Registered Nurse - Pre-Surgery Holding- PRN Days

Job Summary
Provides professional nursing care for assigned patient(s) in one or more patient care departments according to State Board of Nursing Practice Act, American Nursing Association Code of Ethics and standards of practice and professional performance. Responsible for assessment, diagnosis, outcomes identification, planning, implementation and evaluation for patients served. As an active participant in decisions related to patient care and nursing practice, serves as instructor, colleague, researcher, advocate and leader. Must demonstrate competency in assuring quality care, Process Improvement, patient and employee safety, collaboration, consultation and professional development. Assumes responsibility for planning, organizing, delegating and evaluating patient care rendered by LPNs, technicians, medical receptionists and other staff.
 

Essential Functions
•Assessment: Involves the patient, family, other healthcare providers in collecting and prioritizing patient health information (PHI). Uses appropriate evidence - based assessment techniques and tools. Documents relevant data in the appropriate format. Performs initialand ongoing assessments. Notifies physician of significant changes in patient status, includingcritical results. Interprets and documents PHI for determining plan of care. Identifies anddocuments patient/family learning and discharge needs. Incorporates information from otherresources in assessment and planning care of the patient. Assesses discharge barriers onadmission and when appropriate.
•Nursing diagnosis: Identifies and documents the diagnoses, problem list or issues based onassessment. Validates the diagnoses, problem list or issues with the patient, family, andothers when appropriate.
•Outcomes Identification: Involves the patient, family, and other healthcare providers inidentifying and documenting expected outcomes & timelines. Defines expected outcomes interms of the patient, patient values, ethical and cultural considerations, environment, situationand continuity of care.
•Planning: Involves the patient, family and other healthcare providers in developing anddocumenting a plan of care that is culturally sensitive, to include discharge and learning needs.Updates the care plan to address each of the identified diagnoses, problems or issues andassures plans are achievable and patient-centered. Utilizes the plan to assure continuity ofcare. Integrates evidence based practice and research affecting care in the planning process.
•Implementation: Provides/ documents age appropriate care into a culturally sensitive manner.Provides nursing care based on patient-focused outcomes and are evidence based standardsof care. Safely administers patient care, medications and treatments in accordance withstandards of practice. Recognizes and responds appropriately to emergency situations.
 

Job Description
Utilizes community and other resources and systems to implement the plan, facilitating referrals when appropriate.
• Coordination of Care and Professional Models of Care: Coordinates all facets of care. Coordinates implementation of the plan, documenting in a timely and appropriate manner. Demonstrates familiarity and awareness of regulatory agency impact on various aspects of care. Demonstrates how the patient/family centered care model addresses patient’s needs and patient satisfaction. Assists the patient and family in identifying and securing appropriate and available services and resources to address health-related needs. Assists the patient and family in becoming informed consumers about the options and benefits of treatment and care. Demonstrates application of Benner’s novice to expert model in patient education and staff competency. Demonstrates understanding of shared governance participation providing input, feedback and varying degrees of involvement and participation to assure involvement in budget and resource development and accountable care.
• Evaluation: Evaluates and documents the effectiveness of the plan. Uses ongoing assessment data to revise the nursing diagnoses, outcomes, plan and the implementation as needed.
• Quality: Uses the results of quality improvement activities, creativity and innovation to improve patient care. Incorporates new knowledge to initiate changes in nursing practice. Verbalizes/participates in, unit-specific nurse-sensitive/ National Patient Safety Goals/ core measures/ throughput indicators being monitored, results and actions taken to improve coordination and delivery of care. Maintains awareness of current professional trends and procedure/policy changes, which affect the delivery of patient care and unit activities. Ensure documents are legible using concise terms, correct terminology and approved abbreviations. Assures timely throughput patient processes via demonstration of “pull” behavior, effective/ proactive discharg