Perform patient assessment according to hospital/unit policy.
Performs initial assessment appropriate to the patient’s clinical presentation/diagnosis, care setting, age, development level, and cultural and religious orientation in a timely manner.
Performs completely and accurately including, but not limited to, physical (i.e. assessment for pain, skin breakdown, risk for falls), psychological (i.e. cognitive and communicative skills or development), social status and other patient needs.
Identifies and prioritizes the need for further assessment based on the patient’s clinical presentation/diagnosis, care setting, desire for care and responses to any previous care.
Initiates discharge planning for each patient upon admission as appropriate.
Develops a Patient Plan of Care that:
Is individualized for each patient based on assessment of needs that include input from the patient, family and other multi-disciplinary health care team members.
Includes plan for discharge/transfer.
Identifies specific nursing diagnosis is relevant to assessment findings.
Identifies interventions, for each nursing diagnosis, specific to identified patient needs.
Performs interventions identified for each nursing diagnosis on the Interdisciplinary Plan of Care.
Demonstrates the ability to effectively communicate patient care needs to all members of the multidisciplinary health care team.
Conducts patient/family education that:
Is appropriate to the patient’s age, learning needs, level of understanding and readiness to learn.
Includes the family/significant others when appropriate.
Documents nursing intervention and patient teaching on designated forms.
Evaluates and documents the patient’s response to the Plan of Care and to interventions.
Revises and updates the Plan of Care as evidenced by documentation.
Documents patient’s response to teaching on designated form.
CRITICAL THINKING SKILLS LEADERSHIP SKILLS:
Accountable for own conduct and independent decisions made in the course of job performance.
Participates in unit activities designed for improvement of services.
Acts as preceptor for new health care team members and student nurses when asked.
Effectively delegates tasks to appropriate health care team members.
Provides input for policy/procedure development.
Demonstrates sound judgment and effective decision-making in following the nursing process.
Triages/prioritizes multiple patient interventions.
Changes priorities based on new assessment data.
Identifies supplies, equipment, and additional personnel necessary to complete a given assignment.
Analyzes data collected, weighs alternatives, and acts appropriately.
Facilitates systems/processes in response to situations that have the potential to negatively impact patient/family outcomes.
Follows the five rights of medication administration and maintains transcription accuracy.
Administers blood products per hospital policy.
Administers IV therapy per hospital policy.
Able to function effectively during an emergency patient care situation.
Demonstrates appropriate interventions regarding the use of restraints per hospital policy.
Performs waived testing following hospital policy.
Assumes responsibility for maintaining a high level of clinical expertise and adapts to new information, technology, and changing trends in nursing practice.
Maintains required certifications.
ESSENTIAL KNOWLEDGE / SKILLS:
Effective written and verbal communication skills in the English language.
Ability to calculate figures and amounts such as proportions, percentages, area (BSP), circumference and volume.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to work in high volume, fluctuating census environment.
Subject to many interruptions.
Subject to irregular hours.
Ability to work in fast-paced environment where noise levels fluctuate
Current CA RN License
Murrieta, California , 92562
40-45 an hour DOE
Mar 11th, 2019