A Brief Overview Delivers care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation in coordination with other health team members. Effectively interacts with the patient, significant others, and other health team members while maintaining high standards of professional nursing. Provides high quality care to the following patient populations: Geriatric, Adult, and Pediatrics. Duties are included but are not limited to those below for specified units. Perform Bedside shift report at beginning and end of shift. Utilize policies and procedures to keep patients safe from falls. Assist in wound prevention and Hospital acquired pressure injuries. Assessment Demonstrates the ability to obtain a comprehensive admission history, performs physical assessment of patient Differentiates variations of normal and abnormal assessment findings Analyzes and prioritizes abnormal findings. Initiates appropriate response Anticipates actual or potential problems or health concerns in the hospital and/or home setting Demonstrates ongoing assessment of patient's psychosocial, physiological and educational process per unit policy Anticipates, recognizes and documents subtle changes in patient's physical and mental status Integrates analysis of diagnostic information in patient assessment and care Analyzes ongoing assessments to determine patient's and/or significant others learning and discharge needs Diagnosis Integrates assessment data and formulates an individual nursing diagnosis according to policies and procedures Planning Formulates an individualized plan of care including discharge planning based on standards of care and policies and procedures Modifies individualized plan of care based on ongoing assessment and changes in patient status Anticipates and manages changing situations Implementation Administers prescribed treatments and medications according to hospital policies and procedures Recognizes and questions unsafe, incorrect or inadequate orders. Intervenes to clarify patient order Utilizes opportunities during delivery of patient care to teach the patient information necessary to attain the optimal level of self-care Evaluation Evaluates patient's response to care and comprehension of education Documentation Documents all aspects of the nursing process in a legible, concise, clear, and timely manner utilizing PCS or appropriate hospital forms, utilizing correct medical terminology and accepted abbreviations Communication Involves patient and significant other(s) in all aspects of the nursing process Acts as a patient advocate and respects the rights and confidentiality of patients Promotes communication and relays information in a clear manner Understand and acts within the guidelines for addressing ethical concerns Communicates delays or wait times to patient/significant other Judgment Demonstrates sound judgment with the Nursing Process based upon critical thinking skills and a problem-solving approach Anticipates and takes proper action in emergency and complex patient care situations Equipment Demonstrates the ability to utilize appropriate equipment when providing nursing care according to unit/organizational policies, including ability to trouble shoot equipment What you will do Assess and monitor patient condition, documenting and communicating results to physician as appropriate Document all aspects of patient care provided in the medical record, adhering to documentation standards. Administer prescribed medications adhering to the six rights of medication administration, IV fluids, enteral feedings, monitoring their effectiveness, and addressing needs. Answer patients' calls and provides assistance or determines how to assist them. Assemble equipment, performs procedures and treatments and/or assists medical staff with patient procedures Provide basic patient care and treatments such as dressing wounds, preventing and treating pressure ulcers or performing catheterizations. Prepare patients for examinations, tests or treatments and explain procedures. Collect samples such as blood, urine and sputum from patients, and perform routine laboratory tests on samples (such as blood glucose monitoring) or sends the specimen to lab appropriately labeled. Evaluate nursing intervention outcomes, conferring with other health care team members as necessary. Help patients with bathing, dressing, maintaining personal hygiene, moving in bed, or standing and walking. Measure and record patients' vital signs, such as height, weight, temperature, blood pressure, pulse, respiration, oxygen saturation and pain. Provide patient and family education. Work as part of a health care team to assess patient needs, plan and modify care and implement interventions. Participate in performance improvement activities, including quality assurance, quality monitoring and improvement efforts. Delegate aspects of care to others including certified nursing assistants, patient service associates, and licensed practical nurses; provides oversight for ensuring completion of the functions. Adhere to safety practices and evidence-based practices. Prioritize specific aspects of assignment based on patient care needs. Coordinate and oversee nursing care provided for patient care assignment. Access resources to plan and coordinate patient care.
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Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
Number of Employees
251-500 employees