Department: 34404 Wake Forest Baptist Medical Center - Nursing Med Surg: 7 Reynolds Cardiology Status: Full time Benefits Eligible: Yes Hours Per Week: 35.1 Schedule Details/Additional Information: Nights Pay Range $34.90 - $52.35 Major Responsibilities: Unit Management - Facilitates the organization and management of the unit. Contributes to the provision of safe, quality patient care. Prepares shift assignments utilizing knowledge of staff member's education level, work experience and job description and patient acuity (per Patient Classification System). Monitors unit activities to ensure assignments are completed in a timely, neat and appropriate manner. Collaborates with the Patient Care Supervisor and/or Director of Patient Care to make schedule/ assignment changes to provide for safe, consistent and smooth functioning of the unit (i.e., calling in additional staff, sending staff home and reassigning staff as needed). Receives and records calls for absences in the absence of the staff. Supervises and delegates patient care as needed. Maintains awareness of notification of appropriate physician, when indicated, of changes in patient's condition. Notifies Director of Patient Care or Patient Care Supervisor of unusual occurrences, change in patient's condition, etc. Evaluates, monitors and documents patient and/or situation; appropriately intervenes to eliminate, prevent or minimize crisis. Observes all patients at least twice per shift. Makes rounds with physicians, when indicated, or delegates to staff nurse. Assists in coordinating patient's admissions, transfers and discharges. Initiates appropriate action to correct disciplinary problems. Documents and communicates action to Director of Patient Care. Assists Director of Patient Care with employee performance evaluations. Conducts monthly meeting with shift employees from a prepared agenda. Submits copy of minutes to Director of Patient Care. Directs staff during emergency situation and/or drills. Reviews safety and emergency procedures with staff at least twice per year and documents. Gives a copy to Director of Patient Care. Participates in developing and/or revising Rehabilitation Nursing Standards and Nursing Policies and Procedures. Attends and participated in a least 80% of Nurse Management and Performance Improvement Meetings. Voluntarily accepts additional responsibilities. Patient Care - Contributes to the provision of safe, quality patient care utilizing the nursing process to provide care to assigned patients. Assessment: Performs and documents patient assessment on admission and throughout patient's stay including patient's/family stated goals and response to the rehabilitation program. Formulates nursing diagnosis based on data collection, overt and covert needs and anticipated or predicted needs. Utilizes lab, radiologic, medical and departmental reports to anticipate and/or predict changes in patient's health status. Plan of Care: Develops and reviews/revises and individualized Rehabilitation Nursing Plan of Care that begins on admission and continues throughout the hospitalization and is congruent with the interdisciplinary treatment plan to include goals and discharge plans. Implementation of Patient Care: Utilizes individual nursing care plans to prevent complications and to maintain or restore the patient's physical and psychosocial function at a realistic and optimal level. Ensures nursing actions are consistent with the interdisciplinary care plan and congruent with Rehabilitation Nursing Standards to achieve patient goals. Demonstrates the ability to set priorities and shows knowledge of multiple complex health problems, diagnosis, signs, symptoms of actual/potential problems based on the principles of pathophysiology. Must be trained and competent to treat patients with any diagnosis, at any age, and be able to demonstrate knowledge and skill appropriate to the age served. Evaluation: Documents that mutual goals identified by the patient, family and primary nurse have been met. Reviews, revises and prioritized interventions consistently as patient's needs change. Utilizes appropriate resources to assist in resolving difficult problems. Documents objective solutions to problems. Documents on patient/family Education Form and Discharge Summary, the patient's understanding of procedures to continue after discharge Safety -Complies with Central Georgia Rehabilitation Hospital policies and procedures relating to safety for self, patient, visitors and staff. Promotes safe environment for self, patients, visitors and other employees. Adheres to Universal Precautions/Body Substance Isolation. Instructs patients and/or families of safety rules during admission and as patient's condition dictates (i.e., side rails, safety belts, wheelchair brakes, smoking, etc.). Consistently documents such instructions and patient/family responses. Identifies high risk factors through patient and/or family verbalization, direct observation and assessment. Intervenes to minimize risks. Utilizes principles of body mechanics. Seeks assistance when transferring heavy, agitated and/or impulsive patients. Wears and monitors nursing staff member's use of Back Savers braces. Instructs staff, patients, families and/or visitors in principles of infection control/Body Substance Isolation. Identifies need for equipment repairs or replacement and initiates work request for repairs when indicated. Identifies and reports factors in the environment that are not in compliance with fire codes. Attends and participates in annual mandatory inservices (fires, safety, disaster, infection control, body mechanics, guest relations, etc.) and maintains current CPR certification. Demonstrates knowledge and competence in response to codes and other emergencies and documents properly (i.e., code sheet, variance report, patient's chart). Initiates and completes variance report and employee injury form when indicated. Documents incident in patient's chart if appropriate. Performance Improvement - Participates in Performance Improvement as scheduled. Recognizes and reports deviations from the standard. Monitors and initiates audits of medication cart and crash cart and reports discrepancies to the Director of Patient Care. Initiates and completes at least one additional PI study per year. Documents patient's use of chargeable items. Education Provides teaching patients, families, and staff to assist in the learning process. Prioritizes and documents knowledge deficits of actual, potential and/or possible health problems. Evaluates and documents the effectiveness of patient/family learning. Serves as a professional role model and mentor to nursing staff. Practices within the scope defined by the Georgia Nurse Practice Act.