RN - PD

About the Role

Performs an age-specific plan of care for a designated group of residents using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of resident care. Collaborates with physicians and other team members in coordinating and implementing procedures and treatments. Uses leadership skills and clinical judgment in coordinating resident care and directing and delegating activities of the resident care team, specifically the LPN, CNA, and Unit Secretary.

Responsibilities

• 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.
• Assesses patient’s psychosocial health status:
  • Elicits perception of medical/nursing care and 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, including support groups, counseling services, and social services.
• Identifies patient outcomes:
  • 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 statements and establishes individualized patient goals.
• Formulates the plan of care and establishes priorities to achieve expected outcomes:
  • Identifies care activities and establishes priorities necessary to achieve expected outcomes.
  • Coordinates the cost-effective use of supplies, equipment, and medication.
  • Documents the plan of care and collaborates with physicians and other health team members.
• Implements the plan of care:
  • Maintains constant vigilance over patient care to ensure safety precautions/needs are followed (e.g., side rails up, call lights and bedside stand within reach).
  • Exercises professional skills related to the plan of care.
  • Reassesses patients as needed and appropriately revises the plan of care.
  • Correctly administers prescribed treatments.
  • Correctly uses equipment necessary for patient care.
  • Provides emotional support to patient and significant others.
  • Applies scientific principles in performing procedures safely, timely, and efficiently.
  • Makes accurate observations of patient’s conditions during treatments/procedures and reports/records them 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 emergency situations, managing self, patients, and other employees.
  • Provides a calm, quiet, restful atmosphere and 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 others.
• Evaluates care provided for patient outcomes:
  • Demonstrates ability to measure the effectiveness of care provided and documents it.
  • Performs variance analysis related to outcome data for performance improvement.
  • Designs, implements, and evaluates systems to improve care in the unit.
  • Keeps accurate documentation of patient’s treatment, activity, and condition.
  • Uses appropriate methods of documentation according to departmental policy.
• Collaborates with other care team members in planning and carrying out treatment regimens and provides direction to other members of the care team:
  • Collaborates with the appropriate physician on the patient’s plan of care.
  • Accurately interprets and implements the 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, ensuring assignments are completed in a timely fashion.
• Performs Grade I-IV decubitus care:
  • Performs preventive skin care measures.
  • Applies simple dressings, maintaining principles of aseptic technique.
  • Applies warm and cold compresses consistent with facility procedure.
  • Performs irrigations consistent with facility procedure.
  • Performs other procedures related to skin care as necessary.
• Administers medications correctly and safely:
  • Correctly identifies medication: action, dosage, side effects, and implications for the patient.
  • Meets standards on medication administration examination.
  • Demonstrates preparation of local solutions and IV drips.
  • Administers and documents medication correctly.
  • Administers IV push (IVP) medication as per department policy and procedure.
  • Educates patients and significant others related to drug and food interactions.
• Participates in patient and family education:
  • Provides the patient with an explanation of their condition as indicated.
  • Communicates assessment data in an orderly fashion by recording, updating, and verbalizing pertinent information to care team members and appropriate agencies.
  • Recognizes and utilizes health teaching opportunities and resources/materials available for 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 it.
• Performs related duties as required.

Qualifications

• Graduate from an accredited School of Nursing.
• Bachelor’s Degree in Nursing preferred. Must be enrolled in an accredited program within 24 months of employment if hired after September 1, 2010, and obtain a BSN degree within five (5) years of employment date.
• Current license to practice as a Registered Professional Nurse in New York State.
• BCLS and ACLS certifications preferred.