Location: Oakdale, CA
The Med-Surg Registered Nurse is responsible for assessing patient/family health problems and resources, and takes a leadership role in the development, implementation and outcomes evaluation of a plan for nursing care. Provides professional nursing care and interventions to medical surgical patients to include, but not limited to, general surgery, orthopedic, pediatric, family practice and internal medicine.
1. Collects data and determines measurable, realistic, attainable diagnosis and expected outcomes with a time estimate for attainment; verifying patient information for accuracy and taking corrective action when necessary
2. Observes patient minimally, per department standards or as condition warrants, and maintains awareness of patient and significant others’ psychological needs as well as the patient physical needs and promotes care of the total person.
3. Provides Plan of Care by developing an effective, comprehensive and individualized plan of care for assigned patients, deriving nursing diagnosis from assessment data and expected outcomes and medical treatment plan. Consistently documents specified nursing orders, develops short and long-term expected outcomes following intervention. To the extent possible, develops this plan with the patient, significant others’ and health care providers.
4. Performs and documents nursing interventions, receiving reports from off-going nurses and when requested, provides Physician with summary of assigned patient current status, verifying information with Physician when in question.
5. Communicates patient responses and the effectiveness of nursing interventions in order to reduce patient anxiety and promote cooperation and compliance. Reports patient care or management problems through proper chain of command. Maintains a calm, professional attitude and interactions while dealing with rapidly changing situations, including emergencies.
6. Accurately and completely transcribes all Physician orders and documents nursing intervention on the patient medical records according to established procedures per department protocol, to reflect patient status and condition. Observes, records, and reports legibly and accurately any legal/medical documents and/or significant deviations to the Physician; completing the correct forms required in the day-to-day operation of the department. Maintains legal/medical documents legibly and accurately.
7. Assists Physician’s with diagnostic tests and special procedures. Reviews Physician orders and implements within a reasonable time frame. Implements nursing interventions consistent with plan of care and carries out treatment plan as prescribed by Physician, complying with the five rights of medication administration. When in question notifies Physician to prevent misunderstandings or miscommunication.
8. Makes effective decisions during emergency situations and evaluates the results of actions taken.
9. Evaluates patients progress and when appropriate involves patient, significant others and care providers in evaluation of patient progress. Uses ongoing assessment data to revise diagnoses, out comes, and plan of care, as needed
10. Maintains professional standing, demonstrating knowledge of the legal aspects and liabilities of nursing practice and consistently combines ethical judgement with technical skill within the policy and legal guidelines of the hospital. Annually completes continuing education classes updating competency levels on topics required by department.
Graduate of a RN School of Nursing
Bachelor degree preferred
Associate Degree in Nursing
One (1) year recent acute care experience preferred
Able to perform basic mathematical calculations
Excellent written and verbal communication skills
Med-Surg certificate preferred
National Certification in related specialty preferred
Current California RN License
Current AHA BLS
Current AHA PALS (within 3 months of hire)
Current AHA ACLS
Prolonged, extensive or considerable standing/walking
Lifts, positions, pushes up to 50 pounds
Considerable reaching, stooping, bending, kneeling, crouching
Manual dexterity and mobility
Ability to move quickly
Frequent reach, twist, push and pull
Heavy lifting (50 lbs. and over) 50% of the time
Moderate lifting (25-49 lbs.) 25% of the time
Light lifting (under 25 lbs.) 25% of the time
Must be able to move heavy patients up to 350 lbs. at times in bed and transfer from bed to gurney or wheelchair
Heavy carrying (50 lbs. and over) 25% of the time
Moderate carrying (25-49 lbs.) 35% of the time
Light carrying (under 25 lbs.) 45% of the time
Must assist with ambulation orthostatic vital signs
Ability to adjust vision sufficiently to perform duties
Regularly exposed to the risk of contagious and blood borne diseases
Exposure to unpleasant elements (accidents, injuries, illness)
Subject to irregular hours
Increased stress due to multiple calls and inquiries
Able to work in spite of frequent interruptions
High exposure to communicable diseases and blood borne pathogens, rare exposure to toxic substances such as radiation, nuclear isotopes, chemotherapeutic agent