Registered Nurse Surgical Unit

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Responsibilities:

Complies with governmental and accreditation regulations. Performs other duties as assigned. Independently assesses, plans, implements, and evaluates the nursing care of patients from admission through discharge. In collaboration with the patient and family, provides theory-based professional nursing care and coordinates care delivery with the physician and other members of the healthcare team. Based on assessment of physical, emotional, bio-physical, and spiritual needs, provides direct patient care and evaluates outcomes. Incorporates the principles of patient-centered care. Communicates patient's clinical information clearly and accurately in verbal and written format. Clearly and accurately documents pertinent information in the patient's medical record. Consistently demonstrates effective documentation practices and develops strategies to ensure complete documentation of patient care. Completes timely initial and ongoing patient assessments, considering the physiological, psychosocial, spiritual, cultural, and developmental needs of patients and families. Serves as resource in planning care for complex patients. Contributes to optimal patient outcomes as coordinator of a unit-based healthcare team. Supervises the provision of nursing care to assigned patients. Consistently demonstrates effective leadership behavior. Maintains patient privacy and confidentiality. Facilitates collaboration among other health team members fostering effective communication with other disciplines. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Seeks opportunities to participate in developing/revising standards of practice to meet changing patient population requirements. Evaluates the patient's response to treatment and progress toward identified goals and revises plan of care as appropriate. Monitors medical condition, intervenes using critical thinking, and reports patient changes to appropriate personnel. Identifies health teaching needs of patients and families. Develops, implements, and evaluates a health teaching program to meet the identified needs. Effectively uses and adapts a variety of teaching resources in meeting the learning needs of patients/families. In collaboration with the patient, family, and other members of the healthcare team, systematically develops, revises, and coordinates the patient's plan of care. Formulates nursing diagnosis as necessary. Assists others in developing, revising, and coordinating patient's plan of care. In coordinating the delivery of patient care, delegates activities to unlicensed staff in accordance with system policies, principles of Patient- Centered Care, and the Maryland Nurse Practice Act. Supervises the performance of the delegated nursing task by the unlicensed staff. Assists staff in delegation/time management skills. Identifies ways to facilitate working relationships among all levels of staff. Initiates and monitors discharge planning activities in collaboration with other members of the healthcare team. Takes the lead in facilitating timely discharge. Maintains a safe and therapeutic environment of caring for patients and families. Provides basic patient comfort measures during procedures. When necessary, provides environmental support to expedite timely patient admission or transfer. Identifies and acts upon opportunities to improve the environment of care. Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams. Provides for the emotional support of patients and families during the crisis of illness. Demonstrates patient/family advocacy.