DescriptionSummary:
Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries and other clinical/clerical associates. By assignment, may function as charge nurse for the unit. Involves provision of patient care/service to older adolescent, young adult, adult, geriatric and pediatric patients.
Responsibilities:
Patient Care Planning
- Develops comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment.
- Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference.
- Reviews and updates nursing care plan and collaborates with team members as changes occur.
Patient Care Provision
- Implements patient care as planned in nursing care plan and interdisciplinary care plan.
- Sets priorities based on knowledge of patient acuity and patient needs.
- Provides safe and therapeutic care and seeks resources when appropriate.
- Safely performs and accurately documents procedures, consistent with established nursing policy and procedure.
Patient Care Evaluation
- Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team.
- Evaluates progress toward nursing goals and revises goals as needed on a weekly basis.
Completes nursing progress note for assigned patients on a daily basis.
Completes nursing flow sheets for assigned patients on a daily basis.
Teaching
- Evaluates education needs of patient and significant others and documents their response to teaching.
- Utilizes, adapts, and revises teaching resources to meet patient education needs.
- Explains procedures, tests, and disease process to patients and families as needed.
- Acts as role model for health care students and other team members.
- Acts as preceptor to assigned orientees.
- Assists in orientation of new staff by sharing knowledge and experience.
Patient Care Communication
- Reports and documents accurately and concisely to appropriate persons the patient's condition.
- Maintains patient confidentiality.
- Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others.
- Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed.
- Gives and accepts constructive feedback appropriately.
- Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives.
Other duties as assigned
Requirements:
Education/Skills
- Associate's Degree in Nursing
Experience
- One year experience in nursing preferred. Will accept a new graduate.
Licenses, Registrations, or Certifications
- Current Texas State RN License or Compact RN License
- BLS (American Heart Association)
- ACLS required at time of hire for experienced RNs. New graduate nurses must obtain ACLS by the end of the clinical orientation period.
- PALS required at time of hire for experienced RNs. New graduate nurses must obtain PALS by the end of the clinical orientation period.
- Crisis intervention training required within 12 months of hire/transfer date
- For trauma designated facilities, TNCC required within 6 weeks of hire for experienced RNs. New graduate nurses must obtain TNCC within 18 months of hire/transfer date.
Work Type:
Per Diem As Needed