Overview

Assesses 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 an ill 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
  • Telemetry transmitter
• Other duties as assigned.

Qualifications

EDUCATION/TRAINING/EXPERIENCE

 

Graduate of a RN School of Nursing

BSN- Preferred

Excellent written and verbal communication skills

Bilingual (English/Spanish/Vietnamese/Chinese) preferred

Computer skills

 

LICENSES/CERTIFICATIONS

Current California RN License

Current ACLS, BLS (AHA)

NIH Certification - within 90 days of hire