Registered Nurse - Acute

Position summary

Using independent and interdependent judgement, the registered nurse (rn) in compliance with the state of california, title 22 nursing service maintains the delivery of quality care by assuring the nursing care plan is followed. In collaboration with the physician, the rn assures implementation of the assessment plan, evaluation, and follows up the plan of care for the patient population.

Position qualifications

This position requires a valid temporary or permanent ca state registered nurse license. The individual must have strong interpersonal skills, the ability to manage multiple priorities, be dedicated to the provision of quality patient care, and use sound judgement in decision-making. Cpr certification required. Advanced cardiac life support (acls) certification required within six months of hire. Ekg (advanced 12 lead for medical professionals) certification required within six months of hire.

Duties and responsibilities

I. Responsibilities to the patient

A. Initiates an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient/family through interview, observation, and physical examination.

1. Receives admissions and/or transfers to the unit.

2. Completes nursing admission notes within 24 hours.

B. Interprets assessment data and information to develop a nursing care plan which contains problem identification, nursing diagnosis, nursing orders, approaches, interventions, short/long term goals, and discharge planning.

1. Develops nursing care plan utilizing nursing diagnosis

2. Assesses safety and fall risk levels for patients

C. Teaches and counsels patients/families, and makes referrals to appropriate resource personnel when needed.

1. Documents patient, family, and significant other teaching

D. Participates as a productive member of the interdisciplinary team in assessment, planning, implementation and evaluation of rehabilitation goals.

E. Assures that medical orders are transcribed and processed accurately, and integrates the medical care plan into the provision of nursing care.

F. Assures that medication/i.v. Administration is correct and according to the established nursing policies and procedures.

1. Looks up unfamiliar medications

2. Processes medication orders

3. Administers medications as ordered

4. Evaluates effectiveness of prn medications

5. Verbalizes process for self-administered medications

6. Verbalizes patient education on identified medications

7. Verbalizes standing orders

8. Verbalizes policy and procedure for maintenance and care of central line catheters

9. Administers i.v. Drugs

G. Provides for personal and environmental safety in accordance with hospital and nursing policies and procedures

H. Demonstrates skills in handling emergency and life-threatening situations

1. Locates and uses crash cart items

2. Calls code blue and medical emergency

3. Initiates cpr

4. Follows p&p and polst

I. Assures that documents in the medical record are complete, factual, accurate and timely.

1. Documents materials and equipment used.

2. Verbalizes method to noting orders.

3. Documents discharge in chart.

4. Initiates and updates care plan as appropriate.

5. Provides discharge instructions.

6. Completes interagency transfer form.

J. Provides nursing care to meet patient needs:

1. Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools.

2. Acts promptly on changes in patient condition, utilizing sbar method

3. Reviews lab and test results, notifying physician of abnormal and critical results

4. Performs wound care in accordance with policy, utilizing proper documentation tools.

5. Performs basic ventilator management and trouble-shooting.

Ii. Responsibilities to unit staff

A. Provides direction and leadership in patient care to assigned personnel.

1. Acts as a team leader.

2. Makes assignments for team.

B. Prioritizes activities and plans for effective use of time and staff in meeting patient needs.

C. Communicates the plan of nursing care for each patient through reports, conferences, rounds, and patient care records.

1. Shift to shift report and shift huddle with aides

2. Delegates tasks to aides;…