Rn (fh) (medsurg)

Job Description

Performs an age-specific plan of care for a designated group of patients using the nursing process: assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills and clinical judgment to coordinate patient care and delegate activities within the patient care team.

Job Responsibilities

• Assess the patient's physiologic health status

• Conducts patient interviews, explains policies and procedures, reviews charts, and responds to questions courteously;
• Assesses gastrointestinal, cardiovascular, respiratory, renal, and neurological health;
• Determines mobility, sensory deficits, prostheses use, and skin condition, adjusting care plans accordingly;
• Assesses pain levels and management;
• Documents and communicates patient's physiologic health status and care plan.

Assess patient's psychosocial health status

• Gathers perceptions of care and expectations;
• Determines coping mechanisms, knowledge, and comprehension;
• Identifies cultural/ethnic needs to reduce anxiety and improve satisfaction;
• Documents psychological status and care plans; coordinates support services.

Identify patient outcomes

• Develops criteria for measuring outcomes;
• Identifies actual and potential problems;
• Determines educational needs based on assessments;
• Establishes patient goals and outcome statements.

Formulate the plan of care and set priorities

• Identifies necessary care activities and priorities;
• Coordinates resources to achieve outcomes;
• Documents and collaborates on care plans with physicians and team members.

Implement the plan of care

• Ensures safety precautions are followed;
• Uses professional skills to deliver care;
• Reassesses and revises care plans as needed;
• Administers treatments and uses equipment correctly;
• Provides emotional support;
• Performs procedures safely and efficiently;
• Records treatments, observations, and responses accurately;
• Acts swiftly in emergencies;
• Communicates effectively with patients and families;
• Participates in discharge planning and referrals.

Evaluate care and patient outcomes

• Measures and documents care effectiveness;
• Performs variance analysis for quality improvement;
• Implements systems to improve care quality;
• Maintains accurate documentation.

Collaborate with the care team

• Works with physicians on treatment plans;
• Interprets and implements treatments;
• Assists during procedures;
• Reports changes in patient condition;
• Delegates appropriately to team members.

Perform grade I-IV Decubitus Care

• Prevents skin breakdown;
• Applies dressings and compresses;
• Performs irrigations and related procedures.

Administer medications safely

• Identifies medications and educates patients;
• Prepares and administers medications, including IVs;
• Documents administration and educates on drug interactions.

Participate in patient and family education

• Explains conditions and treatments;
• Records and communicates assessment data;
• Utilizes educational resources;
• Plans for discharge and referrals;
• Evaluates teaching effectiveness.

Other duties as required

ADA Essential FunctionsJob Qualifications

• Graduate from an accredited School of Nursing; Bachelor's preferred. Enrollment in an accredited program within 24 months if hired after September 1, 2010, with a BSN within five years.
• Current NY State RN license.
• BCLS and ACLS preferred.

Additional Salary Details

The listed salary range is a good-faith estimate and may change. Factors such as location, experience, education, and internal policies may influence the actual salary offered.

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