Job Function: 01
Responsible for implementing the Nursing Process based on established Standards of Practice and ensuring all patient care policies and procedures are adhered to in accordance with Newton Medical Center policies, the Nurse Practice Act and the New Jersey State Licensure requirements. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Job Function: 02
PERFORMS PATIENT ASSESSMENT Collects health history data from patient/family/significant other, and from previous medical records, while interacting with patient based on adolescent, adult or geriatric principles of communication. Completes admission assessment within the acceptable time frame. Notifies consults when admitting criteria has been identified. Completes Braden scale appropriately. Continually reassesses the developmental biophysical, psychosocial, environmental, self-care, educational, and discharge needs of patients. DEVELOPS PATIENT PLAN OF CARE Creates individualized age appropriate plan of care by involving patient family significant other, reflecting the need for safety, education, and a healing atmosphere. Updates and revises the plan of care as needed and as patient status changes, in consultation with patient, family and caregiver. Develops realistic outcomes/resolutions based on developmental stage in life, integrating into practice the physiological changes and psychological needs related to the elderly (i. E., skin integrity, safety, depression). Recognizes and documents interventions needed to obtain outcomes/resolutions. IMPLEMENTS AND EVALUATES PATIENT PLAN OF CARE Continually reevaluates patients' needs accurately, initiating appropriate nursing actions to address needs. Delegates responsibilities for care, when applicable, and makes assignments according to skill level of care giver. Performs patient care activities based on priorities of care. Integrates, delegates and coordinates patient care using an interdisciplinary approach.
Job Function: 03
DOCUMENTS PATIENT DATA Documentation reflects the patient's response to nursing interventions, medications, treatments and education while corresponding to age appropriate expectations. Documentation is legible, timely, accurate and in accordance with policy and procedure. Complies with Department of Health and other regulatory agency requirements. Updates bed boards and communication of bedsides needs. PROVIDES FOR PATIENT EDUCATION Assesses patients/family's/significant others comprehension, skill level and barriers to learning. Initiates and coordinates patient/family/significant other teaching utilizing age appropriate instructions and teaching tools to reinforce areas of knowledge deficit. Provides teaching bag to each patient, reviewing its contents upon unit admission. Documents all teaching performed to both patients/families on interdisciplinary teaching record. PROVIDES FOR COORDINATION OF EFFECTIVE DISCHARGE PLANNING Discharge plan is initiated at the time of admission and implemented throughout the hospital length of stay. Participates in interdisciplinary patient care meetings. Develops, initiates, and participates in the process of patient education, discharge instructions, and preparation of patient/family/significant other for discharge. Continues education and reinforcement of patient discharge plan with all involved. Accomplishes a timely, comfortable, and safe discharge. Participates in the patient call back process post discharge.
Job Function: 04
MAINTAINS TECHNICAL COMPETENCY IN I.V. THERAPY Establishes and maintains rapport with patient utilizing age appropriate verbal and non-verbal communication. Assesses and maintains I.V. S according to policy and procedure. (Follow up check list is completed during orientation.) Administers I.V. drugs, blood and blood products according to policy, taking into account the biophysical changes associated with aging. Monitors patient for signs and symptoms of blood transfusion reaction. Initiates corrective action and documents same. Is knowledgeable of reasons for use of a blood warmer and can safely demonstrate its operation. MAINTAINS TECHNICAL COMPETENCY IN MEDICATION ADMINISTRATION Consistently administers the correct drug/dose/route to the properly identified patient in a timely manner. Ensures that all medication orders are co-signed on medication administration record (MAR), verifying accuracy of transcription, prior to administering first dose. Consistently documents medication administration according to procedure. Is aware of potential patient responses to medication based on patients' condition, age, and history; documents actual response. Assesses, initiates and manages a plan of care for patients in pain. Documents patients pain a minimum of four (4) hours utilizing the pain scale 0-10. Is knowledgeable with regard to adverse drug reactions and responds appropriately.
Job Function: 05
DEMONSTRATES ACCURACY IN TRANSCRIPTION AND IMPLEMENTATION OF ORDERS Transcribes orders correctly. Signs off orders, using date, time, 1st initial, full last name and status correctly and in a timely manner. Utilizes Computer system. Accepts phone orders as per policy and documents readback. Clarifies unclear, illegible, or non-specific orders, prior to implementation.
