Registered Nurse – Clinical Care

Overview

An experienced subacute Staff RN is a professional caregiver who assumes responsibility and accountability for the assessment, nursing diagnosis, planning, implementation and evaluation of care for patients and their families in compliance with the standards for care at Greater El Monte hospital subacute, federal and state regulations.

Responsibilities

Clinical Practice: Nursing

Assesses, collects and documents health assessment data focusing on the physical, emotional, spiritual, psychosocial and educational needs of the patient.

a) Interviews the patient/family/significant other to complete Admission information.

b) Identifies actual and potential needs and determines priority.

c) Identifies barriers to learning.

Completes and documents assessment, focusing on abnormal systems and actual and potential problems.  Performs ongoing assessment as indicated.

Plans nursing care, based on priority of physical and psychosocial-emotional needs.

a) Develops realistic short term/ long term goals for each problem, involving the patient, family or significant others. 

b) Plan demonstrates understanding of age-related needs of the patient.

c) Consults with patient, family, significant other and health care team members in planning for education and discharge needs.               

Implements the plan of care including prescribed procedures and treatments. 

a) Organizes and prioritizes care based on individual needs and unit activity.

b) Assesses for changes in patient’s condition and appropriateness of the plan.  

c) Initiates interventions using appropriate clinical expertise and knowledge.

d) Coordinates the activities of health care team members in completing diagnostic and therapeutic interventions.  

 Evaluates the effectiveness of nursing care delivered to reach the expected outcome.

a) Evaluates the plan of care according to the current condition and changing needs of the patient. 

b) Accurately and concisely documents the patient’s status and response to the care delivered.

Utilizing professional nursing knowledge and skills. Appropriately assesses for:

a) Physical and psychosocial-emotional needs.

b) Barriers to learning.

c) Educational/learning needs.

d) Discharge needs.

e) Age-related needs.

f) Issues related to assault or abuse.

Utilizing professional nursing knowledge and skills. Appropriately assesses for:

a) Physical and psychosocial-emotional needs.

b) Barriers to learning.

c) Educational/learning needs.

d) Discharge needs.

e) Age-related needs.

f) Issues related to assault or abuse.

Analyzes patient related data, such as vital signs, past medical history, physical exam findings, laboratory values and other information, including age-specific criteria, to determine appropriate care.

 Utilizes advanced, specialized knowledge and skills to implement interventions for all patients, by prioritizing needs, and using a patient centered approach. 

 Provides health education and teaching to patient’s, family members and/or significant others, that is age specific, providing for any barriers to learning.  Clearly communicates health, treatment and discharge information, ensuring the patient, family member or significant other understands all discharge and follow-up instructions.  

 Effectively performs procedures, such as initiation of IV catheters and fluids, medication administration, dressings, patient teaching, etc., within their scope of practice, and unit, department and Medical Center policies and procedures.

 Appropriately recognizes and quickly responds to emergency medical situations.

a) Accurately assesses “A-B-Cs.” 

b) Initiates appropriate emergency treatment, i.e., CPR, O2, etc.

c) Communicates critical information to other team members.

Remains current on treatments/practices/procedures through attendance at continuing education events, in-services and the review of professional literature.

Integrates/applies new knowledge from education and research into clinical practice.

Demonstrates knowledge of and competence in age-related patient care.

Consistently demonstrates knowledge of state and federal regulations, such as Title XXII. 

Consistently and accurately completes required documentation.

Direct, oversee and evaluate all nursing personnel (registered nurses, L.V.N, C.N.A, etc.)

Guide staffing procedures

Set objectives and long-term goals for the nursing department

Organize and coordinate admission, nursing and patient care procedures

Manage record-keeping procedures

Collaborate with other departments and professionals to streamline operations

Report to Director of Nursing

Take responsibility for clinical supervision in the nursing department to insure high standards of care are being delivered in accordance with established policies and procedures and federal and state regulations.

Assist nurse manager in decisions regarding nursing care.

Helps coordinate educational offerings for the nursing department.

 Participate in Medicare and Insurance assessments, completing worksheets. 

Tracking nursing department documentation accordingly facility protocol.

Qualifications

EDUCATION:

Graduation from an accredited school of professional nursing preferred.  

Baccalaureate degree in Nursing preferred.

Knowing and Complete Plan of Correction 

CERTIFICATIONS/LICENSURE:

Current California licensure as a Registered Nurse.  

Current training in Basic Life Support through American Heart Association

Hospital Description

Greater El Monte community hospital--Subacute