RN - Med Surg
3 days ago
PRN /ON CALL/ FLEX POSITION SUMMARY: As a member of the Interdisciplinary Care Team (IDT), the Registered Nurse (RN) performs physical assessments and completes health histories; monitors the physical and psychological health of the client; interprets patient information; and makes critical decisions about needed actions. This nurse collaborates with the physician and other healthcare providers and educates clients, families, and staff. This nurse practices within the scope of Pennsylvania's Nurse Practice Act and in accordance with Elwyn's policies and procedures and those of Elwyn's regulatory agencies. DUTIES AND RESPONSIBILITIES * Complete a comprehensive nursing assessment upon admission/readmission and as changing health needs indicate * Complete a Quarterly Nursing Assessment every three (3) months that includes a review of systems, full body exam, skin checks, Braden Scale, and Fall Risk Assessment * Upon discharge, complete a Discharge Summary that includes all relevant medication, medical follow up, and pertinent health care information to provide for continuity of care * Present clinical data obtained through direct observation, interview, physical assessment and other reports to the IDT members; present information in a concise and organized manner * Develop a health care plan for clients requiring 24/7 nursing care that will include specific nursing goals and directions for meeting the client's health care needs * Review and revise the health care plan at a minimum of every 90 days and incorporate data gathered through nursing assessments and communication with the IDT * Collaborate with Day and Work Services to ensure that the health care needs of the client are communicated and the necessary documentation forwarded * Collaborate with physicians, physical rehabilitation professionals, therapists, health care professionals and other members of the IDT to plan and implement the therapeutic program of care * Monitor weight and blood pressure measurements at a minimum of monthly and more frequently as indicated by nursing judgement or physician orders Administer enteral tube feedings, blood glucose testing, nebulizer treatments, and skin care as ordered by the physician; use discretion during administration to provide as much client privacy as possible * Document administration of prescribed medications and treatments on hard copy MARs or in an electronic format (eMARs); use discretion during administration to provide as much client privacy as possible * Instruct direct care staff on the administration and documentation of specific treatments including but not limited to topical creams and other over the counter (OTCs) agents * Evaluate the therapeutic effectiveness of medications and treatments and report any observed side effects and relevant laboratory values to the Health Care Coordinator/Charge Nurse; Contact the physician as directed * If using hard copy MARs, review the monthly MAR and validate that all medication and treatment orders are correct and update as needed; remove old MARs from the medication binder and replace with new MARs at the start of every month * Assess client progress with the self-administration of medication and work to actively promote increased independence in client function; assist with data collection related to medication goals * Prepare clients for medical appointments through communication and maintenance of NPO (nothing by mouth) status, procedural preps, and the administration of pre-sedation medication * Document all relevant information in the MAR, nursing progress notes, and 24 Hour Change in Status Report * Provide significant clinical and informational updates to the Charge Nurse throughout the shift; contact the Charge Nurse by phone (1) hour prior to the end of the shift to provide verbal report * Contribute nursing knowledge to the development and maintenance of a safe and therapeutic living environment; inspect the general living areas for present and potential hazards and report to the Unit Director, Health Care Coordinator, or Charge Nurse * Monitor for potential infectious disease among clients and staff and report to the Health Care Coordinator/Charge Nurse who will then report to the Director of Nursing, * Provide nursing coverage to all units as needed; demonstrate flexibility, adaptability, and team work when nursing assignments must be modified EDUCATION/SKILLS/EXPERIENCE REQUIREMENTS: * Licensed as a Registered Nurse in the Commonwealth of Pennsylvania * One (1) year general nursing or medical surgical experience required; Developmental Disabilities nursing experience preferred * Demonstrated skill using an electronic medical record system * Ability to work in a fast-paced environment and manage and prioritize multiple, often competing, priorities * Demonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervision * Demonstrated ability to anticipate future needed changes or identify problem areas and take effective actions * Excellent planning, communication, customer interaction, collaboration, and documentation skills required * Current CPR certification * Demonstrated ability to work effectively as part of a team * Must be able to perform CPR and crisis intervention techniques using agency-trained protocols * Must have current, valid driver's license in state of residence, 3 years driving experience in the United States, and acceptable driving record PHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physical Demands Checklist below which represents the general physical demands and environment conditions to which the employee holding this position must meet, in addition to the duties and responsibilities listed above, to successfully perform the essential functions of this job. Elwyn will engage otherwise qualified candidates for this position whose disabilities may require reasonable accommodations to enable an individual to perform the essential functions. Elwyn reserves the right to revise or change job duties and responsibilities as needed. This job description is not meant to be an all-inclusive statement of duties and responsibilities of the job nor does it constitute a written or implied contract. Elwyn is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation and identity, gender identity, national origin, citizenship status, genetic information, disability status, military or veteran status, marital or family status, political activities or affiliations, or any other characteristic protected by local, state, and federal law.
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