Job Description of a Staff Nurse

A. Morning/Afternoon Shift 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 24hour 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 patients assigned. 5. Checks patients 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 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 its 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 2days 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 patients 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 patients admission, transfer, post operative and post partum patients. Sees to it that the room is prepared. Checks on patients 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 patients 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 night-time demand even more efficiency than during the day. Night nurses are expected to be especially dependable, observant, and ready to meet any patients demand especially during emergency. Duties and Responsibilities: 1. Receives endorsements from the afternoon nurse taking note of patients 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 patients 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 doctors 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. Accomplishes the 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 patients diet per doctors order to be done anytime. 7. Prepares medicines following the 10 standard rights in administration of medicines. 8. Checks the patients charts: a.) Sees to it that all sheets are with correct address graph. b.) Checks doctors order sheet- sees to it that all orders are dated, countersigned, copied in the kardex and carried out correctly.

c.) Checks standing order sheets- keep 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 patients 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 patients 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, patients name, doctor, doctor, service, chief complaint/diagnosis/impression, trans in, transout 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, problems met during the shift, etc. 24. Participates actively on various quality activities/programs of the hospital/nursing division. C. PM Shift 1. Checks the chart and encode in the computer any changes in patients 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 vacant 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 including supplier, the cotton balls, disposable syringe. 13. Sees that the ward is quiet, lights 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: A BSN graduate of an accredited college or university of nursing. License in the Philippines. Good moral character. Physically and mentally fit to work. Experience: At least 2 years of nursing experience