RN-Clinical - N7010- Short Stay Unit

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.
• Receive and complete annual Blood Borne Pathogens training (if required).
• Perform comprehensive nursing assessment and reassessment throughout the patient’s stay.
• Conduct age‑appropriate admission or transfer assessments and obtain input from family or guardians.
• Accurately document findings, assessments, medication administrations, and nursing interventions.
• Assess post‑operative and post‑invasive procedure patients.
• Document education and discharge needs for patients and families at admission and throughout the hospitalization.
• Reassess patients and record observations according to the plan of care, noting changes in condition and response to care.
• Develop, coordinate, and evaluate individualized plans of care based on assessment data, diagnoses, lab results, orders, protocols, and other relevant information.
• Identify short‑ and long‑term goals and formulate nursing interventions to achieve desired outcomes.
• Integrate disease‑specific evidence‑based practice into care plans and documentation.
• Collaborate with health‑team members to coordinate daily plans of care for assigned patients.
• Provide, coordinate, and communicate patient care, including accurate handoff reports.
• Administer and document medications accurately according to policies and procedures.
• Monitor, maintain, and document accurate IV fluids and parenteral nutrition per policies.
• Complete referrals as indicated by assessment data and request consultations for special needs.
• Provide patient/family education and discharge planning in accordance with documentation guidelines and protocol.
• Clarify all physician orders as warranted and acknowledge implementation in a timely manner.
• Assist physicians with procedures or delegate to a care partner as appropriate.
• Document “Readback” for all telephone or verbal orders, taking orders only in emergency situations.
• Recognize changes in patient condition and take appropriate nursing actions, involving family or guardians when relevant.
• Identify risks to patient safety and implement appropriate actions.
• Incorporate infection‑control practices into daily care and communicate care changes as needed.
• Perform ongoing evaluation of effectiveness of care, patient and family education, and modify plans of care as necessary.
• Recognize significant changes in clinical parameters and report promptly to physicians and other relevant staff.
• Identify problems, gather pertinent data, suggest solutions, and work toward resolution using appropriate lines of authority.
• 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 and monitor patient response throughout restraint periods.
• Document restraint use and associated care thoroughly; provide consultation for peers on alternatives and 1:1 observation.
• Assess pain at admission and during reassessments, incorporating cultural or spiritual beliefs into pain‑management plans, and implement preventative pain‑management techniques.
• Identify and report signs of potential abuse or neglect to designated departments and take appropriate actions to support patient safety.
• Adhere to all quality and performance standards, policies, procedures, and protocols when implementing clinical and technical aspects of care.
• Participate in learning experiences to increase professional competence, maintain currency in policies and procedures, and stay updated on institutional changes.
• Attend staff meetings, review minutes when absent, and participate in committees and shared governance activities.
• Provide assistance and support to peers, co‑workers, and other team members and adapt positively to changing work demands.
• Orchestrate orientation and precepting for…