Check the chart for new orders that must be carried out.
7. If in total nursing care attends to each patient assigned.

a.) Sees to it that patient has been served, with meal tray. Assist those that
need assistance. Sees to it that the patient on non per orem (NPO) is not
served. Advices the patient and watchers not to bring food trays out of the
room to prevent it’s loss. It will be collected later by the Dietary Staff.
b.) Takes V/S and records
c.) Prepares and gives medicines and due treatments
d.) Encourages patient to have self-care with assistance and supervision
when necessary
e.) Checks in patients elimination pattern. Refers to AP/ROD if (-) BM for 2
days or more. Collects specimen, puts labels and send to laboratory
whenever necessary
f.) Calls the ROD/IOD and assist in dressing, giving venoclysis etc. as
needed by patient
 g.) Observes patients reaction towards general care, medications and
treatment given to them.
h.) Accompanies patient’s to and from x-ray and clinic, or when transferring to
another unit
i.) Makes patient comfortable, sees to it that all their needs are met, physical,
spiritual, emotional etc. as much as possible.
j.) Follow up consumed IVF and remove out of vein IVF and calls intern or
resident for insertion
k.) Prepares medicines following the 10 standards rights in administration of
medications

8. Assist in the different procedures being done in the unit like intubations,
tracheotomy, cutdown, pacemaker, insertion, subclavian insertion
9. chart all procedures treatment, medications and observation made as
soon as possible.
10. reports to the Head Nurse/Head Nurses

a.) Changes in patients condition

b.) Untoward reaction to treatment and medication
c.) Problems encountered in the care of the patient

11. Updates kardex every now and then for new orders. Sees to it that everything
ordered which need to be done in shift is carried out.

12. Receives patient’s admission, transfer, post operative and post partum
patients. Sees to it that the room is prepared. Checks on patient’s condition,
needs and belongings.

13. Answers bells. Remembers that although one is assigned a patient, one is
expected to know the rest of the patients in the unit. Keeps self informed. Works
as a team.

14. Assists the Head nurse.

a.) Makes rounds with doctors.

b.) Answers telephone calls and relays the message to the people
concerned.

c.) Interprets and puts into effect policies and regulations of the hospital
e.g. visiting hours, watchers etc…

15. Attends to discharged patients as they come along. Sees to it that no

personal belongings are left in the room and no hospital articles are taken home.
Gives all extra medicines with home instructions sheet and explains; have it
received.
16. After lunch or supper, makes rounds to ascertain patients’ condition. Sees to
it that the environment is conductive to rest.

17. Checks extra assignment. Reports missing items to head nurse.

18. Completes charting. Keeps an accurate record of the things done for the
patients and the observations made. Records doctors visit. Keeps standing order
up to date.

19. Measures IVF level.

20. Attends to patient’s needs while the outgoing nurse makes her report to the
incoming staff.

21. Endorses particular patients, extra assignments, stock medicines and articles
before going off.
B. Night Duty

General Function: Nursing responsibilities during nighttime demand even more

efficiency than during the day. Night nurses are
expected to be especially dependable, observant, ready to
meet any patients’ demand especially during emergency.

Duties and Responsibilities:

1. Receives endorsements from the afternoon nurse taking note of patient’s

conditions, blood examinations, special procedures, patient having IVF or blood
transfusions, etc..

2. Makes rounds to all patients. It is important that nurses check on patient’s

conditions, awake or not, sees to it that IV fluids are dripping at the desired rate,
urinary catheters are draining well, oxygen tents and other apparatus are working
properly, see to it that environment is conducive to sleep and makes additional
information as necessary.

3. Checks supplies, equipment and medicines. Reports any missing items and
makes necessary replacements if possible.

4. Reviews kardex and doctor’s orders to check that no orders were left uncarried
and to ascertain further things that must be done during the night. Plans,
organizes and delegates duties to co-staff according to level of their experience
and job description.

5. Accomplishesthe daily floor census slip and sees to it that number of patents
tally with the number of patients/census in the ward.

6. Encodes all the patients’ diet before 5 AM. Changes patient’s diet per doctor’s
order to be done anytime.

7. Prepares medicines following the 10 standard rights in administration of

medicines.

