Description
Job Description
RESPONSIBILITIES PERFORMANCE STANDARD
ASSESSMENT:
1. Interviews patient, family, significant
others to formulate a nursing history.
2. Observes, identifies and collects data
to identify nursing care needs of the
patient and family.
3. Correlates the medical plan of care
with the nursing plan of care.
4. Identifies and reports to the
appropriate person(s) abnormal
diagnostic data and clinical changes
in the patient's condition.
PLANNING:
5. Develops and/or updates
individualized nursing care plan on
each patient.
6. Documents patient problems and
nursing care needs of the patient and
family/significant others.
7. Actively involves patient and
family/significant others in planning
patient's care.
8. Develops short- and long-term goals
for the patient and family/significant
others. Identifies the need to involve
other disciplines in the patient's care.
9. Initiates discharge planning upon
admission.
IMPLEMENTATION:
10. Performs common nursing
procedures as defined in Policy and
Procedure Manual.
11. Implements changes in physicians'
orders in a timely manner.
12. Explains treatments and procedures
to patient and family/significant
others.
13. Provides patient and family teaching.
14. Provides for the safety, cleanliness
and comfort of the patient.
15. Initiates emergency procedures as
needed within the scope of practice
and hospital policy.
EVALUATION:
16. Evaluates the patient's response to
nursing care.
17. Updates and revises care to be
delivered as patients' needs change.
18. Appropriately communicates
changes and care given to other
members of the health care team.
PROFESSIONAL GROWTH AND
RESPONSIBILITY:
19. Assumes leadership role and
delegates nursing care.
20. Assigns tasks appropriately and
guides team members based on their
skills and abilities.
21. Maintains awareness of legal aspects
of hospital nursing.
22. Conducts patient care conferences.
23. Updates skills and knowledge and
attends peers' patient care
conferences.
24. Assists in orientation and/or acts as a
preceptor for new personnel.
25. Sets goals and objectives with target
dates.
26. Participates in patient care Quality
Assurance programs.
UNIT SPECIFIC:
27. Manages patients as a team leader
or primary care giver.
28. Demonstrates ability to assess
patients' signs and symptoms with
impending CVA, Pulmonary Edema, MI, CHF, PE, respiratory distress.
29. Assures and teaches patient's
pre/post open heart surgery, heart
catheterization, PTCA.
30. Assesses neurological status
(including cognitive levels) in post
head injured patients.
31. Maintains all intravenous lines and
fluids (i.e., CVP, Hickman catheters,
mini infusers hyperalimentation,
dialysis catheter, etc.).
32. Clearly documents effectiveness of
nursing care (i.e., pain management
and response to treatments such as
wound care).
33. Demonstrates basic computer entry
skills.
34. Demonstrates knowledge and skills
in application of various types of
monitor leads.
35. Demonstrates knowledge and skills
in recognizing and acting accordingly
to life threatening arrythmias.
36. Point of care testing
Physical Demands:
Employee must meet physical and mental requirements as identified by the physical activity evaluation form
Qualifications: A. Minimum Education: Current California RN license. Current American Heart Association BLS certification. ACLS
and Initial Dysrythmia Recognition within 90 days of hire.
B. Minimum Experience: Recent acute care experience preferred.
C. Preferred Skills and Abilities:
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