POSITION SUMMARY

Registered Nurse responsible for the delivery of patient care through the nursing process of assessment, planning, implementation and evaluation to the “emergent” patient.

POSITION QUALIFICATIONS

• Requires a valid temporary or permanent CA State Registered Nurse License.
• Basic Life Support (BLS) certification required.
• Advanced Cardiac Life Support (ACLS) certification required
• Pediatric Advanced Life Support (PALS) certification required within 30 days of hire
• At least one year of emergency department experience or previous critical care experience
• CEN, TNCC preferred
• The individual must have strong interpersonal skills, the ability to manage multiple priorities, be dedicated to the provision of quality patient care, and use sound judgment in decision-making.

DUTIES AND RESPONSIBILITIESRESPONSIBILITIES TO THE PATIENT

• Initiates an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient/family through interview, observation, and physical examination.
  • Receives admissions and/or transfers to the unit.
  • Completes nursing admission notes within 24 hours.

• Interprets assessment data and information to develop a nursing care plan which contains problem identification, nursing diagnosis, nursing orders, approaches, interventions, short/long term goals, and discharge planning.
  • Develops nursing care plan utilizing nursing diagnosis
  • Assesses safety and fall risk levels for patients
  • Consults and coordinates with health care team members to asses, plan, implement and evaluate patient care plans.

• Teaches and counsels patients/families, and makes referrals to appropriate resource personnel when needed.
  • Documents patient, family, and significant other teaching

• Participates as a productive member of the interdisciplinary team in assessment, planning, implementation and evaluation of rehabilitation goals.
• Assures that medical orders are transcribed and processed accurately, and integrates the medical care plan into the provision of nursing care.
• Assures that medication/I.V. administration is correct and according to the established nursing policies and procedures.
  • Looks up unfamiliar medications
    **Processes medication orders
    **Administers medications as ordered
    **Evaluates effectiveness of PRN medications
    **Verbalizes process for self-administered medications
    **Verbalizes patient education on identified medications
    **Verbalizes standing orders
    **Verbalizes policy and procedure for maintenance and care of central line catheters
    **Administers I.V. drugs

• Provides for personal and environmental safety in accordance with hospital and nursing policies and procedures
• Demonstrates skills in handling emergency and life-threatening situations
  • Locates and uses crash cart items
  • Calls Code Blue and Medical Emergency
  • Initiates CPR
  • Follows P and P and POLST

• Assures that documents in the medical record are complete, factual, accurate and timely.
  • Documents materials and equipment used.
  • Verbalizes method to noting orders.
  • Documents discharge in chart.
  • Initiates and updates care plan as appropriate.
  • Provides discharge instructions.
  • Completes interagency transfer form.

• Provides nursing care to meet patient needs:
  • Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools.
  • Acts promptly on changes in patient condition, utilizing SBAR method
  • Reviews lab and test results, notifying physician of abnormal and critical results
  • Performs wound care in accordance with policy, utilizing proper documentation tools.
  • Performs basic ventilator management and trouble-shooting.

II.RESPONSIBILITIES TO UNIT STAFF

A.Provides direction and leadership in patient care to assigned personnel.

1.Acts as a team leader.

2.Makes assignments for team.

B.Prioritizes activities and plans for effective use of time and staff in meeting patient needs.

C.Communicates the plan of nursing care for each patient through reports, conferences, rounds, and patient care records.

1. Shift to shift report and shift huddle with aides

2. Delegates tasks to aides; monitors to make sure delegated tasks are completed appropriately.

D.Demonstrates responsibility for the teaching of staff in areas of new techniques, policies and procedures.

1. Preceptor

E. Participates in the quality improvement activities of nursing.

1. Attends appropriate meetings.

F. Communicates identified learning needs of self and others to the DON/CNO.G.Assists the DON/CNO in the orientation of new staff.

H.Adheres to established policies and procedures of the hospital and Nursing Department.

I.Actively participates on nursing committees.

J.Performs other duties as assigned or requested.