8. Checks the patient’s charts:

a.) Sees to it that all sheets are with correct address graph.

b.) Checks doctor’s order sheet- sees to it that all orders are dated,
countersigned, copied in the kardex and carried out correctly.

c.) Checks standing order sheets- keeps it up to date. Recopies if untidy. Affixes
signature below with date.
d.) Checks graphic sheet- TPR, chartered as often as ordered, weight taken on
admission and as often as ordered, BM recorded every shift, etc…

e.) Intake and Output sheet- performs accurate feeding.

f.) Medication sheet- observes proper documentation.

9. Documents all medicines, treatment, complaints and other pertinent

information.

10. Admits patient as they come. Copies orders in the kardex and carries out all
those that must be done in shift. Notifies attending physician at around 6 AM or
immediately, depending on patient’s condition. Informs residents, interns of
admission or department concerned.

11. Makes frequent records during the night. Sees to it that IV catheters and
other apparatus are working well.

12. Anticipates patient’s needs. Sees to it that environment is conducive to rest.

13. Checks dressing cart and emergency cart.

14. Completes patients logbook as to: Room No., time admitted, patient’s name,
doctor, doctor, service, chief complaint/diagnosis/impression, trans –in, trans-out
date and time and time of discharged.

15. Checks on work performance of co-staff. Delegated responsibilities according

to job description and level of experience.

16. Prepares patient for sponge bath or bathes patient, puts on gown. Removes
dentures, nail polish and hairpins. Gives pre-op medicines at time ordered. Sees
to it that consent has been signed by patient for surgery or special procedure.
Provides tracheostomy care or endotracheal care when applicable.

17. Collects specimen as ordered and labels properly. Sends to laboratory

together with the request and encodes in the computer.

18. Renders or assists patients in doing self-care/morning care.

19. Measures empty level and records drainage level from catheter and tubes.
Collects bedside intake – output sheet, summarizes 24 hours intake and output
list. Replaces bedside record with a new sheet.

20. Makes sure blood extractions are done.

21. Completes charting

22. Makes 24-hour condition report. Sends to NSO.

23. Endorses properly to morning duty, putting emphasis on particular patients

treatment, and medicines not started, doctors not notified, problemsmet during
the shift, etc.

24. Participates actively on various quality activities/programs of the

hospital/nursing division.

Qualification(s):

Education
• A BSN graduate of an accredited college or university of nursing
• License in the Philippines
• Good moral character
• Physically and mentally fit to work
PM shift

4. Checks the chart and encode in the computer any changes in patient’s diet.
5. Check equipments and supplies with the morning nurses and the ward
clerk; sees that there is sufficient supply for afternoon such as:

a.) Sterile supplies for the dressing cart like cotton balls, OS 4 x 4,
dressing kit, disposable syringe etc.
b.) Stock medicine
c.) Treatment trays – external perineal care tray, enema tray, IV tray,
dressing tray

6. Makes rounds with doctors as they come. Transcribe orders accurately on

Kardex, check and affix signature and time on the doctors order sheet after
copying

7. Checks discharges – sees to it that patient is given the evaluation sheet.

Before the home instruction and extra medicines are given and explain to
relative/patient, ask for the evaluation sheet.

8. Sends schedule slip to OR for patient who is for surgery X-ray request
ultrasound, CT scan etc.

9. After supper, Head Nurse II will make her rounds and see to it that

a.) All patients are served supper and helpless patients are fed
b.) That all ordered treatment have been done
c.) Take note of the valant rooms that need to be sprayed and report to the
Nursing Supervisor. Check if spraying has been done and ask the janitor
to clean the room.
d.) Gives final instructions to patients who are for surgery for x-ray and for
blood works.

10. Reviews charts and checks if orders have been carried out and charting in
the Graphic Sheet, I/O sheet, IV fluid sheet, Diabetic sheet, Nurses notes and
medication sheet if completed.

11. Checks on medication cards. Set aside all medication cards of patients
who are for surgery, x-ray and blood chemistry. Who needs special
preparation like fasting and endorse properly to incoming duty.

12. Checks and instruct ward clerk the charges medicines to be used the next
day except for too expensive IV medicines inclding supplier, the cotton
balls, disposable syringe.

13. Sees that the ward is quiet, ligts lowered and patients are comfortable.
14. Reports to the night nurses and finalize endorsement regarding patients,
equipments, supplies, medicines and keys.

15. Participates actively in various quality activities/program of the

hospital/nursing service division

16. Directly responsible to head nursing service division and nursing

supervisors/administrative coordinators/

QUALIFICATION

Education:

Graduated from an accredited school or college of nursing

A BSN degree holder/graduate

Experience:

At least 2 years of nursing experience

Physically and mentally Healthy.