Job Description

Position Highlights: R4 Medical- Surgical

• Number of beds on unit: 15 units, available to flex up to 20
• Patient population (age, diagnosis, specifics about unit): Medical-surgical, variety of diagnosis . Adult population over 17 years of age. Semi-private rooms.  
• Nurse to Patient ratio: 1:5-6
• Department culture and resources: Fast paced unit with medically complex patients. Unit relies on strong communication skills between all team members. Supportive teamwork plays huge role in success of care of the patient population and staff satisfaction.
• Frequent nursing skills/equipment used: Assessment, all forms medication administration, good communication skills with provider team, IV insertion, ADL needs. Use of plum pump, wound vacs, telemetry monitoring, tube feeding pumps and electronic EMR. Basic BLS (within 30 days of hire) and ACLS (within 1 year of hire).

• Performs all responsibilities and duties required by unit as specific to the scope of service. Implements procedures and theories related to the specific area of practice. Maintains up-to-date and accurate documentation of nursing care provided to assure the integration of information for use by the healthcare team.
• Completes initial assessment upon patient admission and develops appropriate plan of care in accordance with unit standards and that is based on patient and family needs. Implements plan of care, nursing interventions, and patient care procedures. Modifies plan of care based upon continuous evaluation.
• Takes responsibility for patient and employee safety by reporting and/or correcting safety hazards and incidents.
• Communicates with others directly and in private when necessary to resolve issues. Offers constructive feedback to assist in the professional development of peers, and confers with colleagues to expand knowledge base. Identifies own learning needs and takes initiative to begin appropriate solution.
• Fulfills all requirements of departmental competencies.

• Receives patient Bedside Shift Report from an RN at the beginning of each shift, ensuring the inclusion of the patient input, visual validation of a safe patient room environment at the time of shift change and updating of the patient communication board found in each patient room
• Delegates patient care tasks/responsibilities to assigned HCTs and validates completion of delegated tasks throughout the shift
• Completes and documents basic RN patient care activities such assessments, interpretation of vital signs, ensure physician order completion, admission/discharge of patients, hourly rounding completion on each assigned patient, care plan documentation and patient education
• Meets Carle Med/Surg RN documentation standards for each assigned patient
• RN will provide patient medications utilizing the patient 5 Rights: Right Patient, Right Medication, Right Route, Right Dose and Right Time
• Maintains patient safety as the highest priority level: ensuring safety measure compliance such as fall precautions, pressure ulcer prevention, isolation precautions and patient ambulation safety
• Maintains a positive attitude at all times on unit that promotes a healthy work environment and a healing patient environment
• Keeps a diligent focus on prompt answering of patient call lights to ensure effective triage and completion of patient requests/medical needs
• Uses critical thinking to evaluate the overall patient condition and uses nursing judgement to identify and act on changes in patient status
• Effectively communicates within the healthcare team to promote interdisciplinary collaboration, effective patient care coordination and patient safety
• Effectively manages time to enable the quick admission/discharge process for Observation status patients and facilitates completion of patient testing to move patients quickly towards discharge disposition

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