RN- MedSurg Nights - Warren, United States - Bradley County Medical Center

Description

Job Description

Position Summary: Responsible for identifying patient needs and priorities for care through assessment, planning for and delegating care based on patient needs, executing therapeutic physician- or nurse-initiated interventions, and evaluating the patient's response to care and progress towards outcomes. For this position, RN must also be able to function in the role of Charge Nurse as needed. This is a SAFETY SENSITIVE POSITION.

Position Accountabilities:

1) Job Specific Criteria:

-Receive report before giving care.

-Assess patient conditions/needs and staff skills.

-Assign and delegate duties appropriately.

-Assess need for supervision of LPN's, Ward Clerks, CNA's and new staff

-Admit patients and perform initial assessment.

-Make rounds on patients and thoroughly and accurately assess the physical and psychological status of patients, including the reactions to illness and treatment regimens before the beginning care and as frequently as indicated thereafter.

-Check medical record for physician orders and results of diagnostic studies and communications from ancillary departments.

-Prepare appropriately for medications administration:

-Research medications;

-Be aware of patient's vital signs, telemetry pattern and especially when giving blood pressure meds and/or cardiac drugs.

-Be aware of lab results, i.e. K+levels, BUN, CR, Theophlline levels, dioxin levels, blood sugar as related to ordered medication.

-Assess patient's need for pain medication on rounds and alert medication nurse.

-Assess IV sites and need for change, note rate and tubing dates.

-Assess need for IV push and other medications requiring RN to administer.

-Anticipate and assess patients for complications of immobility.

-Assess patient's level of understanding before beginning teaching.

-Assess need for and request supervision when needed.

2) Planning and Organization:

-Pre-plan nursing care to perform in an organized manner in caring for groups of patients.

-Obtain materials and supplies needed for patient care.

-Use resource materials as necessary to include nursing policy and procedure books and manuals from other departments.

-Utilize time effectively and productively.

-Identify nursing diagnosis; initiate and update individualized nursing care plans.

-Involve patient/family in the planning of care and in establishing goals.

-Organize work according to priorities.

-Maintain patient kardex as indicated.

-Plan for oncoming shift needs by utilizing the patient classification system.

3) Implementation of Care:

-Deliver basic patient care according to standards of nursing care established by Bradley County Medical Center nursing department.

-Check patient identity before initiating nursing activities.

-Perform technical skills according to policy and procedure, including the following:

-Basic procedures;

-TPR, blood pressure;

-Specimen collection;

-Catheterization;

-NG tube insertion;

-Tube feedings;

-Irrigations (bowel, bladder, NG, colostomy)

-Sterile dressings/wound care;

-Prep for diagnostic studies;

-Restraints;

-Traction/cast care;

-IV procedures and care;

-Insertion/pump use;

-Subclavian care;

-Blood administration;

-Medi-port.

-Cardiac Procedures:

-CPR;

-Electrode placement;

-Rhythm strip interpretation (cardiac/fetal)

-Defibrillation;

-Respiratory Procedures:

-Oxygen administration;

-Suctioning (NASO, endotracheal)

-Tracheotomy care;

-Ventilator care.

-Obstetrical Procedures:

-Contractions;

-Exams;

-Fetal Monitor;

-Other:

-Chest tube care;

-Hemovac care.

4) Administering of Medications:

-Have knowledge of patients, (know diagnosis, special needs, etc.)

-Administer meds by all routes according to approved procedure.

-Teach patients appropriately regarding meds.

-Keep medical carts locked when not in use.

-Keep carts and drug room clean and organized.

-Check unusual dosages on meds (insulin, Heparin, etc.) with another nurse before administering.

-Sign out for narcotics correctly.

-Dispose of drugs/narcotics as required and in accordance with procedures.

-Interpret written and verbal directions correctly and assure their implementations.

-Question situations in which underlying principles or standard of care are violated.

-Promote the psychological and physical well being of patient/family experiencing life threatening diseases that may cause radical changes in lifestyles.

5) Safety Measures:

-Use aseptic technique appropriately.

-Act to prevent accidents and injury.

-Use correct body mechanics.

-Keep necessary items within patient reach.

-Use side rails as indicated according to policy/procedure.

-Do concurrent cleaning in patient areas and staff areas.

-Monitor crash cart.

6) Evaluate results of specific nursing intervention and document in the medical record.

7) Evaluate own learning needs and seek opportunities for new learning experiences.

8) Achieve therapeutic communication by expressing self directly, clearly, and concisely when relating to others verbally and non-verbally (including listening, appearance/body, language, touch).

9) Establish effective interpersonal relationships and supportive communication with patients, staff and visitors.

10) Prepare patients appropriately for surgical and other diagnostic/therapeutic procedures.

11) Teach patient and/or family appropriately according to identified needs and level of understanding.

12) Provide emotional support for patients and families through the use of therapeutic communication.

13) Maintain confidentiality of all information.

14) Instruct patients and visitors regarding hospital rules and regulations and reinforce as necessary.

15) Use courteous telephone manners; identify yourself with name, title, and department.

16) Have an open mind to constructive criticism and suggestions.

17) Do not correct others inappropriately in public places.

18) Communicate appropriately with physicians, staff members and departments to provide continuity of care.

19) Report all pertinent information regarding patients appropriately:

-Changes in Condition;

-Effects of treatments or meds;

-Patient/family concerns;

-Physician concerns;

-Equipment malfunctions/safety hazards.

20) Maintain accurate and concise records of observations, treatment and care of patients.

21) Be knowledgeable of information in patient charts:

-Assessment;

-Flow sheets;

-Nurse's notes;

-Kardex;

-Others;

-Discharge Summary;

-Transfer Sheets;

-Medication Record;

22) Properly chart medications to include:

-First initial, last name and title to correspond with initials;

-Note proper dose, date, time;

-Indicate injection sites appropriately;

-Correct errors appropriately;

-Document effects of PRN

23) Participate as a member of the team/group and contribute to team/group conferences.

24) Maintain appropriate intra-departmental communication:

-Read and adhere to directives (memos)

-Clock time card correctly and be punctual.

-Complete incident reports correctly and appropriately.

25) Professional Development:

-Attend mandatory in-service meetings;

-Attend staff meetings;

-Infection Control;

-Body Mechanics;

-Fire Safety;

-CPR Certification;

26) Competency--Demonstrate proficiency in the following areas:

-Staff/Charge RN;

-MCU;

-Operating Room;

-Emergency Room;

-Staffing Coordinator;

-Nursery;

-OB/Labor & Delivery;

-Supervisor.

27) Communication:

-Listen and initiate feedback to ensure effective communication.

-Use constructive feedback to improve performance.

-Resolve problems with interpersonal relationships, referring them when necessary.

-Participate in the development of solutions to communicate problems.

-Communicate complete and accurate information.

-Practice discretion in information shared with patients and peers.

-Apply basic communication skills (verbal and non-verbal) in all interactions with patients, peers, other departments and the public.

-Avoid excessive noise and protect patient privacy.

-Acknowledge validity of communication from others.

-Address people by their name.

-Respond promptly to requests from supervisor, peers and other employees.

-Participate actively in the nursing QI plan by identifying critical indicators and other problems.

28) Instruct patient according to disease process.

Physical Requirements:

Constant and/or frequent lifting of patients;

Frequent bending and/or stooping;

Standing for long duration of time.

Job Qualifications:

Education: Graduate of an accredited school of nursing, licensed in the state of Arkansas.