The Registered Nurse provides nursing care to all patients in the South Unit & ensures appropriateness of care for all age groups in the unit specific population. He / She demonstrates an ability to incorporate knowledge of patient’s age, growth, developmental level in the provision of care.
ESSENTIAL JOB FUNCTIONS:
· Completes Nursing Assessment upon admission and each shift thereafter in accordance with unit standards and hospital policy.
· Enters, reviews, and updates electronic health record information per unit policy. This includes minimum of one patient care note every shift in addition to other required documentation.
· Includes cultural & gender considerations when assessing appropriate method for care management.
· Creates / follows plan of care to meet patient care goals, incorporating the physical, social, and psychological needs in the process.
· Responsible for monitoring patient safety and wellbeing.
· Participate & ensure that patient contraband search is properly conducted.
· Makes purposeful rounds a minimum of 4 times per shift.
· Is observant of changing patient needs and/or environmental conditions impacting the patient & takes appropriate & timely action. (Including but not limited to ligature risk assessment).
· Delegates patient care activities to appropriate personnel (CBHT / MHT / Unit Secretary), supervises & follows through to assure care completion.
- Effectively addresses & ensures patient safety needs are met & that hospital policies are followed regarding:
- Fall Risk
- Aspiration Risk
- Restraint / Seclusion
- Wound Care Protocol
- Elopement Risk
- Emergency Codes
- Patient Rights
- Patient knowledge of Grievance Process
- Ligature Risk Assessment
· Works & assists collaboratively with all other members of the health care team.
· Administers and documents medications accurately according to established policies & procedures.
· Participates in South Unit / Hospital QAPI activities.
· Follows hospital policy and regulatory requirements regarding use of restraint and/or seclusion.
· Utilizes sound judgment and decision making criteria in observing psychiatric patients, gathering & analyzing information, drawing conclusions, & taking required action. (Problem analysis).
· Able to identify & anticipate patient changes and potential problems, & communicate these issues to other relevant members of the healthcare team and / or significant other as appropriate & in a timely manner.
· Recognizes significant changes in patient clinical parameters and immediately reports to physician & charge nurse. (Critical Value of lab and radiology reporting).
· Responds promptly in accordance with policy and procedure to all emergency situations that arise on the unit or in the hospital.
· Identifies patient/family/significant other needs for health teaching & utilizes available resources to assist in patient / family / significant other teaching as needed.
· Begins discharge planning upon admission & observes hospital discharge policies.
· Utilizes best practices in hand-off communications to oncoming shift.
· Participates in Orientation of new personnel.
· Performs other duties as assigned.
OTHER RESPONSIBILITIES / SKILLS AND ABILITIES:
· Demonstrates appropriate knowledge & skill as a psychiatric nurse.
· Performs in a calm and professional manner during crisis and emergency situations.
· Provides quality nursing care through Nursing Process of Assessment, Planning, Implementation, and Evaluation.
· Adheres to department/hospital safety & infection control standards according to established policies and procedures.
· Ability to give instructions and to supervise other staff members when any need arises.
· Ability to work in teams.
· Prioritize & Complete tasks in a timely manner.
· Graduate of an accredited school of Nursing; ASN required, BSN preferred
· Current licensure as a Professional Registered Nurse in the State of Florida
· Previous psychiatric nursing / relevant nursing experience preferred.
· Current BLS required; ACLS preferred &/ or required per departmental standard.
· Baker Act Training and Aggression Control Education required upon hire and annually thereafter.