Registered Nurse (RN) 6103 Med/Surg - Days (Full Time)

JOB SUMMARY

Reporting to the Unit Manager the staff RN is a professional care giver who assumes responsibility and accountability for a group of patients for a designated time frame and provides care to these patients via therapeutic use of self, the nursing process, the environment/instrumentation, and other health care team members she/he may interact with or delegate duties or supervise in the delivery of care based on the scope of practice outlined by the Board of Nursing.. If assigned as charge nurse, will serve as resource for coordination of activities on a single unit. Responsibilities as charge nurse include, but are not limited to, assessment of unit needs and available resources for current and oncoming shift(s) based on: patient needs, volume, individual and family needs and special clinical procedures or interventions pending.

Job Specific:

• Provides direct quality patient care based on the plan of care and exercises judgment in delegating aspects of patient care appropriately to licensed and unlicensed staff members: Essential Function (EF).
• Participates in professional development of self and staff to enhance patient-focused nursing practice, age, and population-specific to the nursing unit.(EF)
• Performs a timely, comprehensive assessment using appropriate techniques for data collection, analysis, interpretation, and documentation to make age appropriate decisions for the patient plan of care within scope of responsibility, training, and practice. (EF)
• Develops, implements, documents and evaluates on a regular basis the plan of care in collaboration with other team members based on multidisciplinary assessments.(EF)
• Actively participates in unit’s performance improvement initiatives. (EF)
• Performs nursing interventions with emphasis on patient rights, informed consent, patient confidentially, HIPAA compliance, adaptation of care according to age, cultural and ethical considerations.(EF)
• Administers medication according to facility standards and demonstrates safe and accurate administration of medication/control substances.(EF)
• Observes and reports patient progress and changes in patient status to the physician and documents in the medical record.(EF)
• Screens for and communicates discharge needs on a regular basis in collaboration with the multidisciplinary team members.(EF)
• Accurately records vital signs, intake and output and other physical observations on the appropriate forms.(EF)
• Focuses on prevention/care of pressure ulcers.(EF)
• Evaluates the need for and consistently provides and documents education provided to the patient and/or patient care givers.(EF)
• Evaluates with the physician or independent allied health professional the need to initiate restraints, monitors use of restraints, and evaluates on a regular basis according to hospital policy the ability to discontinue restraints.(EF)
• Monitors appropriate pain management and performs interventions.(EF)
• Performs patient care activities; assisting with ADLs, mobilization of patients, drain, dressing, wound care, associated therapeutic devices and nutritional needs.(EF)
• Obtains physician orders to meet the needs of the patient.(EF)
• Develops and maintains proficiency in the use of equipment and facilitates maintenance of equipment by completing maintenance requests.(EF)
• Demonstrates “Service Excellence Initiatives” by presenting a positive first impression; anticipates customer needs, and is actively involved in role of Team Player. (EF)
• Follows universal precautions . (EF)
• Complies with Employee Health requirements for employment. (EF)
• Works in manner that promotes safety, adhering to dress code policy. (EF)
• Knows role in emergency situations and reports unsafe practices to management. (EF)

If assigned as charge nurse:

• Uses knowledge of the staffing plan, skill mix/staff competencies, and patient acuity to develop an appropriate shift assignment.(EF)
• Able to assess the need for adjusting staff resources based on changes in census or acuity. (EF)
• Coordinates with other disciplines and department the process of admissions, transfers, and discharges. (EF)
• Uses effective leadership and organizational skills for problem solving; mentoring and directing staff; and reporting issues on a timely basis to physicians, assistant directors of nursing and/or other department leaders or their representatives. (EF)