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
- Assess the patients' physiologic health status
- Conducts patient interviews, explains policies and procedures to patients/significant others, reviews patients' charts, and answers questions correctly and courteously;
- Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health status;
- Determines mobility, sensory deficits, prostheses use, and skin condition, and adjusts the plan of care as appropriate;
- Assesses level of pain and pain management;
- Communicates and documents patients' physiologic health status and plan of care.
Assess patients' psychosocial health status- Elicits perception of medical/nursing care and expectations of care;
- Determines coping mechanisms, knowledge level, and ability to comprehend;
- Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction;
- Communicates and documents psychological status and care plan; support group, counseling services, social services.
Identify patient outcomes- Develops criteria for measurement of patient outcomes;
- Identifies actual or potential patient problems;
- Identifies patients' need for teaching based on psychosocial and developmental assessments;
- Develops patient outcome statements and establishes individualized patient goals.
Formulate the plan of care and establish priorities- Identify care activities and establish priorities necessary to achieve expected outcomes;
- Coordinate the cost-effective use of supplies, equipment, and medication;
- Document the plan of care and collaborate with physicians and other health team members.
Implement the plan of care- Maintain vigilance over patient care to ensure safety precautions are followed;
- Exercise professional skills related to the plan of care;
- Reassess patients as needed and revise the plan accordingly;
- Administer prescribed treatments correctly;
- Use equipment properly for patient care;
- Provide emotional support to patients and significant others;
- Apply scientific principles in performing procedures safely, timely, and efficiently;
- Make accurate observations during treatments and procedures, reporting and recording as appropriate;
- Keep accurate documentation of treatments, activities, conditions, and responses;
- Use appropriate documentation methods per departmental policy;
- Act effectively during emergencies, managing self, patients, and staff;
- Create a calm, restful atmosphere and communicate effectively with patients' families or caretakers;
- Participate in discharge planning and coordinate referrals, providing discharge instructions.
Evaluate care and patient outcomes- Measure and document the effectiveness of care provided;
- Perform variance analysis for performance improvement;
- Design, implement, and evaluate systems to improve care;
- Maintain accurate documentation of treatment, activity, and condition;
Collaborate with the care team- Plan and execute treatment regimens with team members;
- Interpret and implement treatment plans as prescribed;
- Assist physicians during treatments and procedures;
- Keep management and physicians informed of patient status and treatment changes;
- Delegate assignments appropriately to team members.
Perform grade I-IV Decubitus Care- Perform preventive skin care measures;
- Apply dressings, compresses, irrigations as per procedures;
Administer medications safely and correctly- Identify medications and understand their actions, doses, and side effects;
- Prepare solutions and administer medications according to policies;
- Educate patients on drug interactions.
Participate in patient and family education- Explain conditions and care plans to patients;
- Record and communicate assessment data;
- Utilize educational resources and materials;
- Plan for discharge and post-hospital care;
- Evaluate teaching effectiveness and document.
Perform related duties as required.Job Qualifications
- Graduate from an accredited School of Nursing. Bachelors Degree preferred. Must be enrolled in an accredited program within 24 months if hired after September 1, 2010, and obtain a BSN within five years.
- Current RN license in New York State.
- BCLS, ACLS preferred.
Additional Salary Details
The listed salary range is a good faith estimate and may be adjusted based on factors like location, experience, and credentials.