Under the general supervision of the Nurse Manager or Nurse Supervisor, provides direct nursing care to patients.
Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.
ASSESSMENT
Identifies and documents initial observation and assessment of the patient's needs for immediate nursing action.
Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.
Identifies appropriate foci.
Selects, plans, evaluates, and documents care based on this assessment.
Assesses, intervenes, and documents appropriately to meet patient's health, educational, psychosocial, and discharge planning needs.
Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.
DIRECT PATIENT CARE
Gives comprehensive patient care.
Initiates and follows through with patient and family teaching.
Consults with unit Nursing Leadership regarding significant changes in patient's condition.
Collaborates with all members of the health care team.
Communicates relevant patient care information on shift to shift report.
Utilizes patient care standards in clinical practice.
Provides individual and group therapy.
Documents pertinent information regarding patient's response to treatment and progression toward goals in patient's chart.
Completes Admission/Transfer Summary Sheet and/or Discharge Summary.
Transcribes physician's orders in patient chart accurately and timely.
Seeks clarification of physician's orders that are unclear or inappropriate.
Interprets clinical data and notifies the physician promptly if immediate changes in management are indicated.
Administers medications in compliance with policies and procedures.
Titrates medications as per physician's prescriptives, protocols, and standard.
Assures that the practice of nursing by the registered professional nurse is centered around the New Jersey Nurse Practice Act defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician.
Assures that RNs diagnose in the context of nursing practice by identification and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing care as evidenced by the psychiatric and medical problems identified on the treatment plan.
Assures that RN’s select and perform therapeutic measures essential to providing quality care as evidenced by identified nursing goals and actions on the interdisciplinary treatment plan.
Assures that the LPN’s practice is limited to performing tasks and responsibilities within the framework of reinforcing the patient teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician as demonstrated by the charge RN’s ability to assign LPN’s appropriate tasks on the assignment sheet.
Assures that the RN takes responsibility for the nature and quality of all nursing care including the assessment of the nursing needs, the plan of nursing care (within the interdisciplinary treatment plan) the implementation, and the monitoring and evaluation of the plan. Assures the RN delegates selected nursing tasks (as deemed appropriate in the BHS division) in the implementation of the nursing plan of care to LPN’s, RA’s and MHA’s.
Assures that when the RN’s delegate select nursing tasks to LPN’s, RA’s, or MHA’s, the RN shall be responsible for exercising that degree of judgment and knowledge reasonably expected to assure that proper delegation has been made. A registered professional nurse may not delegate the performance of a nursing task to persons who have not been adequately prepared by verifiable training and education. No task may be delegated which is within the scope of nursing practice.
Assures that the RN is responsible for the proper supervision of LPN’s, RA’s and MHA’s on the assigned shift as the charge nurse.
Assures that the RN’s uphold the Code of Ethics for Nursing established by the American Nurses Association, which is a statement of the moral obligations and duties of every individual who enters the nursing profession.
Assures that the RN, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems as evidenced by observation of the RN with 1:1 interactions and group leadership with patients.
Assures that the RN’s primary commitment is to the patient, the recipient of nursing services, and that the interdisciplinary treatment plan reflects uniqueness.
Assures that the RN promotes, advocates for and strives to protect the health, safety and rights of patients by assuring that the patient is knowledgeable of the patient rights on admission and throughout his/her hospital stay.
Assures that the nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care
Assures that the nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth.
Assures that the RNs deliver primary mental health care as outlined in the Standards of Psychiatric Mental Health Clinical Nursing Practice written by the American Nurses Association.
Assures that the RN performs intakes including physical and psychosocial assessments on new admissions completing the nursing assessment form fully, renders diagnostic and dispositional judgments, and facilitating the patient’s movement in their hospital stay.
Assures that the RN utilizes skills and resources to foster the restoration of individual patient’s previous adaptive abilities and allows for the acquisition of new ones.
Assures that the RN maintains all aspects of a therapeutic milieu, which will facilitate the patient’s potential growth and change. Evidenced by nursing group skills and milieu management during emergencies and on a daily basis.
Assures that all nursing staff take advantage of the learning potential inherent in the daily life cycle of personal hygiene, feeding, socialization skills and practical skills of community life.
Assures that the nursing staff will comfort, guide, and set limits to make use of the patient’s experience of daily living to help them move from dependent to more independent modes of behavior.
Assures that the RN employs psychobiological interventions which include various emergency procedures and standard nursing measures such as relaxation techniques, medication education, nutrition / diet regulation, exercise and rest schedules, monitoring response to medication, and other somatic treatments including monitoring the patient’s responses to psychobiological interventions and the overall treatment program.
Assures that nursing staff provide direct crisis intervention services to patients in crisis and that the appropriate interventions are used as evidenced by observation of staff during Team 20 and Dr. Strong emergency codes.
SAFETY
Checks to ensure that emergency equipment is on hand and in good working order.
Recognizes and reports malfunction or failure of equipment used in the area to Biomedical Engineering; takes appropriate action to repair/replace such equipment (e.g. cardiac monitors, defibrillators, suction apparatus, pumps, O2 tank).
Checks that all monitoring equipment and ventilator alarms are set according to standards.
INDIRECT PATIENT CARE ACTIVITIES
Participates in patient care rounds by presenting findings on patients.
Applies principles of infection control and safety.
Assists in the orientation of new personnel.
Provides clinical supervision of LPNs, Nursing Attendants, and other ancillary staff.
OTHER JOB DUTIES
Orients patient's family to new environment; develops rapport with patient's family.
Relieves the Nurse Manager and Assistant Nurse Manager as required.
Assists in data collection and analysis of Quality Assurance/CQI monitors; participates in implementation of follow up action.
Effectively utilizes the hospital computer system as it pertains to job responsibilities and in accordance with hospital policy.
Participates actively on Quality Improvement committees as assigned.
Assists other personnel as needed.
Keeps up-to-date with current trends pertinent to area of assignment.
Participates in continuing education activities; attends scheduled inservice programs; shares information gained at conferences with colleagues.
