Job Abstract

Under the general supervision of the ER Director or Assistant Director of Nursing, provides direct nursing care to patients.

ASSESSMENT

Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.

Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.

Assesses the needs of patient’s family or significant others in regards to the patient’s direct or long term care.

Selects, plans, evaluates all pertinent data and documents care based on this assessment.

Assesses, intervenes, and documents appropriately to meet patient's educational, psychosocial, and discharge planning needs appropriate to outpatient care and effectiveness.

Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.

DIRECT PATIENT CARE

Gives comprehensive, confidential patient care.

Initiates and follows through with patient and family teaching and evaluation.

Consults with unit Nursing Leadership regarding significant changes in patient's condition.

Collaborates with all members of the health care team.

Communicates relevant patient care information upon in house transfer.

Utilizes patient care standards in clinical practice.

Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.

Transcribes outpatient physician orders, gives written and verbal instructions to patient and/or significant others and documents in patient chart accurately and timely.

Seeks clarification of physician's written prescriptions and orders that are unclear or inappropriate.

Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.

Administers either IM, PO or subcutaneous medications in compliance with policies and procedures and does teaching with patient, family, and significant other (e.g., signs and symptoms of medication, food and drug interaction, physical, psycho social and nutrition in accordance to cultural needs).

Checks to ensure that emergency equipment is on hand and in good working order.

Checks that policy and procedure is followed accurately and consistently on proper handling of sharps.

Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e.g., cardiac monitors, defibrillators, suction apparatus, doppler, O2 tank, liquid nitogen tank, laser equipment, CO2 tank, pulse oximetry and pacemaker).

Checks that all monitoring equipment and ventilator alarms are set according to standards.

INDIRECT PATIENT CARE ACTIVITIES

Participates in multidisciplinary patient care rounds by presenting findings on patients.

Applies principles of infection control and safety.

Assists in the orientation of new personnel.

Provides clinical supervision of Certified Nurse Aides and other ancillary staff.

OTHER DUTIES

Relieves the Director as required.

Assists in data collection and analysis of Quality Assurance/CQI monitors; participates in implementation of follow up action.

Effectively utilizes the hospital computer system as it pertains to job responsibilities and in accordance with hospital policy.

Participates actively on Quality Improvement committees as assigned.

Participates in all safety and hazard procedures.

Assists other personnel as needed.

Keeps up-to-date with current trends pertinent to area of assignment.

Participates in continuing education activities; attends scheduled in-service programs; shares information gained at conferences with colleagues.

Responds to hospital codes (Code Blue, etc.,) as assigned.

Responds to emergencies in non-clinical areas as per policy and procedure.