RESPONSIBILITIES:
Essential Job Functions: Interviews patient, family history, significant others to formulate nursing history.
Observation: Observes, identifies and collects data to identify nursing care needs of the patient and family.
Documentation:
- Demonstrates decision making process and ability to recognize priorities and resolve appropriately.
- Documents primary assessment in a timely manner.
- Identifies and reports to the appropriate person(s) abnormal diagnostic data and clinical changes in the patient's condition.
PLANNING:
- Develops and/or updates individualized nursing care plan on each patient.
- Documents patient problems and nursing care needs of the patient and family/significant others.
- Actively involves patient and family/significant others in planning patient's care.
- Develops short- and long-term goals for the patient and family/significant others.
- Identifies the need to involve other disciplines in the patient's care.
- Initiates discharge planning upon admission.
IMPLEMENTATION:
- Performs common nursing procedures as defined in Policy and Procedure Manual.
- Implements changes in physicians' orders in a timely manner.
- Explains treatments and procedures to patient and family/significant others.
- Provides patient and family teaching.
- Provides for safety, cleanliness and comfort for patient.
- Initiates emergency procedures as needed within the scope of practice and hospital policy.
- Demonstrates critical thinking skills in dealing with infrequently encountered or difficult situations.
EVALUATION:
- Evaluates the patient's response to nursing care.
- Updates and revises care to be delivered, as patient's needs change.
- Appropriately communicates changes and care given to other members of the health care team.
- Keeps immediate supervisor informed of organizational, staff and patient problems.
PROFESSIONAL GROWTH AND RESPONSIBILITY:
- Maintains an awareness of legal aspects of nursing, including accurate/timely documentation according to standards/policy and procedure.
- Conducts patient care conferences.
- Updates skills and knowledge and attends peer's patient care conferences.
- Assists in orientation and/or acts as a preceptor for new personnel.
- Provides evaluation materials in a timely manner.
- Participates in quality assurance programs and/or committees.
UNIT SPECIFIC:
- Manages patients as a primary care giver.
- Demonstrates ability to utilize equipment in the clinical setting.
- Demonstrates basic computer entry skills.
- Demonstrates knowledge and skills in application of monitoring equipment.
- Demonstrates knowledge and skills in recognizing and acting accordingly to life threatening arrhythmias.
- Attends skills lab (knowledge and clinical ability to perform) Point of care testing.
Physical Demands: Employee must meet physical and mental requirements as identified by the physical activity evaluation form.
Qualifications:
A. Minimum Education: Current California RN License, Current American Heart Association BLS Certification, ACLS and Initial Dysrhythmia Recognition within 90 days of hire.
B. Minimum Experience: Current American Heart Association BLS, ACLS certification and Initial Dysrhythmia Recognition within 90 days of hire.
C. Preferred Skills and Abilities: Recent acute care experience preferred.
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