RN

Under the general supervision of the Nursing Director or Assistant Nursing Director, provides direct nursing care to patients.

Medical / Surgical Unit

Full-Time

7pm – 7:30am

• Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.

ASSESSMENT

• Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.
• Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.
• Identifies appropriate foci.
• Selects, plans, evaluates, and documents care based on this assessment. Documents patient’s plan of care in focus charting format.
• Assesses, intervenes, and documents appropriately to meet patient's educational, psychosocial, and discharge planning needs.
• Initiates appropriate referrals to other departments, services, and/or outside agencies for patientcare.

DIRECT PATIENT CARE

• Gives comprehensive patient care.
• Initiates and follows through with patient and family teaching.
• Consults with unit Nursing Leadership regarding significant changes in patient's condition.
• Collaborates with all members of the health care team.
• Communicates patient care needs (foci) on shift-to-shift report.
• Utilizes patient care standards in clinical practice.
• Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.
• Writes comprehensive focus note which prioritizes patient care needs.
• Documents patient/family education in the Interdisciplinary Patient/Family Education form
• Seeks clarification of physician's orders that are unclear or inappropriate.
• Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.
• Administers intravenous medications in compliance with policies and procedures.
• Titrates medicated infusions as per physician's prescriptive, protocols, and standard.
  
  

SAFETY

• Checks to ensure that emergency equipment is on hand and in good working order.
• Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e.g., ventilators, cardiac monitors, defibrillators, suction apparatus, pumps, doppler, tank, NIPP, and pacemaker).
• Checks that all monitoring equipment and ventilator alarms are set according to standards.
  
  

INDIRECT PATIENT CARE ACTIVITIES

• Participates in patient care rounds by presenting findings on patients.
• Applies principles of infection control and safety.
• Assists in the orientation of new personnel.
• Provides clinical supervision of LPNs, Nursing Attendants, Patient Care Technicians, Unit Care Assistants and other ancillary staff.
• Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards; promotes adherence to Patient Bill of Rights.
  
  
• Indicates an Essential Job Function.

BASIC COMPETENCIES

Education:

Graduation from accredited school of Nursing; BSN preferred.

Current NYS licensure as RN.

Current BCLS certification required.