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 to coordinate and implement procedures and treatments. Uses leadership skills and clinical judgment to coordinate patient care and delegate activities within the patient care team.
Job Responsibilities
- Assesses the patient's physiologic health status
- Conducts patient interviews, explains policies and procedures, reviews patient charts, and answers questions courteously;
- Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health;
- Determines mobility, sensory deficits, prostheses use, and skin condition, adjusting the care plan as needed;
- Assesses pain levels and manages pain effectively;
- Documents and communicates the patient's physiologic health status and care plan.
Assesses the patient's psychosocial health status- Gathers perceptions of medical/nursing care and patient expectations;
- Determines coping mechanisms, knowledge levels, and comprehension abilities;
- Identifies cultural and ethnic requirements to reduce anxiety and enhance satisfaction;
- Documents psychological status and care plans, including support groups, counseling, and social services.
Identifies patient outcomes- Develops criteria to measure patient outcomes;
- Identifies current and potential patient problems;
- Assesses the need for teaching based on psychosocial and developmental factors;
- Creates patient outcome statements and sets individualized goals.
Formulates the plan of care and establishes priorities- Identifies care activities and prioritizes to achieve expected outcomes;
- Coordinates the use of supplies, equipment, and medication efficiently;
- Documents the care plan and collaborates with the healthcare team.
Implements the plan of care- Ensures patient safety and follows precautions;
- Utilizes professional skills in care delivery;
- Reassesses and revises the care plan as needed;
- Administers treatments correctly;
- Uses equipment properly;
- Provides emotional support;
- Performs procedures safely and efficiently;
- Accurately observes and records patient conditions and responses;
- Maintains proper documentation;
- Acts swiftly during emergencies;
- Creates a restful environment and communicates effectively with families;
- Participates in discharge planning and referrals;
- Provides discharge instructions.
Evaluates care outcomes- Measures and documents effectiveness of care;
- Performs variance analysis for quality improvement;
- Implements systems to enhance care quality;
Collaborates with the care team- Works with physicians on care plans;
- Implements treatment regimens accurately;
- Assists with procedures;
- Communicates patient status changes;
- Delegates appropriately to team members.
Performs Decubitus Care- Performs skin care, dressing, and irrigations as per protocol;
Administers medications safely- Identifies medications and educates patients;
- Prepares and administers medications, including IVs;
Participates in patient and family education- Provides explanations, assesses understanding, and plans discharge and follow-up care;
Performs related duties as requiredJob Qualifications
- Graduate from an accredited School of Nursing; Bachelor's degree preferred. Enrolled in an accredited program within 24 months if hired after September 1, 2010, with a goal to obtain a BSN within five years;
- Current NY State RN license;
- BCLS required; ACLS preferred;
- Operating Room Nursing experience is strongly preferred.
Additional Salary Details
The salary range is a good faith estimate and may change. Factors influencing salary include location, experience, education, credentials, and internal policies.