POSITION SUMMARY:

Manages individualized, goaldirected nursing care through use of the nursing process and the principles of professional practice in accordance with departmental and hospital policies and procedures.

RESPONSIBILITIES AND ESSENTIAL JOB FUNCTIONS:

TO PERFORM THIS JOB SUCCESSFULLY, AN INDIVIDUAL MUST BE ABLE TO PERFORM EACH ESSENTIAL DUTY SATISFACTORILY. THE REQUIREMENTS LISTED BELOW ARE REPRESENTATIVE OF THE KNOWLEDGE, SKILL, AND/OR ABILITY REQUIRED. REASONABLE ACCOMMODATIONS MAY BE MADE TO ENABLE INDIVIDUALS WITH DISABILITIES TO PERFORM THE ESSENTIAL FUNCTIONS.

• Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients.
• Performs admission assessment in accordance with specific unit standards.
• Identifies and documents nursing diagnosis on patients plan of care.
• Develops, discusses and communicates a realistic problem list (plan of care) in collaboration with each patient/family/significant other in order to address all identified needs.
• Plan of care will include nursing diagnosis statement for each identified problem.
• Develops patient/family/significant other teaching and discharge plan as per unit standard.
• Demonstrates the skills and judgment necessary to implement medical plan of care, nursing interventions, and procedures as necessary for the care of the patient.
• Demonstrates knowledge of hospital policies and procedures for administering, transcribing, and recording medications.
• Demonstrates knowledge of commonly used meds: action, dose, and side effects.
• Observes five Rs for administering meds: right patient, right drug, right dose, right method, right time.
• Demonstrates proper procedures in all methods of medication administration.
• Administers blood and blood products following hospital policy and procedures.
• Initiates and maintains IV access according to hospital policy and procedures.
• Assesses and documents IV site per unit standard.
• Demonstrates knowledge and proper procedure in administration and documentation of PCA medication.
• Identified problems, care provided, and patients responses are reassessed in order to meet patient and family needs to ensure overall quality of care delivered.
• Reassessment of plan of care is done per unit standard.
• Assesses the patients/significant other's response to teaching plan in order to evaluate its effectiveness.
• Based on reassessment, plan of care will remain the same or be modified to meet the patents/significant other's identified needs.
• Documents outcome of patient care.
• Maintains uptodate and accurate documentation of nursing care provided to ensure the integration of information for use by the health care team, in order to ensure quality care.
• Nursing assessment is complete and accurate within per unit standard.
• Each identified problem must be addressed using P.I.E. format per unit standard.
• Day Surgery record/form accurately reflects nursing interventions and medical plan of care per unit standard.
• Flow sheets and I & O sheets must be accurate and signed with name and title each shift.
• Medication administration record must reflect full signature and title of nurse administering med, time given, reason for omission, and site for injection (if applicable).
• Discharge plan and documentation accurately reflects patients and/or significant other's ability to manage care after discharge. Referrals are made based on identified needs.
• Documents use of narcotics according to hospital policy and procedure.
• Maintains all licensure and certifications as required. Pursues professional growth and development.
• Practices within legal boundaries of nurse practice act and according to hospital policy and procedures.
• Attends continuing education programs in order to maintain licenses.
• Attends hospitalsponsored training programs as required by department.
• Functions as a role model for current and new staff.
• Accepts assignment as preceptor for new staff.
• Facilitates problem resolution among peers as observed by nurse manager and peers.
• Demonstrates a constructive approach during all interactions with staff and nurse manager toward the organization.
• Performs all responsibilities/duties required by Inpatient as defined in the scope of service, to assure that the unique nature of the client is addressed. This includes but is not limited to the age of the client served.
• Demonstrates the ability to rapidly assess the surgery patient differentiating between long and short-term needs.
• Patients are discharged from day surgery with consideration given to age and mobility.
• Discharge instructions are thorough and clear. Signatures obtained as per policy.
• Demonstrates knowledge of anesthetic agents, techniques, and actions.
• Properly demonstrates ability to recognize cardiac rhythms and to treat arrhythmia's appropriately.
• Demonstrates the ability to care for the post-op patient.
• Assumes responsibility for departments operational excellence; assures department delivers quality services in accordance with applicable policies, procedures, and professional standards.
• Manages all activities so that quality services are provided in an efficient and effective manner, as observed by manager
• Creates and maintains an environment that fosters innovation.
• Serves as a clinical resource to all staff members.
• Is a positive role model.
• Collaborates with the nurse manager to provide feedback for performance evaluations.
• Demonstrates leadership behavior in a professional manner.
• Communicates in a constructive manner with colleagues to decrease conflict and promote team work.
• Utilizes problem-solving techniques to prevent conflict and promote development.
• Demonstrates initiative in pursuing own professional development.
• Guides and assists other staff members in growth and development (i.e., resource, preceptor, role model, conducts conferences).
• Attends safety education programs.
• Provides complete and accurate responses to safety questions.
• Operates assigned equipment and performs all procedures in a safe manner as instructed.
• Maintains work area and equipment in condition required by department standards.
• Demonstrates proper body mechanics in all functions.
• If leader, provides for the safety of department employees.
• Effectively utilizes unit manuals as resources in order to clarify and/or resolve hospital policy issues.
• Follows the hospital exposure control plans/bloodborne and airborne pathogens.
• Demonstrates knowledge of techniques, procedures, and correct use of protective barrier equipment.
• Attends annual education programs.
• Wears and/or uses appropriate safety equipment.
• Ensures a safe environment by instituting appropriate control measures.
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
• Interacts with all of the above in a considerate, helpful, and courteous manner as observed by nurse manager and peers.
• Fosters mature professional relationships with fellow employees in a courteous, friendly manner as measured by management observation and peer input.
• Maintains professional composure and confidence during stressful situations.
• Maintains open communication using appropriate chain of command.
• Conducts all work activities with respect for rights and wishes of patients, visitors, families and fellow employees.
• Maintains confidentiality of all hospital and patient information at all times.
• Presents neat appearance in proper attire and displays identification as required by hospital policy.
• Displays a positive attitude that contributes to the overall customer service program at educational corporation.
• Promotes effective working relations and works effectively as part of a department/unit team to facilitate the departments/units ability to meet its goals and objectives.
• Participates in staff meetings as directed.
• Supports the hospitals mission, policies and programs through attendance and participation at committee meetings.
• Demonstrates ability to use the computer system to communicate inter- and intra-departmentally as appropriate.
• Assumes all other duties and responsibilities as necessary.
• Demonstrates willingness to identify and/or assume activities relative to the developmental needs of the unit and the nursing department.
• Demonstrates dependability/flexibility in meeting scheduling needs of the unit and hospital.
• Completes work assignments on time/readily accepts assignments as observed by nurse manager.
• Reports to work on time and is at work as scheduled.
• Other duties as assigned.

REQUIRED QUALIFICATIONS:

• Graduation from an accredited school of nursing.
• RN License, State of Texas.
• 2+ years experience
• BLS, ACLS, PALS

Job Type: Full-time

Required Skills Required Experience