Job Description
Responsibilities:
1. Assesses the patient's physiologic health status

• Conducts patient interview, explains policies and procedures to patient/significant others, reviews patient's chart and answers questions correctly and courteously;
• Assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status;
• Determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate;
• Assesses level of pain and pain management;
• Communicates/documents patient's physiologic health status and plan of care.

2. Assesses patient's psychosocial health status

• Elicits perception of medical/nursing care and the expectation of care;
• Determines coping mechanism, knowledge level, and ability to comprehend;
• Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction;
• Communicates and documents psychological status and care plan; support group, counseling services, social services.

3. Identifies patient outcome

• Develops criteria for measurement of patient outcomes;
• Identifies actual/potential patient problems;
• Identifies patient's need for teaching based on psychosocial and developmental assessment;
• Develops patient outcome statement (s) and establishes individualized patient goals.

4. Formulates the plan of care and establishes the priorities necessary to achieve expected outcome

• Identifies care activities and establishes the priorities necessary to achieve expected outcome;
• Coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome;
• Documents the plan of care and collaborates with physicians and other health team members.

5. Implements the plan of care

• Maintains constant vigilance over patients care to ensure that safety precautions/needs are followed. (Side rails up, call lights and bedside stand within reach, etc.);
• Exercises professional skills related to the plan of care;
• Reassesses patients as needed and appropriately revises plan of care;
• Correctly administers prescribed treatments;
• Correctly uses equipment necessary for patient care;
• Provides emotional support to patient and significant other;
• Applies scientific principles in performing procedures; carries them out safely, timely and efficiently;
• Makes accurate observations of patient's conditions during treatments/procedures. Reports and records same as appropriate;
• Keeps accurate documentation of patient's treatment, activity and condition, as well as patient's responses to medical and nursing interventions;
• Uses appropriate methods of documentation according to departmental policy;
• Acts rapidly and effectively during any emergency situation, managing self, patients and other employees;
• Provides a calm, quiet, restful atmosphere. Communicates effectively with the patient's family or caretakers;
• Participates in planning for discharge and coordinates referrals, as appropriate;
• Provides discharge instructions to patient and significant other.

6. Evaluates care provided for patient outcome

• Demonstrates ability to measure effectiveness of care provided and documents same;
• Performs variance analysis related to outcome data for performance improvement;
• Designs, implements, and evaluates systems to improve care in Unit;
• Keeps accurate documentation of patient's treatment, activity and condition;
• Uses appropriate methods of documentation according to departmental policy.

7. Collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team

• Collaborates with the appropriate physician on patient's plan of care;
• Accurately interprets and implements treatment regimen as prescribed by the Physician;
• Assists the Physician during treatments and/or diagnostic procedures;
• Keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient's condition and/or treatments, as appropriate;
• Uses clinical judgment in delegating assignments to the Patient Care Associate, Support Care Associate and Clerical Service Associate in providing patient care, and ensures that assignments are completed in a timely fashion.

8. Performs grade I-IV Decubitus Care

• Performs preventive skin care measures
• Applies simple dressings, maintaining principles of aseptic technique;
• Applies warm & cold compresses, consistent with facility procedure;
• Performs irrigations, consistent with Facility procedure;
• Performs other procedures related to skin care, as necessary.

9. Administers medications correctly and safely

• Correctly identifies medication: action; dosage; side effects and implications for the patient;
• Meets standard on medication administration examination;
• Demonstrates preparation of local solutions;
• Demonstrates preparation of I.V. drips;
• Administers and documents medication correctly;
• Administers IVP medication as per department policy and procedure;
• Educates patients and significant others related to drug and food interactions.

10. Participates in patient and family education

• Provides the patient with an explanation of his/her condition as indicated;
• Communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies;
• Recognizes and utilizes health teaching opportunities and resources /materials available for this teaching;
• Provides for early discharge planning and appropriate referrals for post-hospital care;
• Evaluates the effectiveness of teaching by feedback from patient/family and documents same.

11. Performs related duties, as required.
Qualifications:
• Graduate from an accredited School of Nursing. Associate's Degree in Nursing, required. Bachelor's Degree in Nursing, preferred.
• Minimum 1-2 years of professional nursing experience in the related specialty.
• Current license to practice as a Registered Professional Nurse in New York State, required.
• BLS/NRP required, plus specialized certifications as needed.