Job Description
Performs an age-specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills and clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.
Job Responsibilities
1. Assesses the patient's physiologic health status
o Conducts patient interviews, explains policies and procedures, reviews patient's chart, and answers questions correctly and courteously.
o Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health status.
o Determines mobility, sensory deficits, prostheses use, and skin condition; adjusts plan of care accordingly.
o Assesses level of pain and pain management.
o Communicates and documents patient's physiologic health status and plan of care.
2. Assesses patient's psychosocial health status
o Gathers perception of medical/nursing care and patient expectations.
o Determines coping mechanisms, knowledge level, and comprehension ability.
o Identifies cultural/ethnic requirements to reduce anxiety and ensure satisfaction.
o Documents psychological status and care plan; involves support groups, counseling, and social services as needed.
3. Identifies patient outcomes
o Develops criteria for measuring outcomes.
o Identifies actual and potential patient problems.
o Determines patient's need for teaching based on psychosocial and developmental assessments.
o Creates patient outcome statements and establishes individualized goals.
4. Formulates the plan of care and sets priorities
o Identifies care activities and prioritizes to achieve expected outcomes.
o Coordinates the use of supplies, equipment, and medication cost-effectively.
o Documents the plan and collaborates with the healthcare team.
5. Implements the plan of care
o Ensures safety precautions are followed and maintains vigilance.
o Executes professional skills related to the care plan.
o Reassesses and revises the plan as needed.
o Administers treatments and uses equipment correctly.
o Provides emotional support and communicates effectively with patients and families.
o Documents treatments, activities, patient responses, and conditions accurately.
o Acts swiftly in emergencies and maintains a restful environment.
6. Evaluates care and patient outcomes
o Measures and documents the effectiveness of care.
o Performs variance analysis for performance improvement.
o Implements systems to improve care quality.
7. Collaborates with the care team
o Participates in planning and executes treatment regimens.
o Provides guidance to team members and interprets treatment plans accurately.
o Assists during treatments and diagnostic procedures.
o Communicates patient condition updates to relevant staff.
8. Performs grade I-IV Decubitus Care
o Performs preventive skin care and applies dressings aseptically.
o Performs irrigations and applies warm/cold compresses as per protocol.
9. Administers medications safely and correctly
o Identifies medications and understands their effects, side effects, and implications.
o Prepares and administers medications, including IV solutions, following policies.
o Educates patients about medications and interactions.
10. Participates in patient and family education
o Explains conditions and care plans clearly.
o Utilizes teaching resources and evaluates teaching effectiveness.
11. Performs other duties as required.
ADA Essential Functions
Job Qualifications
* Graduate of an accredited School of Nursing. Bachelor's Degree preferred. Enrolled in an accredited program within 24 months of employment if hired after September 1, 2010, and must obtain a BSN within five years.
* Current RN license in New York State.
* BCLS and ACLS certifications preferred.
Additional Salary Details
The listed salary range or hourly rate is a good-faith estimate of potential compensation, which may be adjusted based on various factors such as location, experience, and credentials.
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