Registered Nurse - MedSurg

DescriptionPOSITION OVERVIEW:This position must assume responsibility of meeting patient needs effectively and efficiently by applying complete nursing care to assigned patients. Care must be provided through all life stages of ages in medical, surgical, and telemetry areas of nursing. This position also provides direction and oversight to other staff members regarding patient care.ESSENTIAL FUNCTIONS OF JOB: (other duties may be assigned)PATIENT CARE:Communicate pertinent information both orally and written to appropriate staff daily.Report change in patient condition, fall, categories, transfers to other departments, staffing problems, etc. to health team daily.Assist with decision-making and staffing.Maintain patient confidentiality.Use Care Manager by order entry process as necessary.Complete incident reports as necessary.MEDICATION ADMINISTRATION:Administer medication and treatment daily as ordered by physician with proper documentation.Follow the five patient rights: right medication, right patient, right route, right dose, and right time.Complete documentation immediately following medication administration in patient’s chart.Sign and date all documentation.IV MANAGEMENT:Ensure peripheral IV site and tubing is changed every 72 hours.Ensure Heparin/saline locks are changed every 96 hours.Document site and tubing changes.Observe site for any signs of infiltration or infection and document.Sign and date all documentation.Maintain 100% compliance with all Hospital policies and procedures.PATIENT ASSESSMENT:Complete initial and on-going patient assessments to define individual patient needs.Review assessment data and identify patient problems.Develop patient plan of care and update daily.Maintain concise documentation of all patient care that is provided every shift or as needed.Complete nursing care plans daily.Evaluate patient response to therapeutic interventions and document in nursing notes.Ensure patient satisfaction through the distribution of questionnaires.CLINICAL OVERSIGHT:Provide clinical oversight of the nursing care process.Serve as a resource for staff including the licensed practical nurses, nurse aides, and other ancillary staff.Delegate nursing care duties as appropriate for the scope of practice of assignee.Periodically serve as the charge nurse responsible for the overall functioning of the nursing unit.Observe staff with patients regularly to ensure patient satisfaction.Direct staff as needed to ensure 100% compliance with all Hospital policies and procedures.Evaluate patient care provided by other staff members through coaching.Reinforce Hospital policies and procedures to ensure staff continually deliver quality patient care.Assist in orientation of new and transferred staff for three months as needed.Provides education to patients, care partners, and other staff members as needed within scope of practice.Evaluate patient, care partner, and other staff member’s understanding of techniques by successful demonstration.Document procedure upon completion of demonstration.Offer pre/post testing with new techniques.Assist in identifying the educational needs of the Unit.DISCHARGE PLANNING:Coordinate patient discharge planning.Begin planning patient discharge upon admission.Complete discharge summary plan as outlined on physician discharge orders.Review discharge plans with patient and/or care partner.Ensure patient and/or care partner understands discharge instructions.Document discharge planning and patient and/or care partner understanding in patient chart legibly.QUALITY IMPROVEMENT:Assist with departmental evaluation and improvement of nursing practices.Participate in quality improvement, fire safety, infection control, etc.Support change to improve patient care through suggestions offered by patient response forms.Participate in departmental committees or projects.Accept and respond to constructive criticism by improving performance.Up to date with all Hospital policies and procedures.Ensure staff follows appropriate Hospital policies and procedures.Complete documentation following all codes and ensure documentation is accurate and legible.REGULATORY COMPLIANCE:Must remain up to date, knowledgeable and compliant on DOH and other applicable regulatory related to your department and area.Patient safety regulations and goals will be followed (i.e., using 2 patient identifiers, reporting critical values, medication reconciliation, etc.)Perform appropriate documentation regarding narcotics administration (i.e. second signature for count and waste, etc.)Follow the regulations regarding restraints, sentinel event notification, and maintain HIPPA compliance etc.Attend appropriate educational programs related to regulatory standards, updates and new initiatives.EQUIPMENT:Coordinate staff use of equipment, i.e., dynamas, kendel boots, IV pumps, BGM, etc.Demonstrate proper use of equipment.Supervise staff in the use of equipment.Document proper use according to patient response.OTHER DUTIES OF JOB (not all inclusive):Assist with health fairs.Obtain medical records as needed.Respond to hospital codes as trained.Participate in quality assurance initiatives and provide continuous feedback to management to improve quality of the work environment.Adhere to and promote a “customer service” model of interaction with other departments.Keep abreast of nursing principles and apply principles of laws as needed.Perform other related duties as assigned or required.Follow standard precaution guidelines.SUPERVISION RECEIVED:Supervision is received by the Acute Care Services DirectorSUPERVISION ADMINISTERED:This position typically does not require the supervision of staff.MENTAL/PHYSICAL REQUIREMENTS OF JOB:This position typically requires:Managing multiple projects/tasks, close attention to detail, adapt to a constantly changing work environment, meet frequent deadlines, establish own goals, work closely with others, high pressure for results, predictable work schedule and maintain high level of record-keeping/routine paperwork.The ability to constantly stand, walk, use both legs and hands, communicate orally and hear conversation is typically required. The ability to use specific visual requirements and rapid mental/muscular coordination, is also typically required. Depth perception is frequently required. The ability to occasionally sit, stoop, lift a maximum of 65 lbs. and use color vision is typically required.WORK ENVIRONMENT:This position typically requires:Constant contact with patients. Frequent exposure to blood, bodily fluids and gases (i.e., oxygen, nitrous) and pharmaceutical drugs. Occasional contact with chemicals including housekeeping and laboratory chemicals. Occasional work alone.PERSONAL PROTECTIVE EQUIPMENT:This position typically requires:Frequent use of gloves, and occasional use of eye protection, respirator and body protection.QualificationsQUALIFICATIONS:Education/Training/License/Certification:Graduate from an approved school of nursing and minimum diploma of nursing required. Current, validPennsylvania Registered Nurse License required. CPR / BLS, preferred at time of hire, required within 6months of hire or enrolled in next available course. ACLS certification and Dysrythmia preferred.Experience:One year related experience is preferred, although not required.KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:Knowledge of pharmacology principles.Knowledge and ability to follow state nursing guidelines and health standards.Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.Ability to write routine reports and correspondence.Requires flexibility, leadership skills, and good judgment.Ability to properly set up and maintain equipment, i.e. kendel boots, CMP, IV pumps, peg feeding tube, etc.Excellent documentation and observation skills.Excellent communication skills, both verbally and in writing.Effective interpersonal skills and ability to establish and maintain effective working relationships with the staff, management, and other agencies.Ability to add, subtract, multiply, and divide in all units of measure and understand drug calculations.Ability to critically think to carry out instructions furnished in written, oral, or diagram form.Ability to deal with problems involving several concrete variables in standardized situations. #J-18808-Ljbffr Chan-Soon--shiong-Medical-Center-At-Windber