RN - Med-Surg./Inpatient - PT NIGHTS - AVALA Hospital - RH498

Med/Surg Nurse

Provides direct and indirect patient care on the Med/Surg unit. Communicates with Physicians/Nurse Manager/co-workers, as appropriate about changes in patient's clinical condition, including results of diagnostic studies and symptomology. Able to respond quickly and accurately to changes in condition or response to treatment. Able to perform general nursing duties in all departments with adequate supervision. Participates in performance improvement and CQI activities. May also function in the role of Charge Nurse under the supervision of the Director of Inpatient Services. Communicates on behalf of the patient (patient advocate); care provided reflects the mission, ethics and goals of the facility, as well as the focus statement the department.

Essential Duties and Responsibilities

• Monitors and supervises patient care, including diet and physical activities. Communicates appropriately and clearly to departmental charge nurse or director, co-workers, and physicians.
• Prepare patients for and assists with examinations or treatments or procedures to assist physicians.
• Performs a head-to-toe assessment on all patients and reassessments as per policy. Able to interpret data about the patient's status in order to identify the care needed.
• Adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and families regarding pain management.
• Perform waived testing (point-of-care testing), draw blood for lab testing as needed, interpret results and take appropriate actions per Clinical Laboratory's and the patient care unit's policies and procedures.
• Makes decisions reflecting knowledge of facts, knowledge of diseases/surgical conditions, care required and good judgment. Identifies physical symptoms and changes, reports changes to surgeon/ physician, and initiates appropriate actions.
• Knowledge of medications and IV fluids and their correct administration, based on age of the patient and the patient's clinical condition. Administers medications safely using the five medication rights and reduces the potential for medical errors.
• Knowledge in maintenance and care of central / PICC line.
• Knowledge of cardiac monitoring and can identify dysrhythmias, notifies physician of changes, treat appropriately based of facility protocol.
• Able to perform the techniques of cardiopulmonary resuscitation accurately and effectively.
• Performs patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
• Ability to formulate an individualized plan of care, modify patient treatment plans as indicated by patients' responses and conditions and evaluate overall plan daily for effectiveness. Involves patient/family in plan of care.
• Keeps abreast of changing techniques in nursing and maintains a high level of expertise in patient care.
• Ability to be flexible, organized, and function under stressful situations.
• Assists in emergency nursing procedures necessary for prompt control of changes in patient's physical condition.
• Treats patients and their families with respect and dignity, maintains an environment that provides the patient and family feelings of safety and security, practices good guest relations.
• Maintains a good working relationship and effective communication both within the department and with other departments for the benefit of the patient. Consults other departments as appropriate to provide for an interdisciplinary approach of meeting patient needs.
• Ensures completion of documentation, including but not limited to, H/P, consents, handoff communications tool, medication administration, pre-anesthetic questionnaire, medication reconciliation form, and allergies.
• Practices economical use of equipment and supplies, informs proper authority of discrepancies.
• Provides education to staff on performance improvement. Ability to provide in-service training for unit staff members, participates in guidance and educational program.
• Demonstrates ability to perform treatments and provide services to level of licensure.

Charge Nurse Responsibilities

• Updates Table for Inpatient Log Census.
• Completes Patient Classification Form to assure efficient staffing levels and patient assignments.
• Verifies that temperature logs completed.
• Oversee all staff on the Med Surg Unit.
• Follows protocol for admitting a patient and activation of call team.
• Initiates emergency response protocol.
• Effectively communicates pertinent issues with Med/Surg Director.
• Supervises dietary after hours.
• Follows up on consults and outstanding orders.
• Follows protocol for patient transfers.
• In charge of room assignments, assists with admits and discharges and ensures minimal delays in patient treatment.

Core Competencies

Action Orientation - Targets and achieves results, overcomes obstacles, accepts responsibility, establishes standards and responsibilities, creates a results-oriented environment, and follows through on actions.

Communications - Communicates well both verbally and in writing. Effectively conveys and shares information and ideas with others. Listens carefully and understands various viewpoints. Presents ideas clearly and concisely and understands relevant detail in presented information.

Creativity/Innovation - Generates novel ideas and develops or improves existing and new systems that challenge the status quo, takes risks, and encourages innovation.

Critical Judgment - Possesses the ability to define issues and focus on achieving workable solutions. Consistently does the right thing by performing with reliability.

Customer Orientation - Listens to customers, builds customer confidence, increases customer satisfaction, ensures commitments are met, sets appropriate customer expectations, and responds to customer needs.

Interpersonal Skills - Effectively and productively engages with others and establishes trust, credibility, and confidence with others.

Leadership - Motivates, empowers, inspires, collaborates with, and encourages others. Builds consensus when appropriate. Focuses team members on common goals.

Teamwork - Knows when and how to attract, develop, reward, and utilize teams to optimize results. Acts to build trust, inspire enthusiasm, encourage others, and help resolve conflicts and develop consensus in creating high-performance teams.

Professional Requirements

• Meets dress code standards; adheres to dress code policy.
• Completes annual education requirements.
• Maintains regulatory requirements.
• Maintains patient confidentiality at all times.
• Reports to work on time and as scheduled, completes work within designated time.
• Wears identification while on duty, uses computerized punch time system correctly.
• Completes in-services and returns in a timely fashion.
• Attends annual review and department inservices, as scheduled.
• Attends monthly staff meetings.
• Represents the organization in a positive and professional manner.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.
• Promotes professional growth of subordinates by sharing knowledge and/or directing them to sources if information appropriate to given situation. Utilizes journals, books, etc. to learn and/or improve new techniques and equipment.
• Assists other staff members in performing any duty that enhances the delivery of patient care.
• Critical Care experience preferred.

Advanced Orthopedic and Spine Certification Requirements

(CR.1c) As part of the Advanced Orthopedic and Spine Certification, at a minimum, the Program direct-care staff, must have four (4) hours of education specific to the Program scope, initially, and at least annually thereafter.

(CR.1e) As part of the Advanced Orthopedic and Spine Certification, staff possess adaptability to processes as related to up-to-date best practices, collaboration between departments, compliance with protocols/processes, communication, cooperation and exceptional customer service.

Within 90 days of hire or, if currently employed, within 90 days of signing the job description, must adhere to:

• Orientation of Advanced Orthopedic and Spine Certification.
• In compliance with the Program education requirements.
• Completed department specific competencies.

Regulatory Requirements

• Graduate of accredited school of nursing
• Current state Registered Nurse Licensure, within state of practice
• Current BLS and ACLS certification
• PALS certification recommended

Skills