OverviewAssesses patient/family health problems and resources, takes a leadership role in the development, implementation and outcomes evaluation of a plan for nursing care provided by the nursing team. Provides technical nursing care and interventions to designated patient populations.
This position requires providing service to a one or more age populations including young adolescent through geriatric patient population in a manner that demonstrates an understanding of the functional/developmental age of the individual served. Admission coordination, make nursing assignments, coordinate shift activities and quality control functions
Responsibilities- Completes and documents initial assessment/care within required time frames.
- Performs reassessments/care at intervals as required or appropriate to the patient's specific needs.
- Ensures physical assessment/care includes all major body systems.
- Ensures spiritual assessment/care includes actual/expressed needs.
- Incorporates cultural and ethnic factors into assessment/care.
- Correctly differentiates between normal and abnormal findings.
- Makes appropriate referrals for positive high risk screens.
- Identifies educational needs upon admission and thereafter.
- Identifies barriers to learning.
- Provides teaching based on identified needs.
- Evaluates the effectiveness of instruction provided.
- Assessment and teaching incorporates cultural and ethnic factors.
- Assessment and teaching incorporates functional needs.
- Develops and implements the plan of care based on assessment findings.
- Establishes the plan of care on admission.
- Re-evaluates and modifies the plan of care, based on the patient's response to the interventions.
- Communicates the plan of care to members of the nursing team.
- Involves the patient/family in developing the plan of care.
- Demonstrates sound clinical judgement in decision-making regarding patient care.
- Communicates effectively with physicians and allied health team.
- Coordinates nursing care with other disciplines involved.
- Involves allied health team members, as necessary.
- Actively participates in multidisciplinary care conferences.
- Provides local wound care as ordered.
- Applies dressings as ordered or as appropriate to the type of wound.
- Documents nursing interventions using the FOCUS charting format.
- Demonstrates knowledge of procedures and post-care.
- Follows established protocols for patients at high risk for suicide or unpredictable behavior.
- Follows established protocols for patients at high risk for falls and skin breakdown.
- Follows appropriate Code Blue notification procedures.
- Functions in a Code Blue quickly and calmly providing CPR, administering and documenting medications/interventions accurately.
- Effectively prioritizes clinical interventions and care.
- Communicates significant changes in patient's condition/status in a timely manner.
- Understands actions, side-effects, contra-indications of drugs.
- Follows five "rights" of medication administration.
- Adheres to medication policies, practices and standards.
- Administers medication, intravenous therapy and fluid management only on physician request and guidance.
- Obtains necessary training prior to initial equipment use.
- Assures equipment is in operating order prior to use.
- Differentiates between patient complications and equipment malfunction.
- Uses the following equipment in accordance with manufacturer's operating instructions, including but not limited to:
- IV Pump
- Glucoscan
- PCA Pump
- Tube Feeding Pump
- Chest Tube Suction
- Defibrillator
- Bedside monitor
- Other duties as assigned.
QualificationsEDUCATION/TRAINING/EXPERIENCEGraduate of a RN School of Nursing
BSN- Preferred
Excellent written and verbal communication skills
Bilingual (English/Spanish/Vietnamese/Chinese) preferred
Computer skills
LICENSES/CERTIFICATIONSCurrent California RN License
Current ACLS, BLS - AHA
NIH Certification- within 90days of hire
CCRN- Preferred
