Registered Nurse - Clinical - Cardiovascular Stepdown

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.

• Performs comprehensive nursing assessment/reassessment.
• Performs age‑appropriate admission assessment or transfer assessment. Obtains 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 on 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.
• 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 hand‑off 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 as warranted; acknowledges and implements orders accurately and timely.
• Assists physician with procedures/treatments as requested or delegates to care partner as appropriate.
• Documents read‑back for all telephone/verbal orders; takes telephone/verbal orders only in emergency situations.
• Recognizes changes in patient’s condition and takes appropriate nursing actions, involves family/guardian when appropriate.
• Recognizes risks for patient and takes appropriate action; incorporates infection control practices daily.
• Documents and communicates nursing care and changes in patient condition.
• Performs ongoing evaluation of effectiveness of care; evaluates effectiveness of patient/family education; evaluates plan of care and modifies as indicated.
• Identifies and reports significant changes in patient clinical parameters.
• Identifiers problems, gathers data, suggests solutions, communicates using appropriate lines of authority, works toward problem resolution.
• Reports variation from care/treatment following the occurrence reporting policy and procedures.
• Provides specialized care to patients at high risk for injury: restraint care, pain management, abuse assessment as described.
• Adheres to quality and performance standards, policies, procedures, and protocols when implementing clinical and technical aspects of care.
• Participates in learning experiences that increase professional competence; demonstrates appropriate technical and cognitive skills for area of practice.
• Maintains currency in all hospital/unit information, communication, policies, and procedures.
• Participates in committees, shared governance, unit‑based practice council activities and other leadership roles.
• Reviews and keeps up with hospital/nursing publications and policies.
• Provides assistance and support to peers, co‑workers and other team members.
• Adaptable to changing work demands; responds positively to change.
• Provides supervision and teaching to students/new staff nurses as required.
• Complies with safety and infection control…