Manages and supervises the clinical activities and personnel on an established shift. Has principal responsibility for the total nursing care, assessment, planning, implementation, and evaluation of each assigned patient. Plans, provides, and documents discharge planning, teaching, and educates patients, family or others to attain optimal health and continuity of care.
Assures that the plan of care is carried out in a safe environment through performance and supervision of subordinate personnel. Job
A.
Graduate of accredited School of Professional Nursing. B. Personal Job-Related
Effective oral and written communication skills. C. Licensure, Registry or Certification: Registered Nurse currently licensed by the State of Texas Board of Nursing.
Graduate Registered Nurse with temporary licensure in State of Texas. BLS required; PALS, ACLS and TNCC required. D.
1. Prior work
Two years' experience as a professional Registered Nurse required. Two years' experience as Medical/Surgical nurse preferred. 2. Technical Training: IV Therapy course required.
EKG Interpretation Course preferred. E. Physical and Mental
Duties of the position require extended periods of standing and walking. Bending, stooping, twisting, reaching and lifting up to 50 pounds. Occasional heavy lifting when moving or supporting patients who may become weak or helpless.
Must submit to post offer substance abuse testing (drug screening).
and
A. Conducts and directs patient care on the medical/surgical unit to ensure that patient needs are met and that hospital policies are followed. B.
Utilizing the nursing process, completes comprehensive assessment of patients and takes nursing histories to provide a basis for development of patient care plans under the direct supervision of the licensed professional. a. Provides a comprehensive assessment which accurately reflects overt physiological and psychosocial needs of patients and reports unusual findings to appropriate licensed personnel. b. Uses input from patient, family, significant others, physician, and health care team members. c.
Facilitates favorable relationships with other members of the nursing staff, the Medical Staff and other departments. d. Utilizes the nursing process to provide safe care for all patients. C.
Using the nursing process planning - the RN synthesizes data collected during the comprehensive assessment to identify problems, making nursing diagnoses, and to formulate goals, teaching plans and outcomes. a. Formulating appropriate nursing diagnosis and identifies patient problems from admission data base and ongoing assessment. b. Establishes patient outcome goals that are realistic, specific, measurable and progressive. c.
Initiates interdisciplinary communications and incorporates recommendations. d. Assesses and evaluates patient’s response and outcome and makes appropriate modifications on the care plan. e. Reviews and updates the care plan as needed to reflect patient’s current status throughout hospitalization.
D. Implements and monitors appropriate nursing care to meet patient’s needs and identifies expected outcome for planned nursing intervention and insures vital information is passed between shifts. a. Administers medications according to policy including IV’s and IVPB’s as prescribed by physicians. b.
Knows actions, indications, contraindication, precautions, adverse reactions, dosage and route of administration on all drugs before administering to patient and verifies against medication administration record for accuracy on each shift and on an ongoing basis. c. Monitors all blood transfusions. d. Gives exchange report to other health care personnel providing accurate and complete information on each patient at the change of shift, when transferring patient to another unit, and at intervals during the shift. e.
Assesses patients at the beginning of shift for acuity of patient needs/problems and based on that assessment, establishes priority in which work activities are consistently completed by the end of the shift. f. Performs basic nursing skills competently to include but not limited to: intake and output, vital signs, urine testing, specimens/cultures, dressing changes, personal hygiene for patient, skin care, glucose monitoring, airway/suctioning, basic oxygen administration, tube feedings, urinary catheterization, drains, enemas, and intravenous catheterization. g.
Notifies Charge Nurse and physicians of emergency situations promptly. h. Recognizes variances of vital signs and assessments that should be reported to the Charge Nurse and the physician and notifies physician in time appropriate to the variance. i. Functions proficiently in unit nursing modalities. j.
Consistently checks for new patients orders throughout the shift and implements them in an appropriate time frame. k. Maintains the standards of patient care for the medical/surgical unit. l. Transcribes and/or co-signs physicians orders completely and accurately according to hospital policy and practice.
E. Participates in the health care educational needs for the client family and others with regard to patient care needs, disease prevention and health maintenance measures. a. Identifies, initiates and documents progressive patient, family, or significant other teaching/learning/discharge needs at time of admission and throughout hospitalization. b.
Documents teaching completed and patient and family response in the patient record. c. Act as a liaison between patient, physician, family, significant other, and other health disciplines. F.
Maintains accurate and timely records according to hospital policy and procedures. Accurately documents on each shift the nursing patient care activities and the patient response to nursing interventions and delegated medical management. G.
Responds as Code Team Leader. Insures shift has Code team assigned and placed on assignment board for view. Performs Code review after each Code and reports to Nurse manager.
H. Uses TeamStepps – SBAR sheets to report to physician critical information that requires immediate attention and action concerning a patient’s condition. Other Significant
A. Maintains confidentiality while working with confidential matters on a daily basis. Adheres to national standards of confidentiality.
B. Provides service direct to patients while maintaining a positive patient relationship and a supportive atmosphere. C.
Interacts with patients, family members, Medical Staff members, and other department personnel with a respectful attitude and promotes a cooperative manner. D. Performs duties that are consistent with patient advocacy as mandated by the State of Texas Board of Nursing.
E. Utilizes aseptic procedures and maintains aseptic precautions when involved in direct patient contact or handling potentially infectious materials. F.
Provides care appropriate for the neonate and the pediatric, adolescent and geriatric patients served based on demonstrated knowledge of the principles of growth and development over the life span. G. Assesses and interprets data on neonate and the pediatric, adolescent and geriatric patients’ status to identify patients’ requirements relative to their age-specific needs and provides care needed as stipulated in departmental policy.
H. Provides care to patients based on standards recognized and approved by the administration, the physician, and the licensing authority. I.
Responds to emergency situations as needed. J. Assists with securing medications as directed by the Pharmacy Policy.
K. Directs the delivery and administration of medications in a safe manner that is acceptable to the State licensing authority and is aware of consequence of failure to adhere to medication administration standards. Consequences of failure to perform medication administration in a safe manner may result in (but may not be limited to) Peer Review, reporting to the State Board of Nursing, performance restrictions or employment termination.
L. Responsible for administering any blood transfusions as ordered by physician and monitoring patient for any adverse reactions the first 15 minutes of administration of each transfusion. M.
Adheres to and enforces administrative policies regarding attendance and performance.