RN Clinical Cardiac - Surgery Non-Exempt; Union

Overview

As an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients. The Registered Nurse is accountable for the coordination of patient care and education to the patient and family in accordance with the standards, policies, and practices in a compassionate, supportive, and therapeutic environment.

• Follows policies and procedures; demonstrates ability to access online manuals.
• Transfers learned scientific knowledge into practical application in applying the Nursing Process.
• ASSESSMENT:
  Appropriately completes Nursing Assessment upon patient admission, at each shift and with change of condition. Completes patient acuity by 0200/1400 daily.
• DIAGNOSIS:
  Interprets assessment information and formulates Nursing Diagnoses.
• PLAN:
  Develops Plans of Care with individualized interventions. Documents expected/projected patient outcomes. Reviews/Revises/Updates Plans of Care daily based on evaluation and interpretation of patient outcomes.
• INTERVENTION:
  Administers medication and IV therapy appropriately at prescribed intervals. Completes patient care procedures correctly per policy at prescribed intervals. Delegates tasks based on others  scope of practice and competency. Acts as patient advocate. Manages restraint use per policy. Attempts alternative non-restraint measures first. Assures complete MD order per policy. Ensures MD assessment per policy. Ensures patient monitoring per policy. Ensures Restraint Audit Form is completed each shift.
• DOCUMENTATION:
  Documentation is complete and correct on all flow sheets and chart forms as listed (Admission Assessment, Pain scale assessment and reassessment, Daily flow sheet, Restraint flow sheet, Diabetes flow sheet, Educational flow sheet, Kardex, Care Plan, Risk Assessment & Reassessment upon Fall, MAR, Equipment & Supplies, Intra and Inter Facility Transfer Forms, Belonging Tracking Form). Ensures orders are transcribed and signed off prior to the end of the shift.
  
  Completes 12h/24h chart checks.
• EDUCATION:
  
  Provides patient/family education as needed; room/unit orientation;
  Plan of Care; identifies knowledge deficits related to diagnoses and care; uses MICROMEDEX information to patients and families.
• TRANSFER & DISCHARGE:
  Collaborates with Case Manager and/or physician regarding discharge planning. Ensures all transfer paperwork is completed. Ensures belongings are sent with patient.
• EQUIPMENT:
  Utilizes patient care equipment appropriately and safely according to manufacture guidelines (IV pump, feeding pump, PCA pump, Epidural pump, sequential compression device, Wound VAC, heating pad/pump).
• COMMUNICATION:
  Communicates effectively with all members of the healthcare team including patient and family: shift-to-shift report, physician rounds, patient/family interactions, MDP rounds, hand-off reports, facility email, student/new employee/contract employee.
• ORGANIZATION:
  Manages time effectively; able to organize and prioritize responsibilities; takes meal breaks without incurring overtime; completes shift on time.
• REGULATORY AGENCY REQUIREMENTS:
  Adheres to National Patient Safety Goals, patient identifiers, universal protocol, hand-off procedures, medication reconciliation, clinical alarms, hazardous waste management, biohazard/sharps, HIPAA/OSHA requirements, JCAHO readiness, critical values writing and documentation, proper body mechanics, infection control, hand washing.
• MANAGEMENT OF THE CARE OF MEDICAL SURGICAL PATIENTS:
  Includes practice with THA, TKA, spinal surgery, isolation precautions, medications, hepatic encephalopathy care, and related safety practices.
• MANAGEMENT OF THE CARE OF PATIENTS IN THE INTENSIVE CARE UNIT/S:
  Manages complex critically ill patients and advanced therapeutic modalities, including hemodynamic monitoring, CRRT, ventriculostomy, ICP monitoring, VADs, and other critical care equipment.
• MANAGEMENT OF THE CARE OF PATIENTS IN THE STEPDOWN/TELEMETRY UNITS:
  Manages high acuity patients with specialized monitoring and care, including ventilator care and invasive lines.
• MANAGEMENT OF THE CARE OF PATIENTS UNDERGOING DIALYSIS TREATMENT:
  Initiates and…