RN-Stepdown​/Critical Care

Job Summary

The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

• Reports risk management concerns using eSRM.
• Annual Blood Borne Pathogens training (if required).
• Performs comprehensive nursing assessment and reassessment.
• Performs age‑appropriate admission or transfer assessment, obtaining input from family/guardian when appropriate.
• Accurately and completely documents findings.
• Performs assessment of post‑op/post‑invasive procedure patients.
• Assesses and documents education and discharge needs of patient and family upon admission and throughout hospitalization.
• Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc., and standards of care.
• Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant.
• Identifies short and long term goals based on patient care needs.
• Formulates nursing interventions to achieve desired patient outcome and incorporates disease‑specific evidence‑based practice into nursing care plan and other documentation.
• Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.
• Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.
• Provides, coordinates and communicates patient care, including accurate handoff communication reports.
• Administers and documents medications accurately according to policies and procedures.
• Monitors, maintains and documents accurate IV fluids and parenteral nutrition according to policies and procedures.
• Completes referrals as indicated by assessment data.
• Requests consultation for special needs, equipment, or information for patient and/or family.
• Provides patient/family education and discharge planning per documentation guidelines and protocol.
• Clarifies all physician orders, acknowledges and implements them in a timely manner, and documents "readback" for all telephone/verbal orders.
• Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate.
• Recognizes changes in patient's condition and takes appropriate nursing actions, including involving family/guardian in decision‑making and recognizing risks for patient.
• Incorporates infection control practices daily and documents and/or communicates nursing care and changes in patient condition.
• Performs ongoing evaluation of effectiveness of care, evaluates patient/family education, and modifies plan of care as indicated.
• Reports variation from care/treatment following the occurrence reporting policy and procedures.
• Provides specialized care to patients at high risk for injury, including restraint care, pain management, and abuse assessment as specified.
• Restraint Care: initiates/evaluates alternatives, applies restraints, monitors patient response, provides specified care, and documents restraint use.
• Pain Management: assess patient for presence of pain, incorporate cultural/spiritual beliefs, implement pain management techniques, and involve patient/family in pain management plan.
• Abuse Assessment: identify abuse criteria, report signs of possible abuse/neglect to appropriate authorities, take appropriate action for patient safety.
• Adheres to quality and performance standards, participates in learning experiences, demonstrates technical and cognitive skills, maintains currency, attends staff meetings, participates in committees, and responds positively to change.
• Provides assistance and support to peers, co‑workers, and other team members, and adapts to changes in workload.
• Orients and precepts new employees, maintains a collaborative team approach, and serves as a resource to coworkers, patients/families, medical staff, and other team members.
• Performs safety and infection…