JOB SUMMARY: Provides nursing care to a group of patients for a designated time frame. Routinely leads team of care providers. May assume charge responsibility for unit when assigned. Provides guidance/support to lower level employees. Has principal responsibility for the total nursing care assessment, planning, implementation and evaluation of assigned patients according to the regulatory standards for the critical access hospital. Assures that the plan of care is carried out in a safe environment through performance and supervision of subordinate personnel. Provides direct and indirect care on a routine basis. OSHA Bloodborne Pathogens Class I.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Utilizes the nursing process, completes a comprehensive physical and psychosocial assessment of patients.

• Takes nursing histories to provide a basis for patient care plans.
• Completes thorough nursing assessment and history on admission.
• Identifies teaching/learning/discharge needs at time of admission and throughout hospitalization.
• Consistently uses input from patient, family, significant other, physician and health care team members.  
• Provides care appropriate for the neonate and pediatric, adolescent, adult and geriatric patients served based on demonstrated knowledge of the principles of growth and development over the life span.
• Assess and interprets data to identify patient requirements related to their age specific needs and provides care needed as stipulated in departmental policy.
• Provides service direct to patients while maintaining a positive patient relations atmosphere

Using nursing process, plans and provides patient/family care, evaluating patient’s response to care provided and redirects care as necessary

• Formulates appropriate nursing diagnosis and identifies patient problems from admission data base and ongoing assessment
• Establishes patient outcome goals what are realistic, specific, measurable and progressive.
• Develop and implements nursing orders that are specific and measurable.
• Consults with patient and family to include holistic patient needs.
• Reviews and updates care plan on a timely basis through hospitalization.

Implements and monitors appropriate nursing care to meet patient needs.

• Administers medications according to policy including IVs, blood and blood component as prescribed by physician/provider.
• Recognizes actions, indications, adverse reactions, dosage and route of administration on all drugs and accurately verifies medication administration record.
• Gives exchange report to other health care personnel at change of shift, transfer to another unit and throughout shift.
• Performs basic nursing skills including but not limited to specimen collection, dressing changes, personal hygiene, skin care, glucose monitoring, airway suctioning, basic oxygen administration, tube feedings, urinary catheterization, drains, enemas and IV administration.  
• Recognizes, evaluates and intervenes appropriately in a life-threatening situation.  
• Recognizes variance of diagnostic tests, vital signs and assessments and reports to physician/provider in an appropriate time frame.

Participates in the health care educational needs for the client family,or significant other with regard to patient care needs, disease prevention and health maintenance measures.

• Develops and implements an individualized teaching and discharge plan at admission and updates throughout stay.
• Acts as a liaison between patient, physician, family or significant other and other health care team members.

Maintains accurate and timely records according to hospital policy.

• Documents ongoing assessments in medical record
• Accurately documents on each shift the nursing patient care activities and the patient’s response to interventions. 
• Documents teaching completed with patient and family response.
• Documents interdisciplinary recommendations for plan of care.
• Completes all appropriate transfer and discharge forms.
• Transcribes and/or cosigns physician/provider order accurately.

• Education – Graduate of an accredited School of Professional Nursing
• Job Related skills – Demonstrated effective oral and written communication skills
• License, Registry or Certification – 
• Registered Nurse currently licensed in the State of Texas.  
• Current BLS certification and other certifications required for CAH 
• Prior Work Experience -  
• One year as a Registered Nurse preferred.  
• Technical Training – Computer skills required.
• Physical and Mental Requirements -  
• Position requires extended periods of walking and standing. 
• Repeated bending, stooping and reaching, lifting up to 50 pounds.
• Transferring and lifting or supporting patients who may experience sudden weakness or inability to stand.
• The ability to comprehend and follow written or verbal instructions and directions and to instruct employees. 

OTHER SIGNIFICANT REQUIREMENTS

• Follows aseptic procedures and procedures for using precautions when involved in direct patient contact or handling potential infectious materials.
• Interacts with patients, family members, Medical Staff members and department managers on a continuous basis.
• Maintains HIPAA required and all other confidentiality while working with confidential matters on a daily basis.
• Follows MCHD Policies and Procedures and safety guidelines.
• Performs other duties as assigned by the department management staff.
• Performs essential job functions with or without reasonable accommodations.