The Med/Surg RN provides professional direct and indirect patient care in an organized manner that reflects initiative, flexibility, and responsibility with a minimal of supervision. The RN is responsible for carrying out the physicians’ orders, including, but not limited to: Medication administration, treatments and assessments. Accurately determines priorities of care. Communicates with physicians about changes in patient’s status and able to respond quickly and accurately to changes in condition or response to treatment. Promotes positive guest relations to patients, families, visitors, physicians, and fellow associates.
Graduate of accredited school of nursing.
1 year Med/Surg or other acute care unit.
Licenses, Certifications and/or Registrations:
Current registration to practice nursing as a Registered Nurse within the State of Florida. Current BLS and ACLS required. PALS recommended.
Specialized Knowledge and Skills:
Supervised by: Charge Nurse, Chief Nursing Officer
Supervises (Headcount): varies
Supervises (Job titles): LPN II, CNA’s, interns, volunteers
Including, but not limited to: other staff members, physicians, patients, families, ancillary departments, EMS, law enforcement
For Direct Patient Care Positions Only:
Must have the knowledge and skills necessary to provide patient care as defined by job responsibilities and performance standards in this job description to include Patient Safety Performance Standards for the identified population served below:
- Pre-term/High Risk Neonate
- Neonate (newborn to 28 days)
- Pediatric (One month to 12 years)
- Young Adult (18 to 35 years)
- Adult (35 to 65 years)
- Geriatric (65 years and over)
ESSENTIAL FUNCTIONS OF COMPETENT PERFORMANCE FOR THIS POSITION
- Uses at least two patient identifiers (name, date of birth and wristband) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing; or providing any other treatments or procedures.
- Labels all specimens with patient identification, collector’s initials and time of collection before taking to lab
- Documents a full initial assessment in a timely manner that will include all areas required for a problem-oriented, focused assessment which include age-specific criteria.
- Performs reassessments based on the dynamics of the patient’s condition. Vital signs, cardiac monitoring and pain management should reflect patient’s clinical condition.
- Documents pain reassessment on all patients after interventions/medications as required by policy.
- Patient education and care plan is created, reviewed and revised daily and PRN on each patient assigned on unit.
- Provides direct patient care in an organized and timely manner. Demonstrates necessary skills in providing age appropriate care and documents per unit policy.
- Initiates and assists with emergency measures, identifies life-threatening arrhythmias and demonstrates knowledge of ACLS guidelines.
- Has a thorough understanding of all equipment on acute care units, including but not limited to; beds, scales, IV pumps, enteral feeding pumps, SCDs, respiratory equipment, etc.
- Can initiate and maintain a sterile field and assist the physician as necessary with suturing, chest tube insertion, lumbar puncture, etc.
- Maintains current knowledge of medications and their correct administration based on age specific criteria, patient clinical condition and safety policy.
- Ensures that nursing performs daily/nightly narcotic medication reconciliation checks with another licensed nurse to verify correct administration/documentation of scheduled drugs.
- Performs AccuChek testing per policy, ensures that controls are dated with opened and expiration date; responds and documents any actions taken in response to results.
- Labels all medications, medication containers (e.g., syringes, medicine cups, basins) or other solutions on and off the sterile field in procedural settings.
- Compiles a complete list of the patient’s medications to assist in reconciliation of medications across the continuum of care.
- Organizes and prioritizes activities for proper balance of patient care activities/assignments within assigned shift.
- Maintains and updates patient charts per unit policy. Checks each chart for completeness prior to releasing record to health information.
- Provides a safe environment for patients and family members. Reduce the risk of patient falls by keeping patient rooms and areas free of excess
- Complies with infection control standards, performs personal safety precautions (PPE) appropriately. Takes professional responsibility to wear personal protective equipment based on potential risk exposure.
- Follows infection control standards by washing hands or using alcohol gel between all patients and before/after performing any procedures.
- Provides appropriate discharge instructions to patients and family members in a timely manner. Includes instructions and referrals based on patient/family needs and physician orders.
- Notifies physicians or caretakers of all critical test or lab results in a timely manner and verifies understanding by having physician repeat values back as same. Documents the communication and information reported in patient record.
- Gives accurate and complete patient report to any nurse assuming responsibility for any patient. Provides accurate information and includes an opportunity for questions to be asked/answered.
- Ensure shift duties are completed to include stocking, narcotic count, crash cart and ensuring that refrigerator temperatures are checked on a daily basis.
- Assists new personnel orient to department, reviews and completes skills assessments for new personnel, and reports educational needs and concerns to nurse manager.
- Assists other staff members keep work area clean and tidy. Uses break room for all meals and snacks. Removes personal items from work area when shift complete.
- Dates all personal food/drink kept in the staff refrigerator and disposes of such in a timely manner.
- Stays focused on hospital duties and patients while at work. Keeps personal phone calls (hospital phone and cell phone) and taking care of personal business at a minimum while on assigned shift.
- Demonstrates reliability by giving advance notices of absences, appropriate uses of computerized time system, avoids tardiness, and completes shift without unnecessary overtime.
- Avoids clutter, picks up after self, cleans examination rooms between patients and helps maintain general cleanliness of the department.
- Adheres to departmental dress code and keeps ID badge visible at all times.
- Attends and participates meetings and in services as scheduled for nursing and Med/Surg staff.
- Commits to outstanding guest relations and customer service; demonstrates the customer service program in an effort to meet the expectations of patients, visitors, and fellow associates; maintains courteous and professional conduct.
- Demonstrates teamwork; supports, assists, and praises fellow associates whenever possible; feels a sense of ownership and takes pride in the hospital and the unit; looks beyond assigned tasks to achieve goals.
- Supports and promotes the Mission, Vision, and Values; adheres to all hospital policies and procedures; commits to the Standards of Conduct; maintains professional appearance