Trauma OR RN Nights 7p - 7a

About the role

The Registered Nurse provides professional nursing care to patients within assigned areas utilizing the nursing process to assess, plan, implement and evaluate patients.

Responsibilities

• Provides nursing care according to medical regimen and the nursing interventions appropriate for the patients' conditions and according to established standards, policies and procedures, including care of the ambulatory practice patient.
• Initiates assessment based on the patient's presenting problems or needs, the physician's medical diagnosis and the functional health framework upon visit.
• Collects key information from patient, family, laboratory, and other medical reports. Ensures that all consents necessary for treatment/procedure have been signed and that all prescribed identification procedures have been carried out.
• Determines nursing diagnosis and priorities for care with special consideration given to patient teaching, discharge planning, and the growth and development needs of the patient.
• Determines which standards of care and practice apply to the patient.
• Documents assessment, including nursing diagnoses or other clinical judgments.
• Demonstrates knowledge, technical, interpersonal and critical thinking skills to provide care, manage clinical competency and meet age‑specific patient needs within the unit.
• Completes ongoing assessments according to outpatient and nursing policy and/or as determined by patient condition:
  • Re‑prioritizes care based on new information,
  • Continues to update nursing diagnoses,
  • Involves family and/or other significant individuals in assessment activities.
• Assesses, plans and implements care of assigned patients:
  • Performs therapeutic nursing interventions as ordered by the physician,
  • Consistent with primary and population‑specific standards of care and practice,
  • Considers knowledge gained from the initial and ongoing assessment of the patient,
  • Adheres to nursing division policies, demonstrated competencies, risk management, infection control, and patient safety practices,
  • Consistent with the nature of the unit:
    • Completion of history and physical assessment,
    • Administration of medication, treatments and immunizations,
    • Prepares patient for examination/procedures; positions and drapes patients,
    • Pain control interventions,
    • Provides assistance during examination/procedures,
    • Monitors patient responses during treatment/procedure (checks temperature, pulse, blood pressure and respiration),
    • Initiates corrective action whenever monitoring or life‑support equipment shows adverse symptomatology such as respiratory or cardiac insufficiency,
    • Coordinates patient referrals,
    • Provides patient education.
• Documents care based on standards of care and practice and/or clinical priorities, including:
  • Assessment and ongoing assessment findings,
  • Updated clinical priorities for documentation,
  • Therapeutic nursing interventions with special attention to patient education,
  • Patient's response to interventions and progress toward outcomes.
• Responds to and participates in medical emergencies; initiates and/or assists with CPR/BLS as required.
• Provides teaching to patient/family in the care of disease/condition; develops and implements patient teaching outlines including objectives, content, teaching strategies and evaluation of patient progress.
• Maintains patient medical records; documents patient status and care given; performs charting duties; records activities and observations; utilizes patient computer systems to enter and retrieve data.
• Works collaboratively with patient, family, and hospital staff regarding all aspects of patient needs in a courteous, customer‑responsive manner, complying with iRESPECT Standards and promoting patient/customer satisfaction.
• Provides instruction, assigns and supervises LPNs and other support personnel to complete initial and ongoing assessments and provide clinical assistance; assists in orientation and oversees supervision of new staff members and students during patient care.
• Transports monitored patients, specimens, equipment and supplies to and from various areas.
• Collaborates with forensic team and security to provide a safe environment for patients in custody.
• Completes required continuous training and education, including department‑specific requirements:
  • Attends staff meetings, all mandatory in‑services, and additional continuing education as required,
  • Contributes to the annual review of unit‑based scope statement and determination of important aspects of care for clinical review,
  • Assists in the development of indicators, thresholds, study methods, and data collection as assigned,
  • Responds to problems/opportunities to improve care,
  • Supports and participates in the organization’s performance improvement initiatives,
  • Maintains competencies required for the position.
• Maintains a clean, orderly, safe environment for patients and personnel; adheres to established policies, compliance/quality improvement, safety, environmental and infection‑control standards.
• Prepares and maintains required records, reports and files for administrative and compliance purposes.