RN-Clinical - N7010; WO- South WEO PT Nights

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.

• Report risk management concerns using eSRM.
• Complete annual Blood Borne Pathogens training (if required).
• Perform comprehensive nursing assessment and reassessment.
• Conduct age‑appropriate admission or transfer assessments and obtain input from families or guardians when appropriate.
• Accurately and completely document findings.
• Assess post‑operative and post‑invasive procedure patients.
• Assess and document education and discharge needs of patients and families at admission and throughout hospitalization.
• Provide patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, response to care, procedures, and standards of care.
• Establish, coordinate, and evaluate a plan of care based on assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols, and other relevant information.
• Identify short‑ and long‑term goals based on patient care needs.
• Formulate nursing interventions to achieve desired patient outcomes.
• Integrate disease‑specific evidence‑based practice into nursing care plans and documentation.
• Document and implement nursing interventions based on assessed needs, plan of care, and changes in patient status.
• Collaborate with health‑team members to coordinate the daily plan of care for assigned patients.
• Communicate patient care, including accurate hand‑off communication reports.
• Administer and document medications accurately according to policies and procedures.
• Monitor and document accurate IV fluids and parenteral nutrition according to policies and procedures.
• Complete referrals as indicated by assessment data.
• Request consultation for special needs, equipment, or information for patients and/or families.
• Provide patient/family education and discharge planning per documentation guidelines and protocol.
• Clarify physician orders as warranted and implement them accurately and timely, documenting in the record.
• Assist physicians with procedures/treatments as requested or delegate to a care partner when appropriate.
• Document “readback” for all telephone/ verbal orders and take such orders only in emergency situations.
• Recognize changes in patient condition and take appropriate nursing actions.
• Involve family or guardians in care and decision‑making when appropriate.
• Recognize patient risks and take appropriate action.
• Utilize infection control practices in daily care.
• Document or communicate changes in patient condition or nursing care.
• Evaluate the effectiveness of care based on assessment data, patient response to medications, treatments and procedures, and modify plans of care as needed.
• Evaluate the effectiveness of education provided to patients and families.
• Identify problems, gather pertinent data, suggest solutions, and work toward problem resolution.
• Report variations from care or treatment following the occurrence reporting policy and procedures.
• Provide specialized care to patients at high risk for injury, including restraint care, pain management, and abuse assessment.
• Initiate and evaluate alternatives to restraints prior to application.
• Monitor patient response during restraint periods and provide specified patient care (toileting, skin care, hydration, feeding, etc.).
• Provide pain assessment on admission and throughout care, incorporating cultural and spiritual beliefs into the pain management plan, and implement non‑pharmacologic techniques such as repositioning, massage, and music therapy.
• Recognize signs of possible abuse or neglect and report to appropriate authorities.
• Adhere to quality and performance standards, participate in learning activities, maintain currency in all policies and procedures, and attend staff meetings and committees.
• Support and mentor teammates, supervise new staff or students, and contribute to shared governance and unit‑based practice council activities.
• Practice safety and infection control, dispose of hazardous waste…