Registered Nurse - Cardiac Stepdown

Registered Nurse - Cardiac Stepdown - Days

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Job Summary: The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

• Performs comprehensive nursing assessment/reassessment.
• Performs age‑appropriate admission assessment or transfer assessment. Obtains input from family/guardian when appropriate.
• Accurately and completely documents findings.
• Performs assessment of post‑op/post‑invasive procedure patients.
• Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.
• Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc., and standards of care.
• Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant.
• Identifies short and long term goals based on patient care needs.
• Formulates nursing interventions to achieve desired patient outcome.
• Incorporates disease specific evidence‑based practice into nursing care plan and other documentation.
• Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.
• Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.
• Provides, coordinates and communicates patient care, including accurate Handoff Communication Reports.
• Administers and documents medications accurately according to policies and procedures.
• Monitors, maintains and documents accurate IV fluids and parenteral nutrition according to policies and procedures.
• Completes referrals as indicated by assessment data.
• Requests consultation for special needs, equipment, or information for patient and/or family.
• Provides patient/family education and discharge planning per documentation guidelines and protocol.
• Clarifies all physician orders as warranted.
• Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record.
• Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate.
• Documents “Readback” for all telephone/verbal orders.
• Takes telephone/verbal orders only in emergency situations.
• Recognizes changes in patient's condition and takes appropriate nursing actions.
• Involves the family/guardian when providing care and in decision‑making as appropriate.
• Recognizes risks for patient and takes appropriate action.
• Incorporates use of Infection Control practices in daily care.
• Documents and or communicates nursing care and or changes in patient condition.
• Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures.
• Evaluates effectiveness of patient/family education.
• Evaluates plan of care and modifies as indicated.
• Recognizes significant changes in patient's clinical parameters and reports immediately to physician and others as indicated.
• Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.
• Reports variation from care/treatment following the occurrence reporting policy and procedures.
• Provides specialized care to patients at high risk for injury.
• Restraint Care:
  Initiates/evaluates alternatives to restraint prior to application; applies restraints consistent with the approved procedure; monitors and assesses patient's response throughout the restraint period at appropriate intervals; provides specified patient care; and documents restraint use and associated care thoroughly.
• Pain Management:
  Assess patient for presence of pain on admission and during assessments;…