RN Clinical; Cardiac - Surgery Non-Exempt; Union

Job 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.

• Follow policies and procedures and demonstrate ability to access online manuals.
• Transfer learned scientific knowledge into practical application in the Nursing Process.
• Appropriately complete Nursing Assessment upon patient admission, at each shift, and with changes of condition.
• Complete patient acuity by 0200/1400 daily.
• Interpret assessment information and formulate Nursing Diagnoses.
• Develop Plans of Care with individualized interventions and document expected/projected patient outcomes.
• Review, revise, and update Plans of Care daily based on evaluation and interpretation of patient outcomes.
• Administer medication and IV therapy appropriately at prescribed intervals.
• Complete patient care procedures correctly per policy at prescribed intervals.
• Delegate tasks based on others’ scope of practice and competency.
• Act as patient advocate and manage restraint use per policy, attempting alternative non‑restraint measures first.
• Ensure complete MD orders per policy, ensure MD assessment, assure patient monitoring, and complete Restraint Audit Form each shift.
• Maintain complete and correct documentation on all flow sheets and chart forms:
  Admission Assessment, Pain Scale Assessment, 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, and forward orders prior to shift end. Complete 12h/24h chart checks.
• Provide patient/family education as needed, including room/unit orientation, Plan of Care, identification of knowledge deficits related to diagnoses, and use of MICROMEDEX information.
• Collaborate with Case Manager and/or physician regarding discharge planning, ensure all transfer paperwork is completed, and ensure belongings are sent with patient.
• Utilize patient care equipment appropriately and safely according to manufacturer guidelines: IV pump, feeding pump, PCA pump, epidural pump, sequential compression device, wound VAC, heating pad/pump.
• Communicate 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 e‑mail, and student/new employee/contract employee interactions.
• Manage time effectively, organize and prioritize responsibilities, take meal breaks without incurring overtime, and complete shift on time.
• Observe regulatory agency requirements for patient safety, including National Patient Safety Goals, universal protocol, hand‑off medication reconciliation, critical values, telephone orders, documentation, and infection control procedures.
• Manage care of medical‑surgical patients (including THA, TKA, spinal surgery, cystic fibrosis, abdominal organ transplants), intensive care unit patients (neurosurgery, thoracic‑forgut, gastric bypass, orthopedic, transplant patients, advanced therapeutic modalities), step‑down/telemetry units (high acuity patients with advanced tech), and dialysis patients (initiate, perform, terminate treatments, perform safety checks, maintain equipment).
• Engage psychiatric patients in therapeutic interactions, maintain therapeutic milieu, assess and monitor patient safety, and administer psychotropic medications following consent and documentation.
• Implement de‑escalation techniques and apply behavioral restraints/seclusion when appropriate, monitor patients continuously, ensure physician assessment within required time frames, notify the manager, contact significant others as permitted, and debrief patients after incidents.
• Track quality measures, identify data collection opportunities, assist in process improvements, and participate in professional development activities.