RN Clinical - Same Day Surgery; Pre-Op - Rotating Shift; 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 RN is accountable for the coordination of patient care and education to the patient and family in accordance with standards, policies and practices in a compassionate, supportive, and therapeutic environment.

Policies and Procedures

• Follows policies and procedures; demonstrates ability to access online manuals.

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 and 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.
• Ensures complete MD order, MD assessment and 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 end of 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 Agency Requirements

• National Patient Safety Goals, patient identifiers, unapproved abbreviations, universal protocol (procedural time‑out), hand‑off medication reconciliation, clinical alarms, hazardous waste management, biohazard, medication sharps, HIPAA, OSHA, JCAHO continuous survey readiness, critical values, write‑down, read‑back, follow‑up telephone order, appropriate documentation, signed, timed and dated, stamped, entered into unit log.
• Maintains safe practice in the work environment: correct body mechanics, electrical safety, infection control procedures, hand washing.

• Demonstrates ability to manage patients with THA, TKA, spinal surgery, cystic fibrosis, abdominal organ transplants, hepatic encephalopathy.
• Institutes safety precautions and skin care for patients with hepatic encephalopathy.

• Manages complex critically ill patients: neurosurgery, thoracic‑forgut, gastric bypass, orthopedic, liver/kidney/pancreas transplants, hepatobiliary, open heart, heart and lung transplants.
• Manages advanced therapeutic modalities: hemodynamic monitoring, continuous renal…