Med Surg RN - Day Shift

Job Summary :

The Registered Nurse is directly accountable for the care given to patients. Provides direct communication with the Nurse Manager, Team Leader, Providers and Teammates about the changes in the patient's clinical condition including results of the diagnostic studies and symptomatology. The RN is able to respond quickly and accurately to changes in the condition and / or response to treatment.

Responsibilities :

• Monitors hemodynamic / cardiac status of patient and correctly interprets the results
• Initiates discharge and family education planning with proper documentation in the EMR
• Adjusts frequency of assessment as appropriate for patient's condition and reassess nursing action for effectiveness in achieving desired outcome. Accurately documents patients' physical assessments and report abnormalities to the practitioner.
• Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
• Reviews and implements new orders and keeps physician informed of changes in patients' clinical status. Consistently follows policy regarding telephone / verbal orders and the using of "read back".
• Explain all procedures and care to patients.
• Accurately records and / or processes orders in timely manner.
• Administer medications using Rights of Medication Administration. Initiates, titrates and safely monitors all IV medications and blood components. Consistently uses two patient identifiers when drawing labs, medicating, or performing any procedure on a patient and administering blood components
• Follow medication reconciliation policy
• Knowledge of National Patient Safety Goals. Comply with federal, state, and local laws that govern business practices. Comply with all Department of Health Services requirements for CMS, and JCAHO standards that apply to the position.
• Give a thorough, detailed, efficient change of shift report to ensure consistency in the plan of care, utilizing the SBAR method.
• Independently recognize and perform duties which need to be done without being directly assigned. Establish priorities and organizes work and time to meet them.
• Assists physicians with special tests and procedures using time out for bedside procedures.
• Consistently ensures that all clinical alarms (i.e. Cardiac monitor alarms) are set with the appropriate parameters for the patient and are audible at all times.
• Adequately assess and reassess pain, after giving pain medication and upon discharge. Accurately documents information on the patient record
• Does not use unacceptable abbreviations in documentation. Documents evidence of nursing care on the patient's medical record in a legible, concise, timely and complete manner.
• Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit / facility (i.e. suction and oxygen immediately available at all bedside.)
• Ensures Crash cart, including defibrillator function, has been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on the cart checklist.
• Comply with information contained in the Infection Manual and demonstrate appropriate use of personal protective equipment and hand washing techniques. Follow standard and transmission-based precautions.
• Participate in Continuous Quality Improvement Program by assisting in finding new and better ways of performing duties and responsibilities. and verbalizing at least one major goal of the performance improvement program within the hospital setting, ability to describe a quality improvement problem solving process (e.g., PDCA) and how its use assists in reaching improving patient outcomes and / or organizational quality improvement goals and verbalize at least one departmental or hospital wide improvement initiative that has occurred within the last 12 months.
• Demonstrates empathy and respect for patients by explaining all procedures providing privacy and allowing patients to express emotional needs. Understands, respects, and displays sensitivity to culture, age and persons with disabilities.
• Displays honesty and respect for others, and respect for the organization as evidenced by :
• Treating internal and external customers as the most important part of the job
• Being sensitive to customers' emotions, thoughts and feelings
• Refraining from negative comments of any kind where the public or other customers can hear
• Taking appropriate actions to resolve concerns
• Interacts with coworkers, other hospital staff, physicians, and the public in a courteous, professional and efficient manner
• Continually strives for self-improvement in areas of responsibility by attending continuing education classes
• Participate in customer services activities.
• Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses.
• Is familiar with emergency codes and emergency preparedness procedures and understands his / her role in response to each of the emergency codes (Code Blue, Code Green, Code Adam, Code Yellow, Code Gray, Code Silver, Code Red, Code Violet, etc.)
• Adheres to procedures for the disposal of waste - household waste and biohazard waste as well as the proper disposal of sharps.
• Maintains the department in a neat, clean, and orderly manner, especially in own work area.
• Attends scheduled in-services. Communicates ideas to supervisor for a safer layout of equipment, tools, and / or processes.
• Adhere to all hospital and departmental policies governing conduct while at work, including attendance and punctuality requirements. Take corrective action to prevent recurring tardiness or absences.
• Observes dress code policy and wears hospital identification as required by our policies and procedures

Requirements

Education and Experience :

Required Skills / Abilities :

Physical Requirements :