RN - PACU - Nights

Job Summary

Required Qualifications

• •Registered Nurse
• •Maintains current license and certifications
• •Maintain up to date BLS and HI
• •Annual TB Screening and Influenza vaccination
• •Annual Ethics Training (Initial Ethics, if new employee)
• •Annual Safety Training
• •Required Information Security course
• •Required Abuse & Neglect course
• •Annual Blood Borne Pathogens training (if required)
• •Coursework as assigned for .edu
• •Annual competency
• •Age/Population specific competency (if applicable)
• •orientation competency (if new hire)
• •Service Specific
• •Maintains currency in all hospital/unit information, communication, policies and procedures
• •Attends staff meetings/reviews minutes when absent
• •Participates in Committee(s), Shared Governance, Work Team(s), in a leadership and or in membership role
• •Reviews Hospital/Nursing publications
• •Keeps up to date with policies and procedures
• •Participates and or keeps up to date with Shared Governance and Unit Based Practice Council activities and information. Contributes to requests for feedback
• •Adheres to all quality and performance standards, policies, procedures, protocols when implementing clinical and technical aspects of care
• •Participates in learning experiences that increases professional competence
• •Demonstrates appropriate technical and cognitive skills for area of practice
• •Responds positively to change
• •Provides assistance and support to peers, co-workers and other team members
• •Adapts positively to changes in unplanned work load and job demands
• •Participates in and maintains a collaborative team approach toward work
• •Functions as a resource person to co-workers, patients/families, medical staff and other members of the health care team
• •Effectively assumes and delegates care and other activities to the appropriate team member
• •Redirects clinical staff when the medical plan of care is altered
• •Communicates the plan of care to be followed on each individual patient in a precise and professional manner
• •Responsible for the supervision and teaching of students/new staff nurses
• •Practices standard precautions and disposes of hazardous wastes per established guidelines
• •Maintains a safe, clean, comfortable, and therapeutic environment for patients/ families/employees in accordance to hospital standards
• •Maintains clutter free environment
• •Follows hand hygiene procedures
• •Utilizes Safe Patient Handling techniques and equipment
• •Keeps personal conversations/background noise to a minimum
• •Adheres to dress code
• •Reports risk management concerns using eSRM
• •Reports variations from care/treatment following the occurrence reporting policy and procedure
• •Provides specialized care to patients at high risk for injury
• •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 the appropriate intervals
• •Provides specified patient care (toileting, skin care, hydration, feeding, etc.) on a timely basis
• •Provides consultation for peers to determine alternatives to restraints and 1:1 observation
• •Documents restraint use and associated care thoroughly
• •Assess patient for presence of pain on admission and during assessments/reassessments
• •Incorporates patient‘s cultural/spiritual beliefs regarding pain into pain management plan
• •Implement pain management techniques. Focus on prevention rather than treatment
• •Include patient and/or family members in developing a pain management plan
• •Consider other methods of pain control when developing plan of care: massage, repositioning, immobilization, and music therapy
• •Is aware of abuse recognition criteria and incorporates it into assessments
• •Reports signs of possible abuse/neglect to the Administrative Director of Behavioral Health, physician, Risk Management and Social Work
• •Takes appropriate action to support patient safety when signs of abuse are noted
• •Provides 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 evidenced 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
• •Performs and documents ongoing evaluation of effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments and procedures
• •Evaluates and documents effectiveness of patient/family education
• •Evaluates plan of care and modifies as indicated in ‘A‘ above
• •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
• •Demonstrates knowledge and skills of normal growth & development necessary to provide services to the age of the patient served by the department
• •Demonstrates ability to assess and interpret age specific data to identify patient needs
• •Utilizes communication skills necessary to interpret age specific responses to service and interaction
• •Involves family or s