Plans, implements and evaluates nursing regimens for an assigned number of patients. Collaborates with Physician and other Health team members in meeting total health care needs of patients. Serves as the primary Nurse and/or Team Leader in the delivery of nursing care.
- Assesses, plans, implements and evaluates the nursing care of the assigned patients.
- Performs admission assessments evidenced by documentation on Nursing Care Plans and Nurses notes.
- Reassesses patients Q shift, and with change of condition.
- Keeps the supervisor and/or designee informed of changes in patient's condition and/or treatments.
- Collaborates with other health team members when follow-up is necessary.
- Explains procedures to patient before they are performed.
- Administers patient care considering the patient's privacy and dignity as a human being.
- Acts rapidly and effectively during any emergency situation, managing self, patients and other employees.
- Contributes to the evaluation of patient care through participating in unit performance Improvement activities.
- * Collaborates with Health Team Members in planning and carrying-out treatment regimen.
- Interprets and implements treatment regimen as prescribed by Physician.
- Assists the Physician/Residents during treatments and/or diagnostic procedures.
- Makes observations of and reports patient's condition during treatments and procedures.
- * Provides and maintains a safe, clean, noise-controlled environment for patients to reduce stress and anxiety.
- Maintains vigilance over patients ensuring safety precautions/needs are followed (Side rails up, call lights and bedside stand within reach, etc.)
- Applies scientific principles in performing established nursing procedures.
- Provides a calm, quiet, restful atmosphere; communicates with the patient's family or caretakers.
- Maintains principles of universal precautions and infection control.
- * Participates in patient education.
- Provides the patient with explanation of his/her condition as indicated.
- Communicates assessment data by recording, updating and verbalizing pertinent information to Health Team members and to appropriate agencies.
- Recognizes and utilizes health teaching opportunities and resources/materials available.
- Provides early discharge planning and appropriate referrals by giving home instructions to patients and caretakers.
- Evaluates the teaching by feedback from patient/family and documents same.
- * Documents the patient's medical record with observations and action taken during patient's hospital stay.
- Keeps documentation of patient's treatment, activity and condition, as well as patient's responses to medical and nursing interventions.
- Uses the method of documentation according to the policy of the Nursing Department.
- * Performs in whichever capacity staffing level necessitates.
- Assumes charge responsibilities when assigned.
- Assists in extended orientation of new staff.
- Attends nursing, hospital committees as assigned.
- Performs related duties, as required.
*ADA Essential Functions
- Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN degree within five (5) years of employment date.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum one to two years experience in a hospital setting.