Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation and evaluation. Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practices. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Possesses a passion for learning and provides compassionate and family centered care for Psychiatric patients. Practices under the supervision of the Nursing Manager/Director.
Job Specific Duties
- Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
- Ensures completion of patient admission history, and prepares and completes the discharge planning process accurately as per department and hospital policies and procedures.
- Obtains parental consent for every medication administered per policy.
- Follows physician’s orders, checks labs, tests, and administers patient medications when needed. Adheres to six rights of medication administration per Medication administration policy.
- Accesses IV sites after removal of IV to check for infiltration, redness, and infections.
- Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate and fosters a Family Centered Care Environment.
- Ensures safe analgesics/narcotics administration, monitoring and reassessment as per hospital Pain Management policy and procedure.
- Completes all nursing multi-system assessment that includes head to toe, performs systems assessment based upon patient need. Performs mental health assessment.
- Ensures appropriate restraint orders, use, documentation, and monitoring as required by Sedation policy and procedure.
- Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation within 24 hours in the patient’s electronic health record.
- Communicates with patient and family on additional resources available to the patient.
- Ensures voluntary consents and/ or baker acts are up to date and in good standing.
- Coordinates all assignments and tasks for Behavior Health Techs.
- Communicates with patients and families to review plan of care and solicits input. Communicates any patient and family concerns to physician.
- Educates families regarding new diagnosis and provides treatment plan.
- Promotes an “error free” working environment by consistently providing high-quality safe care as prompted.
- Assesses all body systems, and ensures safe, efficient care, while ensuring no medication errors, avoidance of falls, and clean sweeps.
- Provides patient information and effectively completes the hand off process at shift change and patient reassignments.
- Demonstrates proper personal protective equipment (PPE) indication and use.
- Actively participates in the nursing governance council and unit based activities.
- Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH, FACT, COG, COC.
- Provides continuous supervision, observation of behavioral health patients, and adheres to non-violent crisis intervention strategies (CPI).