Job Description Duties:
This position functions under the supervision of the Unit Director and the leadership of the Senior Nurse or designated Charge Nurse. The Registered Professional Staff Nurse has responsibility for providing individualized quality patient care by assessing patient needs through data collection and by designing, implementing and continuously evaluating the plan of care. Works in collaboration with all members of the treatment team. Performs other related duties as assigned or requested. May be assigned to any inpatient unit and Blake to meet patient care needs.
On admission completes Nursing Admission Assessment: identifies strengths, weaknesses and problems and develops ITP considering patients age, disability, ethnicity, culture and religion.
Administers medication and treatment accurately and according to policies and procedures and assesses effect of medication on patient.
Attends multidisciplinary TP conferences for assigned patients and works collaboratively with members of treatment team to achieve identified goals.
Assures patient care is provided in accordance with the MTP.
Understands and implements hospital wide, regulatory agencies and standard nursing policies, procedures, regulations and standards; operates within professional Product of practice.
Effectively collaborates with treatment team and positively supports patients plans for continuing care.
Assesses learning needs, readiness and barriers to learning of patient (and families) and documents appropriately.
Provides age appropriate learning opportunities (individual and group) and documents teaching and outcomes appropriately.
Provides educational materials that are specifically appropriate for patient/family, considering age, educational level, culture and disability.
Provides input to Unit Director regarding unit-based PI measures based on concerns, high risk, and high volume issues.
Participates in units PI activities by accurate data collection which focuses on established indicators, processes & outcomes.
Maintains a safe and orderly work/patient care environment.
Immediately reports all environmental and safety hazards per Policy and Procedures.
Handles and disposes of infectious and hazardous materials per Policy and Procedures.
Review all assigned patient charts for new orders at the beginning of each shift.
Accurately transcribes, reviews and co-signs medication orders within procedural time limits.
Immediately documents adverse reactions and unusual incidents using appropriate reports and follows up as required by Policy and Procedures.
Uses approved hospital abbreviation for charting at all times.
Demonstrates computer literacy and competency for all required systems.
Documents patient information within medical record accurately and within procedural time limits: assessments, progress notes, response to care provided, treatment plan and updates and discharge summary.
Participates in the orientation of new/transfer personnel and students as assigned to the unit.
Identifies one patient problem, patient strength, and intervention within 24 hours of admission.
Attends Treatment Planning Conferences when scheduled and makes additions/revisions to plans as discussed at meeting.
Reviews the Master Treatment plan weekly and makes revisions as warranted by the patients condition.
Plans and conducts nursing psycho-educational groups as per unit schedule.
Demonstrates positive communication techniques in working with other members of the treatment team in order to enhance patient care.
Meets all requirements for annual IV re-cert if applicable .
Models the I CARE standards of behavior.
Population Specific knowledge and skills: Must be able to demonstrate the knowledge and skills necessary to provide care to adolescent, adult, and older adult patients. Must demonstrate knowledge of key principles of growth and development of the life span; demonstrates cultural competence relative to the patient and/or residents status. Must be able to interpret the appropriate information needed to identify each patient and/or residents needs relative to his/her age, culture, ethnicity, disability sexual orientation/gender identity (if applicable) in accordance with the organizations policies and procedures.
Patient Orientation/Admission: Nursing Admission Assessment, accommodates for age, culture, disability issues, sexual orientation/gender identity and language. Initial assessment for abuse, neglect, and domestic violence, pain assessment form, Completes Cardex (Patient Identification Card), vital signs X3 days, Suicide Assessment & Prevention, Status Precautions Seclusion/Restraint/QA P&P, fall Assessment Form, CIWA/Narcotics Withdrawal Scale, BAL readings.
Charting/Confidentiality: Daily Observation Record, SOAPIE, Care Notes (via computer), Patient/Family Education Record, maintains chart security, patients rights and confidentiality; understands advanced directives policy.
Medications: Transcription of Orders, Co-sign Orders, Read-back verbal telephone orders, Pour/Administer: Oral meds, Parenteral, Intradermal (PPD), Intramuscular, Subcutaneous, Inhalation, Insulin; PRN Medications: Charts responses/Relief Scale; Ordering Medication ; Variance Reporting, 24 Degree Chart Check.
Crisis management: Knows different emergency codes & how to respond to them, Knows CPR & how to use AED, Provides care in least restrictive manner, Understands/utilizes Solid Object philosophies, Understands & can properly implement HWC techniques, Ability to effectively communicate verbally and in writing with adults and adolescents, completes Incident Reporting as per organizational policy.
Care of Patients: Maintains Therapeutic Milieu, able to set therapeutic limits, demonstrates effective 1:1 interactions with patients; Understands suicide prevention and assessment; status precautions; seclusion, restraint, and Quiet Area Protocols; Provides care in least restrictive manner. ECT; (ECT Work-up, Pre-Checklist, Post-Checklist); Understands and maintains all different unit specific protocols, rules, and procedures, safe patient handling techniques.