RN - Med Surg- Rotating Shifts

Position: RN – Med/Surg/SCU

Department: Med/Surg

Reports To: Director of Med/Surg

Direct Reports: None

FLSA Classification: Non-exempt

Position Summary

The RN is responsible for utilizing the nursing process to assess, plan, direct, administer and evaluate evidence based outcome oriented patient care in the Medical / Surgical and Special Care Unit department. Provides for the continual assessment of patient needs and implements interventions as necessary to support patient care plans. Oversees the quality of care performed by CNA's and other assigned personnel. Participates in decision making activities related to nursing practices and is able to respond quickly and accurately to changes in condition or response to treatment.

• General Duties, Tasks and Responsibilities
• Performs accurate and complete assessment of patients; performs initial admission assessment; coordinates and ensures completion of interdisciplinary screenings and assessments; assesses and reassesses pain; assessments are age, culture and psychosocial appropriate.
• Formulates a plan of care based on patient needs, modifies the plan of care based on patient outcomes; formulates a teaching plan based on identified learning needs and evaluates the effectiveness of learning to include: educating the patient/family regarding treatment plan and providing discharge planning/instructions.
• Makes comprehensive nursing decisions based on the interpretation of facts and evaluation of patient outcomes; assists physicians with procedures; utilizes other departments to provide interdisciplinary care as appropriate; maintains knowledge of telemetry monitoring system; identifies arrhythmias and treats accordingly.
• Prepares and administers medications based on age / clinical condition of the patient; starts intravenous lines for medications and fluids.
• Assesses the effectiveness of pain medications; revises plan of care as indicated by the patient's response to treatment as appropriate.
• Ensures documentation is complete, accurate and timely; prepares the patient record in both electronic and chart form.
• Performs all aspects of the position in an environment that optimizes patient safety and reduces the likelihood of medical/healthcare errors; utilizes established hand-off communication protocols; maintains the security of the department.