Overview

The Registered Nurse will interview patients and significant others and complete a history documentation. Documents signs and symptoms that indicate actual and potential problems. Provides continuity of care by communicating the plan of care and diagnostic data, in accordance with the unit's guidelines. Involves family members and other health care team members in the development of the plan of care as appropriate. Sets priorities and gives nursing care based on the patient's needs.

Responsibilities

Assessment

• Performs appropriate nursing history and physical upon admission and on an ongoing basis.
• Collects and documents patient data.
• Interviews patients and significant others and completes a history documentation.
• Documents signs and symptoms that indicate actual and potential problems.
• Incorporates information in the written assessment from families/significant others and members of the health care team.
• Assesses safety of the patient care environment.
• Documents patient/family teaching needs in the patient care plan.

Planning

• In conjunction with the patient and family, develops individualized patient care plan.
• Identifies short and long-term goals, including discharge planning consistent with established patient care.
• Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.
• Provides continuity of care by communicating the plan of care and diagnostic data through the shift report, in accordance with the unit's guidelines.
• Involves family members and other health care team members in the development of the plan of care as able and appropriate.
• Revises the initial patient care plan to the changing needs of the patient.

Implementation

• Provides direct nursing care based on the plan of care and established priorities.
• Sets priorities and gives nursing care based on the patient's needs.
• Implements the medical care plan as delegated.
• Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).
• Writes patient discharge plan and makes appropriate referrals.
• Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.
• Coordinates the activities of other disciplines of the health team to implement the individual care plan.

Evaluation

• Evaluates and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.
• Revises plan of care based on evaluation.
• Documents the response of the patient to the medical care plan.
• Documents the response of the patient to nursing interventions.
• Recognizes alterations in physiological and psychosocial status.
• Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.
• Documents revision of the goals and plan of care to meet the changing needs of the patient.

Customer Service

• Consistently strives to implement the unit's customer service standards and to exceed the expectations of patients, families, physicians and visitors.
• Unit surveys consistently meet or exceed hospital benchmark.
• Demonstrates customer service commitment to patients by maintaining flexibility in relation to patient assignment, shift assignment and work schedule.
• All interactions are conducted in a professional manner.
• Verbal and written feedback from patients, family members/significant others, medical staff visitors and co-workers indicates behavior conducive to positive guest relations.
• Consistently exhibits appropriate phone protocol, e.g., answers phones promptly and professionally, is courteous and helpful.
• Interacts with other departments for problem resolution and quality patient care.
• Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.
• Makes rounds to assigned patients; anticipates patients' needs and answers/responds to the patients' call lights or paging promptly.

Professional Conduct

• Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the department or on an as-needed basis or as determined by management.
• Follows attendance and all other established hospital and department policies.
• Demonstrates the philosophy of the team concept.
• Participates in staff meetings with suggestions that enhance the work environment and increase productivity.
• Communicates well with supervisor, reporting problems with equipment, supplies or procedures.
• Requests assistance as appropriate.
• Complies with all safety and infection control standards.
• Maintains confidentiality as related to job responsibilities. Exhibits willingness to resolve problems as they arise.
• Consistently project positive professional image through appearance and behavior.
• Attends 75% of staff meetings or reads and initials minutes.
• Completes assigned work within shift.
• Complies with time and attendance policy (i.e., Kronos).

Performance Improvement

• Demonstrates WHMC's commitment to quality through the maximum individual effort of each employee.
• Completes Annual Updates and Ethics Training within established time frames.
• Completes general and departmental orientation within established time frames.
• Attends 80% of in-service programs.
• Maintains licensure/certification as appropriate.

Professional Growth and Development

• Completes Annual Updates and Ethics Training within established time frames.
• Completes general and departmental orientation within established time frames.
• Attends 80% of in-service programs.
• Maintains licensure/certification as appropriate.

Knowledge of Growth and Development

• Adolescent: Demonstrates ability to obtain and interpret information according to developmental age, e.g., sensitive to body changes (need for privacy); non-judgmental and accepting of behavior.
• Early to Middle Adulthood: Demonstrates ability to obtain and interpret information according to developmental stage, e.g., sensitive to need for control over own environment and need for explanation education regarding condition and treatment.
• Geriatric: Demonstrates ability to obtain information and recognize multiple disease entities associated with the aging process, e.g., increased need for personal possessions and personal safety maintained.

Range of Treatment

• Adolescent: Demonstrates ability to effectively care for patients with UTI, respiratory distress, trauma, toxic substance abuse/overdose, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.
• Early to Middle Adulthood: Demonstrates ability to effectively care for patients with UTI, acute neurological deficit, chest pain/MI, cardiac arrest, respiratory distress, trauma, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.
• Geriatric: Demonstrates ability to effectively care for patients with UTI, acute neurological deficit, chest pain/MI, cardiac arrest, respiratory distress, trauma, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.

Assessment

• Adolescent: Demonstrates ability to identify normal physiological parameters of the adolescent and assess for deviation, e.g., V/S, breath sounds, neurological deficit (reflexes), urinary output, nutritional status.
• Early to Middle Adulthood: Demonstrates ability to identify normal physiological parameters of the adult and assess for deviation, e.g., V/S, breath sounds, neurological deficit (reflexes), urinary output, nutritional status, cardiac arrhythmias.
• Geriatric: Demonstrates ability to identify normal physiological parameters of the geriatric patient and assess for deviation, e.g., decreased cognitive behavior and sensory perception, nutritional status, decreased skin integrity, fluid/electrolyte status.

Unit-Specific Competencies

• Procedural Sedation
• Discharge from Outpatient Anesthesia
• Malignant Hyperthermia
• H. Pylori

Cultural-Specific Competencies

• Exhibits culturally responsive attitude, including flexibility, empathy, respect and awareness of communication needs.

Qualifications

• Minimum Education: Graduate of approved nursing program.
• Minimum Experience: 1 year acute care experience preferred.
• Required Certification/Registration: Current California License; BLS; proficiency in both written and oral English. ACLS + PALS required.