JOB DESCRIPTION
Completes initial assessment on new patients within 2 hours of arrival, including functional assessment, psychosocial, pain assessment, discharge planning, referrals to interdisciplinary team and code status.
Initiates and updates patient care plan, assess patient educational needs and barriers to learning. Reviews all orders and transcribes when necessary. Follows telephone read back policy. Monitors all telephone orders for signature and validation by the physicians within 48 hours.
Explains all procedures to patients maintaining privacy and allowing patients to express emotional needs. Knowledge of IV medications , ADR and blood components.
Documents evidence of nursing care on the patient’s record. Observe reactions and/or complications and report to the physician in a timely manner.
Knowledge about the National Patient Safety Goals and quality initiatives.
Consistently uses two patient identifiers when drawing a lab, administering medications and performing procedures.
Does not use unacceptable abbreviations in documentation, (using read back on all telephone orders.)
Consistently follows medication reconciliation policy.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Is in compliance with information contained in the Infection Prevention and Control Manual ( i.e. OSHA bloodborne pathogen standards, CDC Guidelines ), and demonstrates appropriate use of personal protective equipment ( i.e. gloves, gowns, masks, goggles ) and hand hygiene.
Adheres to purposeful rounding on all patients as per hospital policy.
Able to give thorough, detailed, efficient change of shift bedside report to ensure consistency in the plan of care.
Assists physicians with special tests and procedures in the unit. Uses time out on all patients for any bedside procedures.
Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e. suction and oxygen immediately available when needed.
Consistent with pain assessment and reassessment with the time frame after giving pain medications and upon discharge or transfer of patients.
Completes documentation of medications given to the patient on the medical record. Resolves any discrepancies in the medication dispensing system.
Recognizes signs of abuse and reports appropriately.
Initiates discharge and patient / family education planning with proper documentation in the medical record.
Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
Formulates , maintains and updates a goal directed plan of care on patients which is prioritized and based on patient outcomes.
Performs other duties as assigned or required.
EDUCATION, EXPERIENCE, TRAINING
Must have a current and valid California RN license
BCLS, ACLS certifications required upon hire
Previous Critical Care experience. Cath lab preferred. If not must complete Critical Care Course Certification within one year
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