|Facility:||St. Joseph Regional Health Center (Bryan)|
|Shift:||Any Day of the Week|
Plans, organizes, administers and evaluates comprehensive nursing care in accordance with hospital and department policies, procedures, regulatory requirements and standards of care and directs nursing care activities of team members to ensure excellent care is provided to all patients.
- Assessment:Does admission and ongoing assessment of patient's condition. Provides nursing care to meet the patient's physical, psychological and spiritual needs. Notifies doctor of changes in assessment that require attention.
- Planning:Designs, directs, evaluates, and documents the plan of care, patient/family teaching and preliminary discharge planning to ensure that all aspects of the patient's stay are addressed in a reverent manner. Works with other clinical disciplines to meet specialized patient care and discharge needs.
- Implementation:Prepares patients physically, psychologically, and spiritually for treatments, , surgeries and diagnostic studies to help reduce patient anxiety. Knows patients' conditions and 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. Follows infection control policies in all aspects of care. Starts and maintains intravenous infusions, including the administration of IV medications. Administers medications and notes patients' reactions. Follows policy, procedure and standards of hospital and department. Floats to other areas as necessary for patient safety. Demonstrates understanding of department specific equipment (i.e., safe use, requisitions, trouble shooting). Initiates falls prevention, wound and other programs and protocols as indicated by assessment findings.
- Evaluation:Reassesses patients at appropriate intervals following interventions. Notifies physician as necessary to modify interventions. Adjusts nursing care to meet patient's emerging and changing needs.
- Documentation:Documents response to treatments, medications, therapies and teaching to assure that patient's records are up-to-date. Maintains accurate and complete records of nursing observations and care to ensure accurate documentation of said observations. Maintains accurate documentation of interventions and supplies used. Completes and documents chart checks to comply with current policy.
- Privacy:Assures privacy of all patient information to protect patient rights and meet HIPPA quidelines. Reports suspected violations immediately.
- Report Skills:Gives and receives report at the bedside. Provides an accurate and comprehensive report to the oncoming shift to help establish continuity of patient care. Receives report from off-going shift and delegates tasks as needed to provide continuity of care according to coworker's experience, abilities and the patient's acuity.
- Environment & Patient Safety:Maintains patient and work environment to maximize safe working space. Promptly removes all used and soiled equipment, linen, etc. to appropriate location. BMV scanning rates comply with current policy. Reports all patient safety and hazard concerns immediately.
- Supplies:Maintains accurate documentation of charges and supplies used to ensure adequate supply replacement and efficient use of allocated funds.
- Time Management:Clocks in and out according to policy to ensure work is started and completed on time and to lead by example. Obtains Director/designee/House Supervisor approval before working overtime shifts.
- License and Competency:Maintains RN license to adhere to Texas Board of Nursing Guidelines and serve the organization in a licensed capacity. Takes responsibility for meeting competency requirements. Assists with the orientation of new employees and floated staff as requested and assigned.
- Meeting/In-service Attendance:Attends in-services, workshops, and reads current journals to keep abreast of new developments in the medical and nursing fields. Attends 6 unit meetings per year, all mandatory in-services, and completes annual competencies. Attends other meetings as designated by Director.
- Patient Care: Notifies M.D. of life-threatening arrhythmias and changes and notes physician response. Starts and maintains IV titrated infusions and ensures correct dosage for patient's weight. Monitors epicardial pacer wires to ensure they are coiled and enclosed in a needle cap and put under tegaderm on the chest. Understands proper and safe operation of equipment on unit (Telemetry monitors, O2, suction equipment, and external pacemakers). Assists physicians with procedures as indicated.
- Performs other duties as assigned to meet the organization`s needs.