RN Clinical; Cardiac - Surgery - Rotating Shifts; Non-Exempt; Union

Registered Nurse - Job Description

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.

• 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.
• 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; ensures MD orders per policy, MD assessment per policy, 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:
  Admission Assessment;
  Pain scale assessment and reassessment before and after intervention;
  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 and provides 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 manufacturer 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 E‑mail;
  Student/New employee/Contract employee.
• Organization
  : manages time effectively, organizes and prioritizes responsibilities, takes meal breaks without incurring overtime, completes shift on time.
• Regulatory Compliance
  : observes National Patient Safety Goals, Patient identifiers, Unapproved abbreviations, Universal Protocol, Hand‑Off Medication Reconciliation, Clinical Alarms, Hazardous waste management, Biohazard, Medication Sharps, HIPAA, OSHA requirements, JCAHO readiness, Critical Values, Write Down, Read Back, Follow up, Telephone order, and related protocols.
• Management of the care of medical‑surgical patients: demonstrates ability to manage patients with THA, TKA, spinal surgery, cystic fibrosis, abdominal organ transplants, hepatic encephalopathy.
• Management of the care of patients in the Intensive Care Unit/S: demonstrates ability to manage complex critically ill patients, advanced therapeutic modalities, hemodynamic monitoring, continuous renal replacement therapy, intracranial pressure monitoring, ventilator care, etc.
• Management of the care of patients in the stepdown/telemetry units: demonstrates ability to manage high acuity patients after heart, lung, liver or kidney transplants, neurosurgery, thoracic‑forgut, gastric bypass, etc.; manages advanced therapeutic modalities.
• Management of the care of patients undergoing dialysis treatment: initiates, performs and terminates all dialysis treatments according to policy; reviews orders…