Description
Description
Under the general supervision of the Director or Assistant Director of Nursing, provides direct nursing care to patients.
Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.
ASSESSMENT
Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.
Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.
Selects, plans, evaluates, and documents care based on this assessment.
Assesses, intervenes, and documents appropriately to meet patient's educational, psychosocial, and discharge planning needs.
Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.
DIRECT PATIENT CARE
Gives comprehensive patient care.
Initiates and follows through with patient and family teaching.
Consults with unit nursing leadership regarding significant changes in patient's condition.
Collaborates with all members of the health care team.
Communicates relevant patient care information on shift to shift report.
Utilizes patient care standards in clinical practice. Establishes IV access and maintains line.
Performs phlebotomy duties as necessary.
Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.
Completes Admission/Transfer Summary Sheet and/or Discharge Summary.
Transcribes physician's orders in patient chart accurately and timely (when Ward Clerk is not available).
Seeks clarification of physician's orders that are unclear or inappropriate.
Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.
Administers intravenous medications/blood transfusion in compliance with policies and procedures.
Titrates medicated infusions as per physician's prescriptives, protocols, and standards. Accesses and coordinates patient's pain management.
Transports patients to and from the OR as per hospital policy.
Monitors patient's nutritional status and collaborates with multidisciplinary team to ensure adequate nutrition to meet metabolic needs (e. g. reports to physician on changes in patient's condition, suggests initiation of enteral feeding).
SAFETY
Checks to ensure that emergency equipment is on hand and in good working order.
Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e. g., ventilators, cardiac monitors, defibrillators, suction apparatus, pumps, Doppler, oxygen tank, and pacemaker).
Checks on policy and procedure on proper handling of sharps.
Checks that all monitoring equipment and ventilator alarms are set according to standards.
INDIRECT PATIENT CARE ACTIVITIES
Participates in interdisciplinary patient care rounds by presenting findings on patients.
Applies principles of infection control and safety.
Assists in the orientation of new personnel.
Provides clinical supervision of Certified Nursing Assistant, Ward Clerks and other ancillary staff.
Participates in continuing education activities, attends inservice programs.
Qualifications
Education
Required
Bachelors or better in Registered Nurse
Licenses & Certifications
Required
IV Therapy
Registered Nurse
*ACLS
*BLS
Experience
Required
1 year: Experience as a registered nurse in a critical care setting.
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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