Registered Nurse Medical Surgical

# RN - Med/SurgHarrisonville, MO 64701Education Level2 Year Degree## DescriptionCASS REGIONAL MEDICAL CENTERJob/Position DescriptionDepartment Name: Med SurgTitle: Night Shift RNEEOC Classification: Non-Exempt**Dimension and Description****Primary Purpose**: To provide quality Patient care following the standards using the nursing process in order to maintain a safe environment to provide patient and family education and to provide proper documentation for billing. Performs other duties as assigned.**Formal Policy-Setting Responsibilities:** No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.**Routine Decision Making**: Alterations in patient assessment; determines patient educational requirements; determines when to contact the provider.**Formal Supervisory Responsibility:** No formal supervisory responsibility.**Required Knowledge**: Nursing process; critical care; medications and treatments; growth and development; disease processes; interpretation of lab results.**Required Skills and Ability**: Good communication skills; assessment skills; time management skills; proficient computer skills; clinic skills; problem solving skills; and knowledge of hospital policies and procedures.**Unusual Working Conditions**: Risk of blood, body fluid contamination. Risk of injury related to poor body mechanics. Risk for injury from aggressive, combative or disoriented patients. Potential exposure to hazardous drugs and chemicals.**Education and Certification:** RN degree required. BSN preferred. Current RN licensure in the state of Missouri or compact licensure to practice in Missouri required. BLS and NIH Stroke Certification required within 90 days of being hired. ACLS and PALS preferred. NVCI or equivalent class as determined to be required by the facility.**Age Specific Competencies:** May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs.); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.## Qualifications**Essential Responsibilities and Tasks****A. Performs the assessment phase of the nursing process. (20% of time)**1. Assesses all assigned patients at start of shift and as needed.2. Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four (4) hours of arrival to the Medical Surgical unit.3. Assesses data relative to age specific needs for every patient within four (4) hours of patient’s arrival to the unit, at start of shift and as needed.4. Repeats assessment and documents on abnormal patient findings at least once and as needed during shift.5. Assesses patient/family learning needs within four hours (4) of arrival to the unit, start of shift and as needed.6. Completes appropriate pain assessment at start of shift and as needed.7. Assesses the patient's and family's learning needs every shift and as needed.**B. Performs the planning phase of the nursing process. (10% of time)**1. Completes an individualized care plan based on patient diagnosis and assessment with each admission and as needed.2. Reviews and updates care plan each shift and as needed.3. Collaborates with interdisciplinary team to facilitate the plan of care after the provider writes orders.4. Interprets significance of abnormal patient findings after assessing patient on admission and as condition changes.5. Updates white boards each shift, to include personalized patient goals and pain control.6. Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.**C. Performs the implementation phase of the nursing process. (15% of time)**1. Implements patient care through team approach each shift and as needed.2. Documents and reports significant abnormal patient findings to the charge nurse/provider/manager immediately.3. Is knowledgeable of location, care and operation of Medical Surgical equipment each shift.4. Acts rapidly, effectively and manages self and others during emergency situations.5. Administers IV's and medications as ordered within one (1) hour of time scheduled according to the five rights on every patient.6. Ensures all provider orders are correctly recorded on EMAR and in computer when acknowledging each order.7. Accurately and correctly wastes used portions of controlled substances within a timely manner.8. Performs narcotic count according to hospital policy.9. Attaches patients name band, fall risk, allergy band etc. immediately after patient’s arrival and upon bands being removed.10. Ensures fall protocol is followed on each patient.**D. Performs the evaluation phase of the nursing process. (5% of time)**1. Evaluates each assigned patients’ response to care each shift and as needed.**E. Provides patient and family education. (15% of time)**1. Provides patient and/or family's education based on assessments and re-assessments each shift and as needed.2. Uses terminology appropriate to patient/family's knowledge base and age specific needs each shift.3. Re-assesses patient and family's learning needs and abilities each shift and as needed.4. Documents education provided including subject taught, method of teaching, who was taught, comprehension of information each shift.5. Provides and documents patient and family follow-up instructions at discharge.**F. Demonstrates accountability to the nursing process through documentation. (15% of time).**1. Documents assessments at least every shift and as needed.2. Documents according to the plan of care at least once per shift and as needed.3. Documents clearly the implementation of specific intervention, including details of methods used, with the time of implementation and evaluation of patient response.4. Utilizes only approved abbreviations in patient documentation each shift.5. Documentation follows hospital and departmental policies for frequency and content.**G. Maintains a safe and comfortable unit. (10% of time)**1. Checks code blue carts each shift and upon using the cart ensuring it has an intact tag attached.2. Ensures alarms on any assigned areas are audible to alert staff, each shift.3. Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem.4. Completes a requisition for repair and sends electronic work request before the end of the shift, pass on any issues to the next shift for follow up and provides a copy to the manager before the end of shift.5. Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification.6. Utilizes correct method of bar scanning patient identification bracelets for medication administration via EMAR 97% of the time.7. Utilizes correct method of bar scanning patient medications for medication administration via EMAR 95% of the time.8. Provides thorough handoff communication to the next shift.**H. Develops and promotes hospital/ unit initiatives. (10% of time)**1. Plans, develops and evaluates self-objectives, annually.2. Participates in planning ways to solve problems and make improvements in the Medical Surgical unit, quarterly, and as needed.3. Participates in implementing planned changes and activities to improve the Medical Surgical unit quarterly, and as needed.4. Evaluates planned changes and activities to improve the Medical Surgical unit, quarterly, and as needed.5. Attends unit staff meetings (3) 80% or greater, (2) 50-80%, (1) less than 50% annually.6. Bedside report to be performed each shift with the off-going nurse.7. Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts #J-18808-Ljbffr