Job Description
Description Job Summary: Provides planning and delivery of direct and indirect patient care through the nursing process of Assessment, Planning, Intervention, and Evaluation. Develops nursing care plans in coordination with patients, family and interdisciplinary staff as necessary. Communicates changes in patient's clinical condition with Physicians, Nursing Supervisor/Manager, and co-workers as appropriate. Participates in discharge planning process.
Essential Functions: - Maintains the standard of nursing care and implements policies and procedures of the hospital and nursing department
- Directs, supervises, provides and evaluates nursing care provided to patients
- Assigns or delegates tasks based on the needs and condition of the patient, potential for harm, complexity of the task, and within scope of practice of the staff to whom the task is delegated
- Assigns nursing care team members in accordance to patient needs, team member's capabilities and qualifications
- Documents patient admission assessment and reassessments, patient care plans and other pertinent information, completely in the patient's medical record according to nursing standards and policies
- Performs assessment on all patients on admission and reassessments as per policy. Makes referrals to other disciplines based on assessment
- Develops nursing care plan of assigned patient on admission, updates plan of care as needed and ensures plan of care is coordinated with patient, family, and other members of the team
- Assesses and reassesses pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management
- Revises the plan of care as indicated by the patient's response to treatment and evaluates overall plan daily for effectiveness
- Performs patient care responsibilities considering needs specific to the standard of care for patient's age
- Receives physician's orders, ensures transcription is accurate and documents completion. Administers medication utilizing the five rights of medication administration reducing the potential for medication errors
- Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning; family is included in teaching as appropriate
- Assists physicians with examinations, treatments and special procedures and performs services requiring technical and manual skills within scope of practice. Performs treatments and provides services to level of licensure
- Treats patients and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and their families. Functions as liaison between administration, patients, physicians, and other healthcare providers
- Interacts professionally with patient/family and involves patient/family in the formation of the plan of care
- Interprets data about the patient's status to identify each patient's age specific needs and provide care needed by the patient group
- Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors
- Initiates or assists with emergency measures for sudden adverse developments in patients' condition
- Answers telephone, paging system, patients' call lights, anticipates patients' needs, and makes rounds of assigned patients and responds as appropriate
- Consults other departments as appropriate to provide for an interdisciplinary approach to the patient's needs
- Provides end of shift report to oncoming nurse, narcotics are counted, documentation is complete, and physician orders signed off
- Communicates appropriately and clearly to management, co-workers, and physicians
- Identifies and addresses psychosocial needs of patients and family; communicates with Social Service/Discharge Planner regarding both in hospital and post discharge needs
- Participates in orientation, instruction/training of new personnel
- Manages and operates equipment safely and correctly
Qualifications Education: - Graduation from an accredited Bachelor of Science in Nursing, Associate Degree in Nursing or Nursing Diploma program
Licenses/Certification: - Current state licensure as Registered Nurse
- BLS, NRP and Fetal monitoring certifications required
- De-escalation training required
Experience: - Minimum six months' Obstetrical experience in an acute care setting preferred
Job Tags
Shift work,