Demonstrates effective assessment skills to ensure quality patient care is provided.
Performs and documents accurate initial assessment per unit standard which may include: initial observation, obtaining and interpreting information in terms of the patients' needs, safety, discharge planning, psych/social/cultural, family needs, multi-system physical assessment, patient/family level of knowledge and readiness to learn about disease process and care requirements. Reports appropriate information in a timely manner to responsible physician.
Observes and monitors patient lab work for trends and reports abnormal lab tests to the appropriate physician and obtains appropriate interventions.
Utilizes clinical data to implement appropriate interventions.
Performs and documents ongoing patient assessment which accurately reflects patients' physical and mental status ranging from child to geriatric according to unit standards and patient condition.
Initiates use of restraints per hospital policy and procedures. Demonstrates commitment in the use of safe and appropriate alternatives prior to the application of any patient restraint device. Maintains competency in the application, monitoring and care of the patient in restraints.
Demonstrates critical-thinking skills when analyzing basic and advanced cardiac rhythms in a safe, competent and independent manner (Unit Specific).
Consistently develops an appropriate plan of care for patient from admission to discharge.
Develops, prioritizes, and documents a plan of care that is individualized and involves patient, family, and/or significant other in goal setting per unit standards.
Demonstrates knowledge and ability in the preparation of patients for tests, procedures and surgeries ordered.
Establishes appropriate implementation of nursing actions to ensure competent nursing care is delivered.
Provides individualized goal directed nursing care to patients in the nursing unit, utilizing the nursing process and standards of nursing care.
Documents physical assessments in on the electronic medical record. Assesses patients for desired and undesired changes in their mental/physical condition according to unit standards. Reports appropriate information in a timely manner to responsible physician and obtain appropriate intervention.
Maintains a professional rapport with physicians, patients, and families. Utilizes communication skills appropriate to age-specific needs.
Provides the necessary and appropriate education to the patient and family from admission through discharge. This includes, but is not limited to, the patient’s know medical and nursing plan of care, medications, tests and procedures, disease process, and discharge instructions. Initiates and documents the education provided including the patient response and outcomes on the patient/family education record. Initiates referrals to health care providers as necessary.
Provides general supervision and guidance of permanent licensed and non-licensed nursing personnel and temporary nursing personnel i.e. – RN, LPN, PCT U.S, M.T. in the job functions for the delivery of safe, therapeutic and quality patient care outcomes.
Provides competent and compassionate care to the patient with pain according to policy.
Must be able to use a high level of abstract reasoning to assess patient, evaluate interventions, and revise plan of care according to patient outcomes.
Basic computer skills – must be able to navigate Microsoft windows based programs.
Graduate of an accredited school of nursing with a minimum of an Associate of Science degree.
Active Florida RN license required.
Current AHA Basic Life Support (BLS) certification.
Current AHA Advanced Life Support (ACLS)
The Registered Nurse is responsible for the delivery of coordinated nursing care for a patient or an assigned group of patients within a patient care unit and for the day-to-day management and supervision of the related clinical activities. The Nurse is responsible for supervising and responsibly directing the activities of various levels of assigned nursing personnel utilizing both professional and supervisory discretion and independent judgment. Uses the nursing skills of assessment, planning, implementation, and evaluation in their patient care delivery. Primary function is the delivery of competent, compassionate, and cost effective nursing care. To utilize the nursing process in the direction and administration of the medical and nursing plan of care. This performance is in compliance with established policies, procedures and protocols under the supervision of the Nurse Manager, Director, Vice President of Clinical Services, and or designee.
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