Registered Nurse

Registered Nurse

Med Surg Department

Contingent - 12 hr. shifts (Flex days and nights)

7p-7:30a

Role/Position Definition: Responsible for the provision of nursing care to patients and to direct licensed and non-licensed staff in the same.   Assesses, plans care, provides treatment regimes, evaluates care and collaborates with the physicians and interdisciplinary care delivery team to provide comprehensive nursing care.   Serves as resource person to licensed and non-licensed staff, assuming leadership roles and responsibilities, as assigned. 

Qualifications/Position Requirements:

1. Knowledge of BLS protocols in code situations, medication administration, pain management, wound care, and performance of patient assessments. 
2. Knowledge of medical terminology, human anatomy, and physiology. 
3. Requires immediate judgment and response; occasionally in response to disasters or emergencies, actual events or drills.
4. Requires high-level visual and auditory acuity for timely response and patient care assessment activities.
5. Requires effective listening and language skills adequate for high-level written and interpersonal communication.
6. Must possess customer service skills and be able to demonstrate at all times.
7. Must be able to demonstrate leadership skills with necessary.
8. Must be able to answer call lights and multi-task.
9. Ability to measure/record/evaluate vital signs. 
10. Ability to move quickly in response to physician and patient needs.
11. Ability to recognize and process confidential and sensitive information appropriately.

Duties & Responsibilities:     

1. Assesses the needs of the patients, including physical, emotional, psychological, spiritual, and social.  Serves as resource and collaborates with the Patient Care Technician regarding abnormal findings, as requested. Completes admission assessments, establishes nursing diagnosis and nursing care plans based on assessment, revises care plans as condition changes.  
2. Reviews laboratory test results, diagnostic test results and consult reports and forwards to physician immediately if abnormal, initiates appropriate nursing interventions immediately.  Documents communication with physician, subsequent medical orders, nursing interventions and administered treatment. 
3. Administers treatments following written physician orders and review of patient’s condition.  Collaborates with interdisciplinary team in determining appropriate treatment type, duration and dosage.  Operates a variety of equipment and performs a variety of treatments, including but not limited to, Tube feeding, EKG, Foley catheter insertion/care, oxygen administration, care of the tracheostomy, wound care, IV insertion, phlebotomy.  
4. Assists patients to optimize independence, including but not limited to, ADL skills, mobility needs, improving cognition, nutritional intake and bowel and bladder retraining.  Provides direct patient care as needed and assists licensed and non-licensed staff members as necessary.   
5. CPSI Documentation is accurate, consistent and concise supporting assessment of patients, all treatments given, patient’s response to treatment, and changes in treatment plans.   Documentation is in approved format and on designated tools.  All documentation, both narrative and flow sheets, is completed prior to the end of tour of duty, including co-signature and review of non-licensed staff documentation.
6. Provides patient education and discharge instructions related to medical and rehabilitation needs.  Documentation reflects all teaching provided and patient/family understanding and return demonstration of self-care, on designated tools.  Refers complicated cases to members of interdisciplinary team for further instruction. Participates as assigned at Team Conferences, communicating patient education and care needs.
7. Provides discharge instructions to patient/family.   Documents all instructions and teaching on designated tools.  Communicates, with facilities receiving patient upon transfer from Hospital. 
8. Administers medication as per policy/procedure; oral, rectal, intramuscular, sub-cutaneous, subdermal, IVPB, IV push,  PICC, ocular and otic.  Demonstrates knowledge of medications and interactions, if questions arise demonstrates appropriate follow through.  Appropriately documents medication held, refused or unavailable, communicating the same to the physician/designee. 
9. Responds quickly and appropriately to emergency situations.  Assumes roles during Code Blue emergency and conducts role without difficulty. Monitors and maintains necessary equipment and supplies.
10. Accurately notes and transcribes physician/designee orders into CPSI. Exercises clinical judgment and discusses/questions orders as applicable, prior to executing.  Transfers all pertinent information to kardex, bedside flow sheets, and in room communication tools.
11. Walking rounds done at least every hour on assigned patients.
12. Serves as resource person to licensed and non-licensed staff.  Assumes leadership roles and responsibilities as assigned, exercising strong clinical judgment in the delegation of duties based on staff licensure/certification and competency in provision of duties being assigned.  
13. Demonstrates customer focus.  Treats all customers, co-workers and supervisors with respect.   Helps create and maintain a positive work environment.  Adheres to and demonstrates Hospital policies, procedures, guidelines and protocols.   Actively participates in process improvement activities and/or committees to improve care delivery and unit operations.
14. Performs all other duties as assigned.