Job Function: 06
INTEGRATES AND PROMOTES PATIENT TREATMENT Manages and prioritizes multiple patient care plans, integrates specific patient needs and available resources and follows through on critical issues. Is knowledgeable in-patient care procedures and follows standards of care for Adult Nursing Services. Is able to assist physicians with therapeutic and diagnostic procedures (i. E., bone marrow, liver biopsy thoracentesis, etc.). Takes an active role in recognizing emergency situations; responds and manages patient/family appropriately. Responds and participates in Code Gray emergencies. Is knowledgeable of de-escalation techniques and documents outcomes as per policy. Promotes a restraint free environment. Applies safety devices/restraints according to policy and procedure after assessing the patient and all other alternatives have failed. Maintains orderliness in work area. Supports and demonstrates scripting communication. Exercises independent judgement. Reevaluates priorities to accommodate patient or unit activity changes; displays ability to adapt to a variety of work-related situations.
Job Function: 07
DEPARTMENT OF TELEMETRY, ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Applies telemetry leads correctly for monitoring; addresses the purpose of cardiac monitoring with the patient family significant other. Coordinates with the Telemetry Technician individualized arrhythmic parameters for the patient's condition to ensure correct alarm settings are set. Interprets and documents telemetry monitoring strips accurately keeping attending Physician informed of ectopy. Initiates chest pain protocol as indicated utilizing appropriate nursing interventions and documenting outcomes. Follows telemetry standing orders. Manages patients on high risk intravenous cardiac drugs and understands the implications of treatment. Assists with elective cardioversion.
Job Function: 08
ASSUMES RESPONSIBILITY FOR MAINTAINING COMPETENCY AS WELL AS FURTHERING SELF DEVELOPMENT Participates in continuing education programs to broaden professional knowledge base. Completes age specific training and learning for the adolescent, adult and geriatric population. Completes annual unit specific safety training. Maintains current healthcare provider BLS. Completes annual unit specific fire training. Completes assigned nursing requirements on Healthstream (i. E., Abuse, Restraints, stroke, I/V Update) annually. Performs annual competency in blood glucose monitoring. (see attached competency) Attends a minimum of six (6) unit meetings throughout the year. Attends all skills lab. Promotes a positive team work environment as evidenced by being receptive and responsive to change and demonstrating a professional and supportive environment. Participates in coaching/mentoring new employees/students. OTHER Performs other essential duties and completes in-services fundamental to the job.
Job Function: 09
Charge Nurse Responsibilities Promotes a positive team work environment as evidenced by being receptive and responsive to change and demonstrating a professional and supportive environment. Participates in coaching, mentoring new employees, students. Maintains currency with respect to all new policies and procedures Administrative Policy (on-line), Generic Policies, and Update Binder. Location and updates staff on new policies. Serves as a clinical role model and direct resource for policies. Monitors and communicates with primary RN of any incomplete orders in Information Management system. Assigns and supervises the clinical and non-clinical employees, including but not limited to RNs, NAs and US direction and assignment of duties. Provides direct patient care as needed. Assures that care plans are complete and updated every 48 hours in conjunction with the primary care nurse. Reviews all blood slips for completion and informs Nurse Manager of any omissions. Assures that the required vaccines are administered and documented upon discharge. Collaborates with the primary care nurse to ensure that pertinent information related to discharge diagnosis is communicated to the patient/family. Checks/assigns crash cart daily, tests Defibrillator per manufacture recommendations. Follows hospital policy related to Pyxis, i. E. Counts, discrepancies, and PCA keys. Assigns patients to rooms in collaboration with the Administrative Supervisor. Follows the chain of Command: reports to Unit Coordinator in person, collaborates with Administrative Supervisor off shift and on weekends. Collaborates with Nurse Educator Oversees the orientation of new employees. Makes recommendations regarding educational needs of the staff. Assumes responsibility for the use of the unit specific blackberry.
Other Tasks Which May be Required:
Physical Requirements:
As defined by Occupation Safety/OMS
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