Registered Nurse - Med Surgery 2nd Floor

Job Title

This position provides safe and effective nursing care and treatment to patients in the Telemetry Medical/Surgical Unit.

Job Description

General Statement of Job:

This position provides safe and effective nursing care and treatment to patients in the Telemetry Medical/Surgical Unit. Employees are part of a managed care team and works collaboratively with ancillary personnel in the provision of proper medical services and treatment. This position provides nursing care and services to patients seeking medical attention and prevents further deterioration of patient's health in accordance with established regulations, policies, nursing standards and medical instructions.

Essential Functions:

• Provides nursing care to meet the needs of the patient population served as qualified; i.e., adolescent, adult, and geriatric patients.
• Delivers patient care within defined hospital and critical care standards for assessment, care planning, interventions, and reassessment, and delegates care appropriately to other team members and support staff.
• Evaluates patient's care status frequently. Reports variances in care and/or medication administration for quality improvement.
• Performs duties with a clear understanding of the JCAHO Safety Goals and delivers care with patient safety as a goal. Follows hospital policies guiding compliance with National Patient Safety Goals.
• Performs duties in accordance with pathogen transmission practices; i.e., follows hand washing procedures and utilizes protective equipment effectively.
• Performs nursing care within the guidelines of the Relationship and Results Oriented Healthcare Model utilizing the recommended bundles of best practice.
• Assess and charts patient's vital signs and notifies physician of abnormal ranges as well as any significant changes.
• Delegates and supervises care appropriately to LPNs, CNAs and Monitor Techs with follow up and feedback procedures to ensure quality of care. Initiates appropriate actions as needed.
• Develops plan of care and patient focused goals with the patient and family as appropriate, ensuring patient understanding and involvement in their care.
• Delivers patient care in accordance with established infection control standards for patient placement, IV therapy, medication administration and the performance of all patient procedures; demonstrating adherence to hand washing policy.
• Follows policies for administration of high risk drugs, patient identification, documentation and taking telephone orders with read back and communication of critical values/diagnostic results.
• Communicates effectively with other patient care providers and team members for efficiencies and safety of care through appropriate ordering procedures, preparing patients for surgery and other procedures, communicating fall potential and other risk identifiers.
• Evaluates clinical/diagnostic reports and reports variances to the physician and documents same.
• Follows guidelines for performance improvement and demonstrates understanding of participation in the Core Measures for Lakeside Medical Center, and for documentation review and restraint review process.
• Utilizes patient care equipment and patient restraints appropriately and safely, following hospital policy and procedure. Reports any identified equipment breakdown or malfunction by hospital policy. Maintains cleanliness of equipment after use.
• Works cooperatively with ancillary departments in ensuring the patient's care is safe, following protocols as applicable.
• Documents and maintains all patient care records and related required documentation. Maintains records and communications with respect to patient's privacy.
• Participates in department's QI activities on a daily basis.
• Participates in the orientation and mentoring of new staff members recognizing importance of bringing new staff into a friendly and supportive work environment.
• Utilizes and ensures staff uses supplies efficiently, following infection control procedures, avoiding waste and follows patient charging procedures.
• Follows ACLS protocol for patients as indicated
• Orders initial lab tests and x-rays by established protocols or per physician orders. Ensures patients are appropriately prepared for tests.
• Serves as an example for team members in cost saving practices.
• Assists manager and other staff members to maintain competence and skills for procedures assigned and assists in validation of skills and competence of new staff members prior to delegation of patient care.
• Participates in the hospital Utilization Management Program by assisting with discharge planning, reporting to case managers, and keeping patient, family, physician, and other personnel informed.
• Participates with team members and manager to identify opportunities for improvement in patient care processes.
• Maintains accurate and current record of patient's care and response to care following the guidelines for appropriate electronic documentation.
• Documents the administration of medicines including dosage, medicine route, medicine site, and patient's response as required in the documentation system.
• Performs time out procedures on all invasive procedures at the bedside as needed.
• Utilizes good communication skills, critical thinking and checkpoints for teamwork. Provides patient information timely and effectively during shift report and with patient's hand-offs.
• Provides teaching and training to staff members as needed.
• Performs monitoring and recovery care to PACU patients per Operating Room Department protocol when necessary.
• Maintains competencies and participates in required training and in-services for unit.
• Demonstrates understanding and commitment to hospital's mission, philosophy, standards, policies and procedures. Recognizes all staff, physicians and visitors, as well as, patients as customers and provides courteous and respectful service.
• Documents and reports any complaints from patients, physicians and visitors to supervisor as guided by hospital policies and procedures.
• Explains all procedures and care plans to patients, and as appropriate to family. Ensures patient and/or family are educated for appropriate health maintenance.
• Participates in the cleanliness of the work environment.
• Demonstrates an understanding of responsibility of emergency plans and is available for patient care as needed or scheduled when hospital emergency preparedness plans are activated.
• Ensures completion of continuing education requirements in subjects pertinent to critical care nursing or position related information.
• Serves as a leader for change, positively promoting new systems and changes implemented which improves the hospital and the service provided to its patients.
• Participates in hospital community activities and helps portray a positive image of the hospital in the community.
• Provides nursing care to patients with either hard or soft splinting devices; assesses circulation, mobility, and neurological status of patients. Applies splints and bandages per physician's orders.
• Observes cardiac rhythm and initiates or ACLS protocol as indicated.
• Completes assessments and documentation of new admissions and discharges including the interim plan of care. Completes discharge instructions with information regarding food and drug interaction.
• Performs specialized patient assessments as needed.
• Defibrillates patients safely in accordance with regulations, policy and accepted procedure.
• Performs monitor/defibrillator checks each shift.
• Conducts inventory checks, including all medications administered at the time of administration. Reconciles the count with oncoming nurse at the end of the shift.
• Ensures availability of age appropriate supplies and equipment.
• Checks code cart and emergency box each shift.
• Performs bedside blood glucose monitoring per physician order and/or hospital policy.
• Assesses lung sound in patients.
• Starts IVs and delivers IV medications to patients as needed. Runs and calculates IV drips.
• Performs NG tube insertion and performs gastric suction per hospital policy and procedures.
• Evaluates pulmonary status by auscultation.
• Performs port flushes, injections and blood transfusions as needed.
• Helps with code assistance.
• Performs respiratory care assessments and specimen collection using the appropriate techniques.
• Obtains and transcribes physician's orders in a timely and accurate manner ensuring all tests are ordered appropriately and efficiently.
• Completes pre-operation check-list.
• Obtains and witnesses consents for surgery, anesthesia and special procedures as per hospital policy.
• Transports patients to appropriate care locations.
• Provides assistance to patients in need of help in bathing, feeding, turning, positioning, oral hygiene and personal hygiene.
• Dresses patient wounds as needed.
• Assists with emotional needs of patients.
• Completes control tests on Accu Check machine daily.
• Conducts walking rounds at the start and end of each shift, visually checking each patient and providing a written end-of-shift report.
• Determines at-risk patients and follows through