CLINICAL NURSE II - PAIN MANAGEMENT

The Clinical Nurse II is a professional Registered Nurse care provider who is responsible and accountable for the overall management of patient care on a specific shift/clinic area as well as maintaining providing quality patient care to our patients their families. As a Registered Nurse, performs an age-specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, and implementation and evaluating of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments, using her leadership skills and clinical judgment in coordinating patient care.

Typical Duties

Assesses the patient's physiologic health status by conducting patient interviews

• Explains policies and procedures to patients and their families; reviews patient's chart and answers questions correctly and courteously
• Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health status.
• Assesses mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate
• Assesses level of pain and provide pain management
• Communications and documents patient's physiologic health status and plan of care

Assesses patient's psychosocial health status

• Assesses perception of medical/nursing care and the expectation of care
• Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction
• Communicates and documents psychological status and care plan; support group, counseling services, social services

Identifies the plan of care

• Develops criteria for measurement of patient outcomes
• Identifies actual and/or potential patient problems
• Identifies patient's need for teaching, based on psychosocial and developmental assessment

Formulates the plan of care and establishes the priorities necessary to achieve expected outcome

• Identifies care activities and establishes the priorities necessary to achieve expected outcome
• Coordinates the cost-effective use of supplies, equipment, and medication to achieve expected outcome
• Documents the plan of care and collaborates with physicians and other health team members

Implements the plan of care

• Maintains standards to ensure that safety precautions and needs are followed
• Reassesses patients as needed and appropriately revises plan of care
• Correctly administers prescribed treatments and properly uses equipment necessary for patient care
• Provides emotional support to patient and significant others
• Applies scientific principles in performing procedures; carries them out safely, timely and efficiently
• Makes accurate observations of patient's conditions during treatments/procedures
• Admits patients for medical procedures, assists with procedure, and ensures appropriate recovery prior to discharge
• Keeps accurate documentation of patient's treatment, activity, and condition as well as patient's responses to medical and nursing interventions
• Uses appropriate methods of documentation according to departmental policy.
• Acts rapidly and effectively during any emergency situation, managing self, patients and other team members
• Provides calm, quiet, restful atmosphere
• Participates in planning for discharge and coordinates referrals, as appropriate
• Provides discharge instructions to patient and significant other

Evaluates care provided for patient outcome

• Demonstrates ability to measure effectiveness of care provided and documents same
• Performs variance analysis related to outcome data for performance improvement
• Designs, implements, and evaluates systems to improve care in unit
• Keeps accurate documentation patient's treatment, activity, and condition
• Uses appropriate methods of documentation according to departmental policy

Collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team

• Collaborates with the appropriate physician on patient's plan of care
• Accurately interprets and implements treatment regimen as prescribed by the physician
• Assists the physician during treatments and/or diagnostic procedures
• Keeps the Nurse Manager, designee and/or physician abreast of changes in patient's condition and/or treatments, as appropriate
• Uses clinical judgment in delegating assignments, and ensures that assignments are completed in a timely fashion
• Monitors the flow and throughput of patients in the clinical area to ensure safe and timely care
• Meets standards on medication administration examination
• Demonstrates preparation of local solutions
• Demonstrates preparation of IV drips
• Administers IVP medication as per department policy and procedure
• Educates patients and significant others related drug and food interactions

Participates in patient and family education

• Provides the patient with an explanation of his/her condition as indicated
• Communicates assessment data in an orderly fashion by recording, updating, and verbalizing pertinent information to team members and to appropriate agencies
• Recognizes and utilizes health teaching opportunities, resources, and materials available for this teaching
• Provides early discharge planning and appropriate referrals for post-hospital care
• Evaluates the effectiveness of teaching by feedback from patient/family and documents same