Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem solving strategies and applies evidence based practices. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director. Provides compassionate and family centered care. |
- Ensures completion of patient admission, history, assessment, & pain reassessment. Accurately prepares & completes the discharge planning process per department and hospital policies & procedures.
- Conducts handoff with oncoming RN utilizing SBAR; documents in Cerner. Conducts assessments and documents.
- Plans, implements, and documents the plan of care (i.e. high risk of falls) in collaboration with other disciplines and services to assure safe and efficient care.
- Provides nursing care that includes: IV site monitoring, suctioning, specimen collection, lines, tubes and drains, and assists medical team with specific procedures.
- Follows physician’s orders and administers medication. Adheres to six rights of medication administration.
- Collaborates and rounds with a multi-disciplinary team during daily care planning rounds as appropriate and fosters a Family Centered Care Environment.
- Utilizes electronic innovations to provide efficient patient care. Attends to patient call lights in a manner that promotes patient safety per hospital policy.
- Reports critical values or change in status to the physicians within Procedure and Policy Standards and documents clinician notification in Cerner.
- Ensures proper and safe wound care as required by Wound Care Policy and Procedures.
- Accesses electronic health record independently according to hospital policy. Completes accurate and timely documentation in the patient’s electronic health record.
- Communicates with patients and families to review plan of care, provide education, and when necessary uses appropriate translation methods. Communicates any patient and family concerns to physician.
- Promotes an “error free” working environment by consistently providing high-quality safe care as per hospital policies.
- Responsible for providing a safe environment for co-workers by placing isolation/precaution signs (droplet, contact, or airborne).
- Creates incident reports for hospital acquired conditions, near misses, malfunction of machine on patients, and adverse events/medication errors documenting the situation within 72 hours.
- Assesses all body systems, ensures safe efficient care, absence of medication errors, avoidance of falls, prevention of central line infections, ouch-free procedural pain, and pain reduction.
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