RN- Med Surg/ Observation (Full Time, Nights)

Job Summary

Responsible for the planning and delivery of care utilizing nursing processes\: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director. Provides compassionate and family center care for the patients admitted under observation status in 2 North.

Job Specific Duties

• Ensures completion of patient admission, history, and assessment. Accurately prepares and completes discharge planning as per department and hospital policies and procedures.
• Conducts handoff with oncoming RN utilizing SBAR; documents in Cerner.
• Plans, implements, and documents the plan of care (i.e. high risk of fall) in collaboration with other disciplines to assure safe and efficient care.
• Provides nursing care that includes\: IV site monitoring, suctioning, specimen collection, g- tube care, and assists medical team with specific procedures.
• Follows physician’s orders and administers medication. Adheres to six rights of medication administration.
• Collaborates and rounds with a multi-disciplinary team in daily care planning rounds as appropriate and fosters a Family Centered Care Environment.
• Accountable for reporting critical values to the physicians within 30 minutes and documents a clinician notification in Cerner.
• Completes all nursing multi-system assessment to include\: head to toe, vitals, dressing changes, applies protective skin barrier, suction, feeding, bathing and repositioning.
• Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation (within 24 hours) in the patient’s electronic health record.
• Communicates and documents critical lab results per hospital policy and procedures.
• Communicates with patients and families to review plan of care and solicits input. Communicates any patient and family concerns to physician.
• Educates family on emergency CPR, reflux precaution, plan of care, skin care, falls prevention, medication administration/side effects, and purpose of medication.
• Promotes an “error free” working environment by consistently providing high-quality safe care as per hospital policies.
• Responsible for providing a safe environment for co-workers by placing isolation/precaution signs (droplet, contact, or airborne) on door.
• Responsible for indicating allergies for patients via Cerner and placing bracelet on patient.
• Creates incident reports for IV infiltrates, near misses, malfunction of machine on patients, and/or falls, documenting the situation.