Registered Nurse -7N Telemetry - Full Time 12 Hour Night - (Non-Exempt) (Union)

Job Summary As an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients. The Registered Nurse is accountable for the coordination of patient care and education to the patient and family in accordance with the standards, policies, and practices in a compassionate, supportive, and therapeutic environment. Departmental Specific Summary Essential Duties Follows policies and procedures; demonstrates ability to access online manuals. Transfers learned scientific knowledge into practical application in applying the Nursing Process. ASSESSMENT Appropriately completes Nursing Assessment upon patient admission, at each shift and with change of condition. Completes patient acuity by 0200/1400 daily. DIAGNOSIS Interprets assessment information and formulates Nursing Diagnoses. PLAN Develops Plans of Care with individualized interventions. Documents expected/projected patient outcomes. Reviews/Revises/Updates Plans of Care daily based on evaluation and interpretation of patient outcomes. INTERVENTION Administers medication and IV therapy appropriately at prescribed intervals. Completes patient care procedures correctly per policy at prescribed intervals. Delegates tasks based on others’ scope of practice and competency. Acts as patient advocate. Manages restraint use per policy Attempts alternative non-restraint measures first. Assures complete MD order per policy. Ensures MD assessment per policy. Assures patient monitoring per policy. Ensures Restraint Audit Form is completed each shift. DOCUMENTATION Documentation is complete and correct on all flow sheets and chart forms: Admission Assessment Pain scale assessment and reassessment before and after intervention Daily flow sheet Restraint flow sheet Diabetes flow sheet Educational flow sheet Kardex Care Plan Risk Assessment & Reassessment upon Fall MAR Equipment & Supplies Intra and Inter Facility Transfer Forms Belonging Tracking Form Ensures orders are transcribed and signed off prior to the end of the shift. Completes 12h/24h chart checks EDUCATION Provides patient/family education as needed Room/unit orientation Plan of Care Identifies knowledge deficits related to diagnoses and care Uses and provides MICROMEDEX information to patients and families. TRANSFER & DISCHARGE Collaborates with Case Manager and/or physician regarding discharge planning. Ensures all transfer paperwork is completed. Ensures belongings are sent with patient. EQUIPMENT Utilizes patient care equipment appropriately and safely according to manufacture guidelines IV pump Feeding pump PCA pump Epidural pump Sequential compression device Wound VAC Heating pad/pump COMMUNCATION Communicates effectively with all members of the healthcare team including patient and family: Shift to shift report Physician Rounds Patient/family interactions MDP Rounds Hand-Off reports Facility E-mail Student/New employee/Contract employee ORGANIZATION Manages time effectively. Able to organize and prioritize responsibilities. Takes meal breaks without incurring overtime. Completes shift on time. OBSERVES REGULATORY AGENCY REQUIREMENTS National Patient Safety Goals Patient identifiers Unapproved abbreviations Universal Protocol (Procedural Time Out) Hand-Off #J-18808-Ljbffr University of Southern California