|Facility:||Grimes St. Joseph Health Center (Navasota)|
|Department:||GSJ MEDICAL FLOOR|
|Shift:||Any Day of the Week|
Responsible for the delivery of patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation. Responsible for directing and coordinating all nursing care for acute care patients based on established clinical nursing practice standards. Collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired outcomes. Supports organization's vision and mission. Utilizes knowledge of patient's age and cultural diversity into provisions of patient care. Contributes to the provision of quality nursing care through participation in performance improvement programs that demonstrate positive outcomes.
Required: CPR,ACLS,Computer related documentation
Preferred: Meditech experience
- Provides care using nursing process to meet patient actual and potential needs:
Determines the priority data collection based on the patient's immediate condition or needs.
Collects pertinent data using appropriate assessment techniques.
Involves the patient, significant others, and health care providers in data collection when appropriate.
Ensures that the data collection process is systematic and ongoing.
Completes admission and ongoing assessment and observation of patient's condition.
Provides nursing care to meet patient's physical, psychological and spiritual needs.
Notifies physician on significant changes that requires attention.
Initiates falls prevention, wound and other programs and protocols as indicated by assessment findings.
Documents relevant data in the medical record according to hospital standards.
Derives diagnoses/patient problems from the assessment data.
Validates diagnoses/patient problems with the patient, significant others, and health care providers, when possible.
Documents diagnoses/patient problems in a manner that facilitates the determination of expected outcomes and plan of care.
Derives outcomes from the diagnoses/patient problems.
Documents outcomes as measurable goals.
Formulates outcomes mutually with the patient and health care providers, when possible.
Ensures outcomes are realistic in relation to the patient's present and potential capabilities.
Ensures outcomes are attainable in relation to resources available to the patient.
Ensures outcomes include a time estimate for attainment.
Ensures outcomes provide direction for continuity of care.
Individualizes the plan to the patient's condition or needs.
Develops the plan with the patient, significant others, and health care providers, when appropriate.
Ensures the plan reflects current nursing practice.
Provides the continuity of care in the plan.
Documents plan of care in patient's medical record.
Establishes interventions that are consistent with the plan of care.
Implements interventions in a safe and appropriate manner.
Prepares patients physically, psychologically, and spiritually for treatments, surgeries and diagnostic studies to help reduce patient anxiety.
Reports significant changes to Charge Nurse/Team Leader, and/or physician.
Transcribes or verifies transcription by others physician orders and is responsible for seeing these orders are carried out.
Starts and maintains intravenous infusions, including the administration of IV medications.
Administers medications and notes patients' reactions.
Demonstrates understanding of department specific equipment (i.e., safe use, requisitions, trouble shooting).
Performs chart checks to ensure that all treatments have been carried out.
Documents response to treatments, interventions, medications, and teachings in patient's medical record ensuring accuracy, completeness and timeliness.