Responsible for the delivery of patient care through the nursing process of assessment, diagnosing, planning, implementation and evaluation. Responsible for directing and coordinating all nursing care based on established clinical nursing care for patients the medical surgical services based on established clinical nursing practice standards. Collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes. Serves as the Resource nurse role when oriented and as directed. Supports the organization vision and mission. Utilizes knowledge of patient's age, developmental status, spiritual and cultural diversity into the provision of patient care. Contributes to the provision of quality nursing care through performance improvement techniques that demonstrate positive outcomes in patient care.
ResponsibilitiesA. KNOWLEDGE OF WORK
1. Identifies patient problems on the plan of care based on the admission assessment within ___ hours.
2. Reviews, revises, and documents plan of care at least every 24 hours for continuity of care. Sets new goals as current problems are resolved.
3. Documents on the patient care plan based on the nursing diagnosis/patient problems.
4. Anticipates potential problems, identifies, and makes the appropriate referral as identified of the educational needs of patients and their significant other.
5. Assures the unit is adequately equipped with supplies, equipment and medications at the beginning of the shift and as needed.
B. DUTIES AND RESPONSIBILITIES
1. Sets priorities according to patient care needs
2. Completes initial assessments & re-assessments of patient care needs, based on hart review and/or direct observation.
3. Documents care on patients according to diagnosis and established standards of practice.
4. Reassess as patient condition warrants and prepares transfer and discharge as appropriate.
5. Recognizes signs and symptoms of potential emergencies to include behavioral and physical changes. Initiates appropriate actions and timely interventions.
6. Recognizes indicators and proper reporting of abuse.
7. Practices National Patient Safety Goals (NPSG), see JCAHO Reference.
8. Utilizes appropriate methods to access risk and prevention patient falls & skin break down on intact skin.
9. Assessment/alternative for management of restraints.
10. Performs and documents legibly/timely and accurate nursing interventions to meet patient care needs.
11. Coordinates total nursing care to the patient using the plan of care to provide continuity of care.
12. Assumes the responsibility for teaching and documenting patient education appropriate and consistently.
13. Assures complete follow-up instructions are given with demonstration or verbalized understanding by the patient prior to discharge and documented in the medical record.
Graduate of an accredited school of professional nursing certificate. Licensure in the state of California as a Registered Nurse (RN). Proficient in oral and written communication skills. Ability to practice leadership, interpersonal skills, communication skills, teamwork, quality improvement and professionalism.
BCLS, ACLS, (AHA), PALS, NIHS Stroke Cert, Basic Dysrhythmia Cert, EMTALA Training Cert, AB508 Workplace Violence Prevention
Proficiency in both written and oral English
1 Year acute care experience.
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