Job Description
Performs an age-specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills and clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.
Job Responsibilities
- Conducts patient interviews, explains policies and procedures to patients/significant others, reviews patient's chart, and answers questions correctly and courteously.
- Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health status; determines mobility, sensory deficits, prostheses use, and skin condition; adjusts plan of care accordingly; assesses level of pain and pain management.
- Communicates and documents patient's physiological health status and plan of care.
- Assesses patient's psychosocial health status. Elicits perceptions of medical/nursing care and expectations. Determines coping mechanisms, knowledge level, and ability to comprehend. Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction. Documents psychological status and care plan, including support groups, counseling, and social services.
- Identifies patient outcomes, develops criteria for measurement, and establishes individualized patient goals.
- Identifies care activities, establishes priorities, and coordinates the use of supplies, equipment, and medication to achieve expected outcomes. Documents the plan of care and collaborates with team members.
- Implements the plan of care, maintains vigilance over patient safety, and revises the plan as needed.
- Administers prescribed treatments correctly, uses equipment properly, provides emotional support, and observes patient conditions during procedures, reporting findings appropriately.
- Maintains accurate documentation of treatments, activities, conditions, and responses to interventions.
- Acts effectively during emergencies, manages self and others, and communicates with patients' families or caretakers.
- Participates in discharge planning, provides instructions, and evaluates care outcomes.
- Performs variance analysis for performance improvement and implements systems to enhance care quality.
- Collaborates with the care team, provides direction, and interprets treatment regimens as prescribed by physicians. Assists during treatments and diagnostic procedures, and communicates patient status changes.
- Performs skin care procedures, including decubitus care, dressings, compresses, and irrigations.
- Administers medications safely, educates patients on drug interactions, and meets standards for medication administration.
- Participates in patient and family education, ensuring understanding and evaluating teaching effectiveness.
- Performs other related duties as required, considering all responsibilities as essential functions under the Americans with Disabilities Act.
Job Qualifications
- Graduate from an accredited School of Nursing required.
- Bachelor's Degree in Nursing preferred.
- Must be enrolled in an accredited BSN program within two years and complete it within five years of employment.
- Current license to practice as a Registered Nurse in New York State required, plus any specialized certifications needed.
- Valid Driver's License in New York State may be required depending on the area of assignment.
*Additional Salary Details: The listed salary range or hourly rate is a good faith estimate and may be adjusted based on location, experience, education, credentials, and other factors.