Under the direction of the Clinical Manager and the Nurse in Charge, this position assesses plans, organizes and evaluates all aspects of patient care for assigned unit/patients.
Reports to: Nurse Coordinator/Charge Nurse
Essential Job Functions
- Utilizes the nursing process to provide quality patient care according to established standards of care which includes planning, implementing, evaluating and adjusting plan of care, and discharge planning based on expected patient outcomes.
- Admits, transfers, and discharges patients.
- Completes ongoing patient assessment and documents according to policy.
- Completes nursing assessment within 2 hours of admission, or designates reason for incompleteness. Reviews database and nutrition screen.
- Participates in the development of patient plan of care to include patient problems, goals, evaluations and interventions.
- Reports symptoms and significant changes in patient’s condition to appropriate personnel.
- Assesses, collaborates and coordinates patient’s discharge planning needs and readiness for discharge with other members of the care team.
- Demonstrates appropriate application of age specific standards, policies and procedures and guidelines in caring for adolescent, adult, and geriatric patients.
- Follows age specific standards in administering medications based on patient’s age.
- Follows age specific standards of care during altered states of consciousness related to analgesia, conscious sedation or anesthesia.
- Uses age specific standards, policies and procedures and guidelines to perform treatments and procedures that are routine for unit/clinic based on patient’s age.
- Incorporates cultural and developmental needs into plan of care.
- In collaboration with the patient/family, and in a developmentally and culturally appropriate manner, implements the plan of care.
- Demonstrates competency in the provision of nursing care according to established standards of nursing practice and in a developmentally appropriate manner.
- Demonstrates critical thinking skills, ability to provide and delegate activities to staff based on patient assessment and the requirements to deliver care in a safe efficient manner maximizing positive outcomes for the patient.
- Provides documentation of patient care in the patient record according to established standards of nursing care.
- Collaborates and works cooperatively with physicians and other members of the multidisciplinary health care team in formal and informal teaching of patients and/or family about his or her disease process and wellness promotion plan and discharge planning.
- Assesses patient/family learning needs, abilities, preferences, and readiness to learn.
- Utilizes a collaborative interdisciplinary process to provide appropriate patient/family education.
- Utilizes available information to evaluate the effectiveness of teaching in producing the desired patient outcomes and makes adjustments in teaching as indicated.
- Participates in performance improvement activities which include collecting, analyzing data to identify quantifiable measures to maintain quality and the promotion of desired outcomes. Also includes participation in development of patient care delivery systems, standards, policy and procedures, and problem solving teams.
- Demonstrates an awareness and relevance of research in nursing. Evaluates practices to identify areas for improvement or opportunities for research.
- Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
- Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.
- Maintains and protects confidentiality regarding all aspects of patient care, personnel and strategic issues. Adheres to Confidentiality Policy.
- Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s Guidelines for Appropriate Conduct in the HR Manual.
- Displays honesty and mutual respect when communicating with peers and other departments.
- Follows through on problems that may compromise effective job performance by using appropriate chain of command.
- Patient Care Unit nurses may have duties addressing the nursing process of assessment, planning, implementation, and evaluation as well as nursing functions of teaching, risk management, time management, and communication in follow manners:
- Obtains initial admission and postoperative physician orders to determine patient needs.
- Obtains and assesses diagnostic data and collaborates with physicians and other health care providers to provide appropriate follow-up actions.
- Utilizes clinical experience and knowledge to anticipate potential patient care problems and collaborates with appropriate individuals.
- Performs assessment of patient, family members, and/or significant others’ knowledge base, health care practices, attitudes of health and illness, and level of understanding.
- Plans patient care based on identified assessment analysis and established standards, policies, and procedures.
- Involves patients and family/significant others in perioperative planning.
- Collaborates with other health care providers to provide appropriate discharge services.
- Performs indicated procedures accurately and according to standards, policies, and procedures. Demonstrates competency in performing phlebotomy, obtaining various types of laboratory specimens, electrocardiograms, or other diagnostic tests.
- Capable of completing admission information, physician orders, or other information data entry.
- Evaluates patient care goals of admission, quality and appropriateness of care provided, and patient outcomes.
10.11 Effectively explains postoperative and discharge care, patient care principles, and nursing goals to patient and family/significant others during admission visit/interview.
Education: Graduation from accredited school of nursing; Bachelor of Science in Nursing is preferred.
Certification, Licensure: Current state license as a registered nurse; current BLS certification or must be obtained within 90 days of employment and ACLS certification required within 6 months of employment.
Experience, Training, Knowledge: One (1) to three (3) years’ experience as an RN preferred. Experience in orthopedic, neurosurgical, pain management specialties preferred.
Physical Requirements: Position requires lifting, carrying, pushing, and/or pulling up to fifty (50) pounds while administering patient care; stooping, kneeling and/or crouching; standing and walking five (5) or more hours per day; reaching, grasping, and handling and/or feeling five (5) or more hours per day. Visual acuity to correctly distinguish skin tone variations, evidence of IV infiltration, infection and to read telemetry, blood pressure gauges, etc; audio acuity to correctly distinguish various body sounds, i.e. respirators, heart sounds, bowel sounds and to discern sounds made by various types of machinery or equipment which would indicate dangerous or improper operation.
Working Conditions/Environmental Exposures
Environmental hazards such as chemicals, solvents, needles, needle containers, sharps, blood, body fluids, various infectious/communicable diseases, infectious medical waste, radiation, and/or radioactive materials and/or radioactive waste, proximity to moving mechanical parts. Protective clothing/equipment may be necessary.
THE JOB DESCRIPTION IS NOT INTENDED TO BE AN EMPLOYMENT CONTRACT, NOR DOES IT DISSOLVE THE "AT WILL" EMPLOYMENT RELATIONSHIP.