Medical Surgical Nurse

Job Description PATIENT CARE

• ASSESS — Assess patient’s physical, psychosocial, learning, discharge needs and document those needs every shift or as directed.
• PLAN — Formulate and write nursing diagnosis based on assessment. Establish and write measurable short‑term and long‑term goals. Write individualized NCP upon patient’s admission within 24 hours.
• IMPLEMENTATION — Document that care is given in accordance with doctor’s orders and the NCP and that the care complies with policies and procedures. Practice and perform risk management safety according to hospital guidelines. Administer medications, IVs, treatments as ordered for assigned patients and document according to policy. Provide patient/family with health‑care information via written/audiovisual aids and/or structured teaching program and document.
• EVALUATION — Document patient response to plan of care. Evaluate and update NCP as patient care need changes. Review and update patient’s acuity every shift. Evaluate physical caregiver needs and instruct in nursing methods and procedures.

• NIGHT SHIFT
  : 7pm‑7am