ESSENTIAL FUNCTIONS 

• Conducts an initial assessment to gather data. 

• Makes an initial assessment of new admissions within 30 minutes of the patient’s arrival to the unit. 

• Completes all areas of the admission assessment database within 24 hours of admission.  

• Identifies patient problems and develops them into an outcome/goal-based plan of care. 

• Initiates the patient problem list and incorporates relevant medical history into the plan of care. 

• Analyzes and interprets the assessment data to identify desired patient outcomes/goals. 

• Determines nursing interventions to achieve those outcomes/goals. 

• Prioritizes patient care needs/ activities. 

• Identifies and makes appropriate referrals (i.e., Patient/Family Services, Nutritional Services, Spiritual Care, Diabetic Educator, etc.), and education needs. 

• Collaborates with other health care disciplines to plan interventions/ patient outcomes/goals. 

• Implements the outcome/goal- based plan of care. 

• Assigns and coordinates patient care incorporating patient acuity and the skills, knowledge and abilities of the team members. 

• Organizes and prioritizes care for the patients within the team. 

• Delegates tasks appropriately to other team members. 

• Implements the plan of care including procedures, treatments, physicians orders, nursing orders, education plan and medications. 

• Coordinates implementation of plan of care with the Case Manager, Social Worker and other health care disciplines. 

• Assists to decrease the patient’s length of stay by helping the patient and family identify and secure appropriate services to satisfy health-related needs upon discharge. 

• Uses nursing judgment to determine the appropriate frequency and components of reassessment. 

• Reassesses at regular intervals to determine patient response(s) to interventions (minimum RN reassessment every 24 hours). 

• Focuses ongoing reassessment on actual and potential problems/needs of the patient including education and discharge needs. 

• Participates in develop discharge plan.  

• Documents discharge instructions for patient and/or significant other and/or other care provider.   

• Evaluates patient progress and revises the outcome/goal-based plan as needed. 

• Evaluates patient response(s) to interventions. 

• Communicates relevant clinical information to the team to optimize patient outcomes/goals. 

• Reports progress toward outcomes/goals and/or changes in condition to other health team members. 

• Maintains ongoing communication with interdisciplinary team members throughout the shift, at shift change, and transfer of care. 

• Documents completely, comprehensively and legibly and in accordance with policy. 

• Demonstrates clinical competence. 

• Utilizes the Patient Care Policies and Procedure as references to guide nursing practice. 

• Assures medication safety by following the “5 Rights” of medication administration. 

• Prioritizes and implements intervention according to patient assessment. 

• Receives, transcribes and processes and implements physician orders per policy including dating, timing and verifying accuracy. 

• Maintains communication with the manager/house supervisor and staffing office regarding admissions, unit needs, acuity numbers and significant events. 

• Completes assigned shift duties and assures resolution of discrepancies. 

• Adheres to all safety, infection control and colleague health policies and procedures. 

• Appropriately and consistently uses the personal protective equipment required of the job. 

• Knows and can demonstrate departmental emergency procedures for fire, disaster and other emergency situations

• Maintains a safe working environment and practices safe working habits. 

• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior

MINIMUM QUALIFICATIONS 

• Associate degree required, BSN preferred. 

• No experience required; critical care nursing experience preferred. 

• Current Iowa RN license, (current IL license if working in IL).  

• BLS, Mandatory Reporter.    ACLS within 12 months of hire.    Cardiac monitoring course and/or select units of advance Nursing / Critical Care Course or comparable training 

• TNCC  

• Non-Violent Crisis Intervention Training (NVCI) within 6 months of hire  

• High language, intermediate to high math, high critical thinking ability.   

• Basic computer skills required.   

• Ability to work with diverse groups of people.   

• Ability to work under pressure and with a large degree of independence and accountability.   

• Ability to lead/direct others in a high stress situation/environment.