Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.

A. ASSESSMENT

Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.

Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.

Selects, plans, evaluates, and documents care based on this assessment.

Assesses, intervenes, and documents appropriately to meet patient's educational, psychosocial, and discharge planning needs.

Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.

B. DIRECT PATIENT CARE

Gives comprehensive patient care.

Initiates and follows through with patient and family teaching.

Consults with unit Nursing Leadership regarding significant changes in patient's condition.

Collaborates with all members of the health care team.

Communicates relevant patient care information on shift to shift report.

Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.

Completes Admission/Transfer Summary Sheet and/or Discharge Summary.

Transcribes physician's orders in patient chart accurately and timely (when Ward Clerk is not available).

Seeks clarification of physician's orders that are unclear or inappropriate.

Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.

Administers intravenous medications in compliance with policies and procedures.

Titrates medicated infusions as per physician's prescriptives, protocols, and standard.

C. SAFETY

Checks to ensure that emergency equipment is on hand and in good working order.

Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e.g., ventilators, cardiac monitors, defibrillators, suction apparatus, pumps, Doppler, O2 tank, and pacemaker).

Checks that all monitoring equipment and ventilator alarms are set according to standards.

D. INDIRECT PATIENT CARE ACTIVITIES

Participates in interdisciplinary patient care rounds by presenting findings on patients.

Applies principles of infection control and safety.

Assists in the orientation of new personnel.

Provides clinical supervision of Nursing Attendants, Ward Clerks and other ancillary staff.

Customer Service: respect, flexibility, knowledge, confidence, professionalism, pleasant attitude, patience and helpfulness. All responses should be timely, professional, caring, and respectful in accordance with Customer Service Performance expectations

Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards. Assesses gaps in policies and procedures, and create necessary policies and procedures to fulfill these gaps.

Understands and adheres to the Medical Center’s Code of Conduct.

OTHER JOB DUTIES

• Orients patient's family to new environment; develops rapport with patient's family.
• Relieves the Nurse Manager as required.
• Assists in data collection and analysis of Quality Assurance/CQI monitors; participates in implementation of follow up action.
• Effectively utilizes the hospital computer system as it pertains to job responsibilities and in accordance with hospital policy.
• Participates actively on Quality Improvement committees as assigned.
• Assists other personnel as needed.
• Keeps up-to-date with current trends pertinent to area of assignment.
• Participates in continuing education activities; attends scheduled inservice programs; shares information gained at conferences with colleagues.
• Responds to Internal/External Disaster Codes as assigned.
• Performs other related duties as required.
• Attends unit monthly meetings.
• BASIC COMPETENCIES

• Graduation from accredited school of nursing.
• Current NJ licensure as RN.
• BLS & IV certification