General Statement of Job
This position provides safe and effective nursing care and treatment to patients in the Med./Surg. 3rd Floor Nursing Department. Employees are part of the managed care team and works collaboratively with ancillary personnel in the provision of proper medical services and treatment. This position provides nursing care and services to patients seeking medical attention and prevents further deterioration of patient’s health in accordance with established regulations, policies, nursing standards and medical instructions.
Provides nursing care to meet the needs of the patient population served as qualified; i.e., infant, child, adolescent, adult, and geriatric patient.
Delivers patient care within defined hospital standards as a team member for patient care.
Evaluates each patients’ care status frequently. Reports variances in care and/or medication administration for quality improvement.
Performs nursing care within the guidelines of the Relationship and Results Oriented Healthcare Model utilizing the recommended bundles of best practice.
Assesses and charts patient's vital signs and notifies physician of abnormal ranges as well as any significant changes.
Delegates and supervises care appropriately to LPNs and CNAs with follow up and feedback procedures to ensure quality of care.
Develops plan of care and patient focused goals with the patient and family as appropriate, ensuring patient understanding and involvement in their care.
Delivers patient care in accordance with established infection control standards for patient placement, IV therapy, medication administration, and the performance of all patient procedures; demonstrating adherence to hand washing policy.
Performs duties in accordance with pathogen transmission practices; i.e., follows hand washing policy/procedure, and utilizes protective equipment efficiently and appropriately.
Demonstrates understanding of JCAHO Safety Goals and delivers care with patient safety as a goal.
Follows policies for administration of high risk drugs, patient identification, documentation, taking telephone orders with read back and communication of critical values / diagnostic results.
Communicates effectively with other patient care providers and team members for efficiencies and safety of care through appropriate ordering procedures, preparing patients for surgery and other procedures, communicating fall potential and other risk identifiers.
Follows guidelines for performance improvement and demonstrates understanding of participation in the Core Measures for Lakeside Medical Center, and for documentation review and restraint review processes.
Communicates effectively with the patient’s physician(s), reporting any changes in condition in a timely manner and provides an accurate assessment of patient status to assist with physician’s rounds, etc.
Works cooperatively with ancillary departments in ensuring the patient’s care is safe, following protocols as applicable.
Uses patient care equipment safely and as directed by policies and instruction. Reports any identified equipment breakdown or malfunction by hospital policy. Maintains cleanliness of equipment after use.
Utilizes and ensures staff utilizes supplies efficiently, following infection control procedures, avoiding waste and follows patient charging procedures.
Ensures that tests are ordered appropriately and that patients are prepared for tests, to avoid extended stays, and potential duplication of tests.
Serves as an example for team members in cost saving practices.
Utilizes good communication skills, critical thinking, and checkpoints for team work. Provides patient information timely and effectively during shift report and with patient hand-offs.
Participates in the orientation and mentoring of new staff members recognizing importance of bringing new staff into a friendly and supportive work environment.
Assists manager and other staff members to maintain competence and skills for procedures assigned and assists in validation of skills and competence of new staff members prior to delegation of patient care.
Demonstrates professional growth in continuing education which is applicable to unit assigned.
Maintains accurate and current record of patient’s care and response to care following the guidelines for appropriate electronic documentation.
Participates with team members and manager to identify opportunities for improvement in patient care processes.
Demonstrates understanding and commitment to the hospital mission, philosophy, standards, policies and procedures. Recognizes all staff, physicians and visitors, as well as, patients as customers and provides courteous and respectful service.
Documents and reports any complaints from patients, physicians and visitors to supervisor as guided by hospital policies and procedures.
Participates in the cleanliness of the work environment.
Demonstrates an understanding of responsibility in emergency plans and is available for patient care as needed or scheduled when hospital emergency preparedness plans are activated.
Participates in hospital community activities and promotes the hospital within the community.
Serves as a change leader, positively promoting new systems and changes implemented which improves the hospital and the service provided to its patients.
Participates in the hospital goals for growth by being an example of good service to patients in our community and in assisting physicians and other team members.
Evaluates clinical/diagnostic reports and reports variances to the physician and documents same.
Assigns various aspects of patient care to selective personnel, as commensurate with the authority of a RN and the scope of practice of the personnel.
Supervises and evaluates all direct patient care provided and initiates appropriate action as needed.
Participates in the hospital Utilization Management Program by assisting with discharge planning, reporting to case managers, and keeping patient, family, physician, and other personnel informed.
Completes assessments and documentation of new admissions and discharges including the interim plan of care. Completes discharge instructions with information regarding food and drug interaction.
Performs specialized patient assessments as needed.
Defibrillates patients safely in accordance with regulations, policy and accepted procedure.
Orders initial lab tests and x-rays by established protocols.
Applies, observes, and documents all patients requiring restraints according to hospital policy.
Documents the administration of medicines including dosage, medicine route, medicine site, and patient's response as required in the documentation system.
Documents attendance of continuing education programs for maintenance of professional license per Florida State Law.
Evaluates pulmonary status by auscultation.
Provides explanation of all procedures/treatments to patients and/or family, including educating them consistently for health maintenance.
Provides nursing care to patients with either hard or soft splinting devices; assesses circulation, mobility, and neurological status of patients. Applies splints and bandages per physician’s orders.
Observes cardiac rhythm and initiates telemetry or ACLS protocol as indicated.
Provides teaching and training to staff members as needed.
Performs NG tube insertion and performs gastric suction per hospital policy and procedure.
Provides care for the patient both pre- and post-specialized procedure and assists physicians during procedure as needed. Completes pre-operation check-list, and obtains and witnesses consents for surgery and special procedures.
Performs bedside blood glucose monitoring and testing per physician order and/or hospital policy.
Performs respiratory care assessments and specimen collection using the appropriate techniques.
Performs considerable administrative support work in documenting, reviewing and maintaining records, files, charts, forms and reports.
Documents and maintains all patient care records and related required documentation. Maintains records and communications with respect to patient’s privacy.
Obtains and transcribes physician’s orders in a timely and accurate manner ensuring that all tests are ordered appropriately and efficiently.
Floats to other units as required.
Reviews status and criteria of OVS patients and promotes appropriate designation.
Participates in department’s QI activities on a daily basis.
Determines at-risk patients and follows through with treatment accordingly.
Assesses lung sound in patients.
Starts IVs and delivers IV medications to patients as needed. Runs and calculates IV drips.
Takes and submits lab specimens from patients.
Performs port flushes, injections, and blood transfusions.
Helps with code assistance.
Transports patients to appropriate care locations.
Provides assistance to patients in need of help in bathing, feeding, turning, positioning, oral hygiene, and personal hygiene.
Conducts walking rounds at the start and end of each shift visually checking each patient and provides a written end-of-shift report.
Assists with emotional needs of patients.
Continues therapies when necessary as guided by the Physical Therapist within the established plan of patient care.
Dresses patient wounds as needed.
Performs monitor/defibrillator checks every shift.
Performs inventory checks, including all medications administered at the time of administration. Reconciles the count on a weekly basis.
Checks code cart and pediatric emergency box during every shift.
Ensures availability of age appropriate supplies and equipment.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or actual disasters, man-made or natural.
Associate’s, Bachelor’s, or Diploma in Nursing from an accredited nursing school required.
Minimum of one (1) year experience preferred.
CPR certification required. PALS required within ninety (90) days of hire. ACLS preferred.
State of Florida Registered Nurse license required. NRP License preferred.
Blood Glucose Monitoring