Inpatient Treatment Inpatient Nurse (LPN)

Admission Screenings

• Admission Assessment Detail — Complete a full nursing intake within mandated timeframes, beginning with verifying identity, reviewing referral paperwork, and confirming medical clearance.
• Obtain baseline vital signs (BP, HR, RR, Temp, SpO₂) and evaluate for abnormalities requiring immediate physician notification.
• Conduct a comprehensive physical health history, including chronic conditions, past surgeries, allergies, current medications, substance use patterns, and prior withdrawal complications.
• Inspect skin integrity for bruising, track marks, rashes, pressure areas, or infection indicators; document all findings with anatomical specificity.
• Assess current withdrawal symptoms, noting tremors, diaphoresis, nausea, agitation, hallucinations, or disorientation.
• Determine initial detox protocol placement if needed, fall‑risk status, and medical monitoring frequency.

Withdrawal Scale Monitoring

• CIWA/COWS Monitoring — Administer CIWA or COWS at scheduled intervals (e.g., q1h, q2h, q4h) depending on taper protocol or stabilization plan.
• Score each domain precisely—tremor severity, nausea, anxiety, tactile disturbances, pupil size, bone/joint aches, GI upset, etc.
• Document scores immediately and notify the physician when thresholds requiring medication intervention are met.
• Evaluate trends to determine whether withdrawal is escalating, stabilizing, or resolving.

Medical Triage

• Triage Protocols — Assess walk‑in complaints such as headaches, abdominal pain, dizziness, chest tightness, or panic symptoms.
• Differentiate between minor issues (e.g., mild dehydration, constipation) and urgent conditions (e.g., chest pain, seizures, suspected overdose).
• Perform focused assessments (lung sounds, neuro checks, blood glucose, orthostatic vitals) when indicated.
• Communicate findings directly to the physician or Medical Director and obtain orders for labs, medications, or emergency transport.

2. Medication Management & Administration

Medication Administration

• Medication Pass Detail — Prepare and administer scheduled, PRN, and MAT medications following the six rights: right patient, medication, dose, route, time, and documentation.
• Monitor residents during ingestion to prevent cheeking, pocketing, or diversion.
• Assess for immediate side effects such as dizziness, nausea, sedation, or allergic reactions.
• Provide MAT medications (buprenorphine, naltrexone, etc.) according to protocol, verifying identity and monitoring post‑dose stability.

Control Count Verification

• Controlled Substance Protocol — Perform dual‑nurse controlled substance counts at every shift change. If no other nursing staff is available have a clinician of direct care staff present.
• Verify each dose, reconcile discrepancies, and document counts in the controlled substance log.
• Investigate and escalate any variance immediately according to diversion‑prevention policy.

MAR Accuracy

• MAR Documentation — Maintain flawless MAR/eMAR records by documenting:
• Administered doses
• Refusals
• Late doses
• Held medications
• Adverse reactions
• Ensure no blank spaces remain; every scheduled dose must be accounted for before shift end.

3. Clinical Collaboration & EHR Documentation

Physician Orders

• Order Management — Receive verbal or written orders, repeat verbal orders back for accuracy, and enter them into the EHR.
• Execute orders promptly—medication changes, lab draws, vitals frequency adjustments, detox protocol modifications.

Interdisciplinary Communication

• Team Collaboration — Participate in multidisciplinary meetings with therapists, case managers, techs, and physicians.
• Report medical concerns, withdrawal progression, medication compliance, and barriers to treatment engagement.
• Provide input for treatment planning and discharge readiness.

Regulatory EHR Logging

• EHR Compliance — Document all nursing interventions, assessments, incident reports, and physician notifications.
• Chart vital sign trends, CIWA/COWS scores, medication responses, and clinical observations according to LDH standards.
• Ensure documentation is time‑stamped, objective, and complete before shift end.

4. Patient Health Education & Crisis Intervention

Health Education Groups

• Health Education Detail — Facilitate educational sessions covering:
• Overdose prevention and naloxone use
• Nutrition and hydration during recovery
• Infectious disease prevention (HIV, Hep C, STIs)
• Medication adherence and MAT expectations
• Provide handouts, demonstrate naloxone administration, and answer resident questions.

Medical Emergency Response

• Emergency Protocols — Act as first responder for seizures, overdoses, respiratory distress, severe panic attacks, or unresponsiveness.
• Initiate emergency protocols: assess airway/breathing/circulation, prepare naloxone, or begin CPR if needed.
• Direct support staff, assign tasks (calling 911, retrieving AED, clearing area), and coordinate EMS arrival.
• Document the event thoroughly and notify the physician immediately.

Expanded Day‑to‑Day Nursing Shift Blueprint

First 2 Hours — Handovers & Morning Meds

• Conduct face‑to‑face report with outgoing nurse reviewing unstable clients, detox progression, new admissions, and pending labs. If face-to-face can not be conducted leave detailed documentation for on coming nursing staff.
• Complete controlled substance count with outgoing nurse, reconciling inventory line‑by‑line.
• Prepare and administer morning medication pass, verifying identity, monitoring ingestion, and documenting all doses.
• Assess residents post‑medication for side effects or complications.

Mid‑Shift — Assessments, Triage & Documentation

• Perform scheduled CIWA/COWS assessments for residents on tapers or stabilization protocols.
• Complete head‑to‑toe assessments for new admissions arriving during the shift.
• Coordinate with pharmacies regarding refills, missing medications, insurance issues, or delivery delays.
• Address walk‑in medical complaints, perform focused assessments, and obtain physician orders.
• Draw blood for labs (CBC, CMP, LFTs, etc.) when ordered and prepare specimens for courier pickup.
• Update EHR with assessment findings, medication responses, and physician communications.

End of Shift — Final Rounding & Sign‑Off

• Conduct afternoon/evening medication pass, documenting all doses and refusals.
• Audit MAR/eMAR to ensure no missing documentation or unresolved variances.
• Complete all nursing notes, incident reports, and physician notification logs.
• Perform final controlled substance count with incoming nurse.
• Provide structured handoff summarizing medical concerns, withdrawal progression, and residents requiring close monitoring.

Pay: $21.00 - $28.00 per hour

Work Location: In person

Salary : $21 - $28