RN Clinical - S ICU Non-Exempt; Union

Overview

As an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients. The Registered Nurse is accountable for the coordination of patient care and education to the patient and family in accordance with the standards, policies, and practices in a compassionate, supportive, and therapeutic environment.

• Follows policies and procedures; demonstrates ability to access online manuals.
• Transfers learned scientific knowledge into practical application in applying the Nursing Process.
• ASSESSMENT:
  Appropriately completes Nursing Assessment upon patient admission, at each shift and with change of condition. Completes patient acuity by 0200/1400 daily.
• DIAGNOSIS:
  Interprets assessment information and formulates Nursing Diagnoses.
• PLAN:
  Develops Plans of Care with individualized interventions. Documents expected/projected patient outcomes. Reviews, revises, and updates Plans of Care daily based on evaluation and interpretation of patient outcomes.
• INTERVENTION:
  Administers medication and IV therapy appropriately at prescribed intervals. Completes patient care procedures correctly per policy at prescribed intervals. Delegates tasks based on others’ scope of practice and competency. Acts as patient advocate. Manages restraint use per policy; attempts alternative non-restraint measures first. Ensures MD order and MD assessment per policy. Ensures patient monitoring per policy. Ensures Restraint Audit Form is completed each shift.
• DOCUMENTATION:
  Documentation is complete and correct on all flow sheets and chart forms (Admission Assessment, Pain scale assessment and reassessment before and after intervention, Daily flow sheet, Restraint flow sheet, Diabetes flow sheet, Educational flow sheet, Kardex, Care Plan, Risk Assessment & Reassessment upon Fall, MAR, Equipment & Supplies, Intra and Inter Facility Transfer Forms, Belonging Tracking Form). Ensures orders are transcribed and signed off prior to the end of the shift.
  
  Completes 12h/24h chart checks.
• EDUCATION:
  
  Provides patient/family education as needed; room/unit orientation;
  Plan of Care; identifies knowledge deficits related to diagnoses and care; uses MICROMEDEX information for patients and families.
• TRANSFER & DISCHARGE:
  Collaborates with Case Manager and/or physician regarding discharge planning. Ensures all transfer paperwork is completed. Ensures belongings are sent with patient.
• EQUIPMENT:
  Utilizes patient care equipment appropriately and safely according to manufacturer guidelines (IV pump, Feeding pump, PCA pump, Epidural pump, Sequential compression device, Wound VAC, Heating pad/pump).
• COMMUNICATION:
  Communicates effectively with all members of the healthcare team including patient and family (Shift to shift report, Physician Rounds, Patient/family interactions, MDP Rounds, Hand-Off reports, Facility e-mail, Student/New employee/Contract employee).
• ORGANIZATION:
  Manages time effectively; able to organize and prioritize responsibilities; takes meal breaks without incurring overtime; completes shift on time.
• OBSERVES REGULATORY AGENCY REQUIREMENTS:
  National Patient Safety Goals, patient identifiers, unapproved abbreviations, Universal Protocol (Procedural Time Out), Hand-Off, Medication Reconciliation, Clinical Alarms, Hazardous waste management, Biohazard, Sharps, HIPAA, OSHA requirements, JCAHO – continuous survey readiness, Critical Values.
• WRITE DOWN / READ BACK / FOLLOW UP TELEPHONE ORDER / APPROPRIATE / DOCUMENTED / SIGNED, TIMED AND DATED / STAMPED / ENTERED into unit log;
  Maintains safe practice in the work environment (correct body mechanics, electrical safety, infection control procedures, hand washing).
• MANAGEMENT OF THE CARE OF MEDICAL SURGICAL PATIENTS (6N):
  Demonstrates ability to manage patients with THA, TKA, spinal surgery; maintain isolation precautions, respiratory and nutrition care for CF patients; manage medications and protective isolation for hepatic transplant patients; institutes safety precautions and skin care for hepatic encephalopathy.
• MANAGEMENT OF THE CARE OF PATIENTS IN THE ICU/S:
  Demonstrates ability to manage complex critically ill…