- Interviews patient, family, significant others to formulate a nursing history.
- Observes, identifies and collects data to identify nursing care needs of the patient and family.
- Correlates the medical plan of care with the nursing plan of care.
- Identifies and reports to the appropriate person(s) abnormal diagnostic data and clinical changes in the patient's condition.
- Reviews each patients chart for completeness. Notifies physician or other appropriate persons if chart is not complete in a timely fashion to avoid delays.
- Completes an immediate assessment of each patient as they arrive in SDS post procedure.
- Based on changing patient needs in the Post procedure phase, evaluates, revises and updates patient care until discharged from the unit.
- Develops and/or updates individualized nursing care plan on each patient.
- Documents patient problems and nursing care needs of the patient and family/significant others.
- Actively involves patient and family/significant others in planning patient's care.
- Develops short- and long-term goals for the patient and family/significant others. Identifies the need to involve other disciplines in the patient's care.
- Initiates discharge planning upon admission.
- Performs common nursing procedures as defined in Policy and Procedure Manual.
- Implements changes in physicians' orders in a timely manner.
- Explains treatments and procedures to patient and family/significant others.
- Provides patient and family teaching.
- Provides for the safety, cleanliness and comfort of the patient.
- Maintains knowledge and skills in emergency procedures per ACLS guidelines and initiates emergency procedures as needed within the scope of practice and hospital policy.
- Evaluates the patient's response to nursing care.
- Updates and revises care to be delivered as patients' needs change.
- Appropriately communicates changes and care given to other members of the health care team.
PROFESSIONAL GROWTH AND RESPONSIBILITY:
- Assumes leadership role and delegates nursing care.
- Assigns tasks appropriately and guides team members based on their skills and abilities.
- Maintains awareness of legal aspects of hospital nursing.
- Conducts patient care conferences.
- Updates skills and knowledge and attends peers' patient care conferences.
- Assists in orientation and/or acts as a preceptor for new personnel.
- Sets goals and objectives with target dates.
- Participates in patient care Quality Assurance programs.
- Recognizes impending post-operative complications.
- Manages patients as team leader or primary care giver.
- Demonstrates flexibility to work as out-patient nurse or ward secretary as needed.
- Maintains post operative drains, tubes and irrigations (i.e., chest tubes, NG tubes, CBI, suprapubic catheters).
- Maintains all intravenous lines and fluids (i.e., CVP, Hickman catheters, IV PBs, portacath hyperalimentation).
- Manages pain effectively (ie, PCA, IVP, IM, PO).
- Maintains proper aseptic technique during dressing changes.
- Clearly documents effectiveness of nursing care (i.e., pain management and response to treatments such as wound care).
- Assists physical therapist in mobilizing patients and assesses progress.
- Keeps accurate record of intake and output.
- Minimum Education: Knowledge necessary to obtain California RN license. Current California RN license and current American Heart Association BLS, ACLS and PALS certification required.
- Minimum Experience: Recent acute care experience preferred.
Job : Surgical Services
Primary Location : CA-Fountain Valley
Hospital/Facility : 024-Fountain Valley Regional Hospital - Fountain Valley, CA
Job Type : PT2Y
Shift Type : Varied