RN CLINICAL NURSE II - 6 HV/CV STEPDOWN
Company: UNC Health Care
Posted on: January 14, 2019
This is a nights position The essential duties and responsibilities of a Staff Nurse for the HV/CV Stepdown Department include: 24 bed unit designated for cardiovascular surgical step-down patients. 1. Supporting Safety Initiatives -Supporting patient safety initiatives by maintaining an environment of safety for patients, self and others -Observing proper hand hygiene before and after patient contact as stated in the Joint Commission Patient Safety Goals -Adhering to the Falls Prevention Protocol according to hospital and/or unit policy and completing the Post-Fall Huddle -Appropriately assessing and utilizing safe patient handling equipment -Cleaning equipment between each patient use, wiping the keyboards at the beginning of every shift and using the appropriate cleaning materials -Keeping patient's rooms, work areas and hallways free from clutter by keeping the equipment on one side of the hall or in designated areas -Using two patient identifiers, including scanning compliance, when delivering patient care (medication administration, PPID, blood glucose and ACT) -Monitoring and resolving any Pyxis discrepancies in a timely manner by completing on-line variances per policy, ensuring proof of use forms are complete and informing the manager of unresolved discrepancies -Obtaining consent prior to procedures such as blood transfusions, HD and other procedures -Following the proper procedures for telemetry monitoring at the time of admission, transfer and discharge 2. Assessing the Patient's Condition -Ensuring Admission Navigator, including PTA meds and vaccines are complete on all admissions/transfers onto the nursing unit within twenty-four (24) hours -Appropriately documenting skin assessments upon admission and maintaining ongoing documentation of skin assessments throughout hospitalization -Using bedside reporting such as WOWs and SBAR at shift change and updating the communication board in the patient's room to include caregiver names, phone number, date and plan of care -Documenting shift assessments according to the current and pertinent diagnostic data and responding according to policies (electrolyte protocols, cardiac enzymes and medication protocols) -Completing pain assessments and as needed responses with documentation per policy/protocol within one hour of medication administration -Verifying Daily Cares documentation on every patient chart every two (2) hours -Checking the IV site at least every four (4) hours or according to hospital and/or unit policy -Documenting cardiac monitoring per unit policy and ensuring appropriate identification measures are followed (TTX number, patient name and room number) -Documenting Falls Risk patients: MORSE scale daily, hourly rounding and post fall injury assessments -Documenting changes in the patient's condition and notifying the MD, PA, or NP in progress notes and/or provider notification form -Documenting critical lab values on provider notification forms within a one (1) hour time frame -For Stroke patients: Verifying NIHSS assessment by credentialed staff at onset, when there are changes in status and prior to discharge and documenting Neuro checks, Dysphagia screens and VS according to policies -Following pre- and post-procedure protocols (VS, specific documentation, etc.) 3. Developing and Initiating a Plan of Care -Initiating and documenting plans of care according to the diagnosis, patient history and Quality Measures -Collaborating with other health care team members in formulating a plan for patients and/or participating in patient care rounds -Individualizing plans of care based on the patient's preferences and completing mutuality per policy -Resolving/completing plans of care as appropriate and at time of discharge -Initiating patient education, including family (as appropriate), to include discharge planning upon admission, diagnosis and care needs and Quality Measures -Delivering and documenting medication education including actions, side effects and patient's understanding -Documenting completion of discharge education as evidenced by patient's verbalization of understanding of instructions 4. Developing Competencies -Following hospital/unit-based policies to maintain standards of care -Demonstrating autonomy in finding solutions to problems -Effectively and appropriately delegating tasks to coworkers -Maintaining competencies and requirements for position to include: license, vaccines, modules, annual skills and other requirements assigned by Leadership -Functioning as a Charge Nurse by making appropriate shift assignments, communicating with staff throughout the shift for appropriateness based on acuity and communicating with A.C./Bed Reservations in order to manage bed flow -Functioning as a preceptor -Participating in the PACE program and/or other opportunities for professional development (ex: nursing organizations, volunteering or other community activities) -Serving as a unit representative for the Council/Committee or Resource Team -Participating in specialty CE classes (ex: Annual Cardiac Update or other conferences, Specialty CE articles, Compassionate Leader classes or other non-mandatory classes)
Keywords: UNC Health Care, Raleigh , RN CLINICAL NURSE II - 6 HV/CV STEPDOWN, Healthcare , Raleigh, North Carolina
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