Registered Nurse - Medical Surgical

Registered Nurse In The Medical/Surgical Department

PRN, Hours Vary

The Registered Nurse in the Medical/Surgical Department delivers direct and indirect nursing care to assigned patients and coordinates that nursing care in collaboration with other members of the health team.

This position is responsible for:

• Administering prescribed medications, treatments, therapies and interventions to patients following approved nursing procedures
• Initiating and implementing a patient care plan for all assigned patients that includes physician ordered treatment and nursing interventions as appropriate
• Observing patients and performing nursing assessments, recording significant patient conditions and reactions, and notifying supervisor and/or physician of patient conditions and significant incidents
• Directing the activities of licensed practical nurses and assistive personnel performing duties related to assigned patients
• This position may be assigned or expected to assume Charge Nurse responsibilities for the area.

Skills-

• Demonstrates department-appropriate fundamental nursing skills.
• Demonstrates ability to give and follow instructions accurately.
• Demonstrates effective interpersonal skills necessary to interact with various levels of health care personnel.

Knowledge-

• Clinical nursing standards of care.
• Advanced Cardiac Life Support concepts and measures.
• Pediatric Advanced Life Support concepts and measures.

Education-

• Graduation from an accredited School of Nursing.
• Current registration as a Registered Nurse with the state of Indiana Health Professions Bureau.

Experience-

• A minimum of two years of previous clinical nursing experience preferred.
• Previous cardiac monitoring experience preferred.

Authority and Accountability

• Extensive exposure to confidential information or matters.
• Frequent contact with various persons or groups within and outside of the hospital including employees, department managers, physicians, patients, volunteers, visitors and outside agency personnel.
• Must be able to work with, communicate with, and manage different types of people.

Aptitudes

• Must be able to prioritize, utilize critical thinking, and adjust to change.
• Must be able to reason and use logical problem-solving skills.
• Performs duties that require some latitude for independent judgment and initiative in handling situations out of the ordinary.

Physical and Mental Effort

• Regular requirement to walk, stand, use hands, reach with hands or arms, talk, and hear.
• Frequent requirement to stoop, crouch, kneel, bend, sit.
• Regular requirement to lift and/or move up to 25 lbs., frequently lift and/or move up to 50 lbs. and occasionally lift and/or move up to 100 lbs.
• Specific vision requirements include close vision, distance vision, peripheral vision, depth perception, and the ability to focus.
• Speaking and listening skills are essential.
• Time management and multiple task management skills are essential.
• Must be able to work under a moderate amount of stress.
• Must be able to read, write and do simple calculations; follow written and oral instructions.

Environmental and Working Conditions

• The noise level in this work environment is usually moderate.
• Work is performed in a clean, well-lighted and ventilated building.
• Could be subject to infectious diseases, cuts, abrasions, burns, and punctures.
• Work schedule may vary

Accountability

• Reports to the Department Director.
• Performs Charge Nurse duties and responsibilities or accepts direction from the designated Charge Nurse.

Quality Assurance-Key Responsibilities

1. Demonstrates knowledge of prescribed medications and treatments based on age of assigned patients and their clinical condition.
2. Administers prescribed medications to patients in a correct and timely manner following approved policies and procedures.
3. Performs and documents a head-to-toe nursing assessment on all assigned patients and reassesses patients per policy and/or as patient condition warrants.
4. Administers and assists with patient treatments as ordered and/or performed by members of the health care team.
5. Assists with physicians with procedures and performs services requiring technical and manual skills.
6. Initiates, implements, and revises a patient care plan for all assigned patients that includes physician ordered treatments and nursing interventions as appropriate.
7. Records significant patient conditions and reactions and notifies supervisor and/or physician of patient conditions and significant incidents.
8. Delegates responsibilities appropriate to the licensure, education and experience of staff receiving assignments.
9. Participates as a member of the multidisciplinary healthcare team with other hospital departments in order to provide resolution of issues.
10. Communicates appropriately and clearly with department director, Charge Nurse, co-workers, physicians and other members of the healthcare team.
11. Demonstrates team attitude; offers assistance to co-workers to provide optimal patient care; solicits assistance from co-workers when necessary.
12. Demonstrates efforts to maintain patient confidentiality as appropriate and per policy; follows HIPAA policies and procedures appropriately.
13. Transcribes written and verbal patient orders in the medical record correctly and in a timely manner.
14. Completes initial nursing physical assessment within 1 hour of assigned patient admission to the department.
15. Demonstrates ability to initiate peripheral intravenous therapy access for patients within 2 attempts; demonstrates ability to request assistance with patient IV access as needed.
16. Documents appropriately with regards to patient care on approved forms; documentation meets current nursing standards and complies with applicable policies.
17. Assists in orientation process for nursing staff members as patient care duties allow; assists in volunteer program as patient care duties allow.
18. Initiates and completes incident reports as necessary when extraordinary or unusual patient care or other situations occur.
19. Demonstrates ability to record a 6-second monitor strip on all assigned monitored patients every 8 hours and more often as patient condition warrants; demonstrates ability to identify rhythm and record it on monitor strip; reports major rhythm changes to physician.
20. Performs all other nursing duties required in the absence of assistive personnel.
21. Serves as a change agent, assisting all staff in understanding the importance, necessity, impact, and process of change.
22. Performs other duties as assigned.
23. If designated as Charge Nurse for the shift, assumes the following duties:
24. Makes patient assignments and assigns duties to coworkers during the shift.
25. Reports or delegates the report of any equipment, supply, or personnel problems to the department director.
26. Completes the routine Charge Nurse duties as assigned.
27. Communicates with Emergency Department Charge Nurse as to patient census, admissions and discharges.
28. Documents the use of additional staffing due to unforeseen patient or staffing issues, and any other significant patient needs or occurrences in the department.

Public Relations

• Maintains effective channels of communication with other employees and patients.
• Takes appropriate action in problem situations to offset adverse effects.
• Projects a professional and positive attitude regarding the hospital.

Other Responsibilities

• Attends 70% of departmental meetings held during the year.
• Attends mandatory in-service and educational offerings.
• Observes hospital dress guidelines and wears ID badge.
• Provides proper notification for absence and tardiness and is punctual for start of scheduled work time.
• Maintains equipment assigned to department and reports malfunctions appropriately.
• Participates in emergency procedures, fire drills, evacuation procedures and internal/external disaster plans and procedures in accordance with departmental responsibilities.

Continuous Quality Improvement

• Participates in the Continuous Quality Improvement Program (CQI) under the direction of Nursing Leadership to