Description Has primary responsibility for the nursing care, assessment, planning, implementation, and evaluation of each assigned surgical patient. Plans, provides, and documents discharge planning, teaching, and educates patients, family, or others to attain optimal health and continuity of care. Assures that the plan of care is carried out in a safe environment through performance and supervision of subordinate personnel.
Requirements
JOB QUALIFICATIONS: Education: Graduate of an accredited School of Professional Nursing.
Skills
- Effective oral and written communication skills. Registered Nurse currently licensed by the State of Texas. Contract nurse may work under a compact license. BLS must be obtained within 90 days of hire. ACLS must be obtained within 6 months of hire. TNCC, PALS & NRP preferred.
- Physical and
- Mental
- Requirements: Duties of the position require extended periods of standing, walking, bending, stooping, twisting, reaching, and lifting up to 50 pounds. Occasional heavy lifting when moving or supporting patients who may suddenly become weak or helpless.
- Essential
- DUTIES
- AND
- RESPONSIBILITIES: A. Utilizing the nursing process, completes a comprehensive physical and psychosocial assessment of patients. 1. Take nursing histories to provide a basis for developing patient care plans. 2. Completes a nursing assessment and history at pre-op visitation. 3. Identifies teaching/learning/discharge needs at time of admission and throughout length of stay. 4. Provides an ongoing assessment which accurately reflects overt physiological and psychosocial needs of patients. 5. Consistently uses input from patient, family, significant other, physician, and healthcare team members. 6. Provides care appropriate for the pediatric, adolescent, and geriatric patients served based on demonstrated knowledge of the principles of growth and development over the life span. 7. Assesses and interprets data on the pediatric, adolescent, and geriatric patients’ status to identify patients’ requirements relative to their age-specific needs and provides care needed as stipulated in departmental policy. B. Using nursing process, plan, and provides patient/family care; evaluates patient’s response to care provided and redirects care, as necessary. 1. Formulates appropriate nursing diagnosis and identifies patient problems and performs ongoing assessment. 2. Initiates interdisciplinary communications and incorporates recommendation. 3. Assess and evaluates patient-response/outcome and makes appropriate modifications on the care plan. C. Implements and monitors appropriate nursing care to meet patients’ needs. 1. Administers medications according to policy including IV’s, blood, and blood components as prescribed by physicians. 2. Knows actions, indications, contraindication, precautions, adverse reactions, dosage, and route of administration on all drugs before administering to patient. 3. Verifies medication administration accuracy and performs the required checks on the medication administration record. 4. Identifies expected outcome for planned nursing interventions and gives exchange report to other healthcare personnel providing accurate and complete information on each patient at the change of shift, when transferring patient to another unit, and at intervals during the shift. 5.
- Performs basic nursing skills competently to include but not limited to: intake and output, vital signs, physical assessment, urine testing, specimens/cultures, dressing changes, neurological assessments, personal hygiene for patient, skin care, glucose monitoring, airway/suctioning, basic oxygen administration, nasogastric tubes, tube feedings, urinary catheterization, drains, enemas, and intravenous catheterization. 6. Recognizes, evaluates and interviews appropriately in a life-threatening situation. 7. Recognizes variance of diagnostic tests, vital signs, and assessments that should be reported to the physician and notifies physician in a time frame appropriate to the variance. 8. Functions proficiently in unit nursing modalities. D. Participates in the healthcare educational needs for the client, family, or significant other with regard to patient care needs, disease prevention, and health maintenance measures. 1. Develops and implements an individualized teaching and discharge plan at admission and throughout hospitalization. 2. Initiates and documents progressive patient, family, or significant other teaching on admission and throughout hospitalization. 3. Act as a liaison between patient, physician, family, or significant other, and other health disciplines. E. Maintains accurate and timely records according to hospital policy and procedures. 1. Documents ongoing assessments, within time frame determined by policy which accurately reflects overt physiological and psychosocial needs of patient. 2. Accurately documents on each shift the nursing patient care activities and the patient’s response to nursing interventions and delegated medical management. 3. Maintains a patient care plan that is current and reflects individual needs or preferences of patients. 4. Documents teaching completed and patient, family, or significant other response in the patient record. 5. Documents interdisciplinary recommendations for plan of care. 6. Transcribes and/or cosigns physicians orders completely and accurately according to hospital policy and practice. 7. Completes all appropriate transfer and discharge forms.
