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Registered Nurse
2 months ago
Summary:
To provide direct and indirect nursing care to a patient or group of patients.
Responsibilities:
1. Mental Status Exam Criteria A: Admission intake has information regarding the mental status of the patient and provides a clear picture to the reader. Mental Status Exam Criteria B: Progress notes provide information as it pertains to the patient's current mental status, including assessment of the patient's progress towards goals and updated assessment on the symptoms that were identified on admission. Mental Status Exam Criteria C: Documentation includes an assessment as it pertains to suicidal ideation and potential for harm to others. Mental Status Exam Criteria D: Discharge documentation includes an assessment as it pertains to suicidal ideation and potential for harm to others.
2. Administration of Psychiatric medications Criteria A: There is noted verbalization to patient regarding the psychiatric medications they are receiving. Administration of Psychiatric medications Criteria B: There is documentation indicating that the patient has received education regarding medication they are receiving. Administration of Psychiatric medications Criteria C: There is an assessment of the patient prior to receiving medications, so that the efficacy of the medication and side effects can be measured. Administration of Psychiatric medications Criteria D: There is an appropriate assessment and documentation for the patient who requires additional prn medications, requires the administration of medications against his/her will, and/or requires intervention with medications for symptoms of drug / alcohol withdrawal.
3. Restraints / One Hour Face to Face RN Assessment Criteria A: Performs "charge" role in any Code Green situation on CP3, which includes quickly identifying self as in charge of the Code, calmly instructing the patient what is expected, making the decision whether to apply restraints or avoiding restraints if patient can be medicated and/or regain control, assigns limbs for the actual restraining and directs Security responders, checks that restraints are applied correctly, ascertains whether anyone was injured during the process, and conducts Outcome Study of Code Green / Restraining immediately after the event. Restraints / One Hour Face to Face RN Assessment Criteria B: Performs face to face assessment one hour after application of restraints, of the patient's physical and psychological well-being. Restraints / One Hour Face to Face RN Assessment Criteria C: There is documentation that all restraint practices were followed according to policy, including all less restrictive measures that were implemented prior to the use of restraints. Restraints / One Hour Face to Face RN Assessment Criteria D: There is a return demonstration at least annually to indicate that the RN can lead the Emergency Restraining Team and apply restraints appropriately.
4. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria A: Demonstrates the ability to appropriately set limits on negative patient behaviors, the ability to assess patients for potential for violence, and intervenes appropriately. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria B: Demonstrates the ability to conduct a contraband search assuring patient rights are maintained. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria C: Exercises principles of confidentiality as it pertains to the behavioral health population. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria D: Assesses the environment as it pertains to issues of safety.
5. Group leadership Criteria A: Demonstrates the ability to lead / co-lead groups exercising principles of group dynamics. Group leadership Criteria B: Leads / Co-leads the daily Community Meeting Group leadership Criteria C: Documents the patient's participation in group.
6. Patient rights Criteria A: Demonstrates knowledge of issues related to patient rights, including the requirements for the involuntary patient, and documentation reflects this. Patient rights Criteria B: Demonstrates the ability to assess the patient who request to sign out against medical advice for issues of safety. Patient rights Criteria C: Assures that the patient is aware of their rights as evidenced by the documentation that these rights have been reviewed.
7. Care delivery Criteria A: Adheres to Nursing Standards of Practice to include assessment, treatment planning, interventions and evaluation of the treatment plan, progress on the goals of the treatment plan, and the effectiveness of interventions. Goals are measurable, specific and individualized for the patient. Care delivery Criteria B: Keeps the treatment plan up to date, adding newly emerging problems and Goals to address the problems, addressing events such as a Code Green called on the patient, self-inflicted harm, a fall, etc., and signing off on Goals that have been resolved/completed, and clearly communicates these changes when handing off care. Progress Notes document the patient's progress on goals. Care delivery Criteria C: Maintains consistency in enforcing unit policies and procedures without becoming overly rigid or harsh in setting limits. Care delivery Criteria D: Demonstrates skill in therapuetic communications and interventions.
8. Patient education Criteria A: Demonstrates the ability to assess the learning needs of the patient/family and documents. Patient education Criteria B: Provides information and instruction on the nature and treatment of psychiatric illnesses and documents this information as well as the patient's response to education provided. Patient education Criteria C: Involves the patient in decisions on his or her own care, after providing education about treatments, tests, medications, appropriate behaviors, aftercare, etc.
9. Leadership ability Criteria A: As Charge Nurse, completely fills out the patient care assignment, including date, shifts, all staff on duty including floated PCTs and sitters, patients on CO and on PEC, and delegates responsibility to other members of the patient care team, commensurate with their abilities and scope of practice. Leadership ability Criteria B: As Charge Nurse, proactively attends to unit staffing needs in relation to safety, acuity, and census, including notifying the Nurse Manager, Clinical Manager, or Staffing Office when staffing is varies from the NASH recommendations. Ensures that the NASH Acuity is done at the designated intervals. Leadership ability Criteria C: As Charge Nurse, supervises the clinical delivery of care for the shift, oversees the work of other RNs, Psychiatric Techs, Unit Secretaries and other assigned nursing staff, and ensures that colleagues on the shift complete their assignments. Leadership ability Criteria D: Acts as a preceptor to new employees, float personnel and students.
10. Communication Criteria A: Demonstrate effective communication skills with all members of the health care team and with the patient and family. Communication Criteria B: Gives concise and accurate verbal reports, and provides essential information during any hand-off. Communication Criteria C: Documents pertinent care information as evidenced by completeness of admission intakes, Treatment and Education plans, Braden Assessments, Fall Risk Assessments, Pain Assessments, PRN Medications, discharge education and summaries and progress notes, etc. Communication Criteria D: Uses the principles of AIDET (Acknowledge, Introduce, Duration, Evaluation, and Thank You) in communicating with patients and family members.
11. Performs other duties as assigned.
12. Fulfills all compliance responsibilities related to the position.
Education: ASSOCIATE'S LVL DGRE
Other Information:
Required: License to practise in the state of Connecticut.
Minimum Experience: zero to six months
Desired: none
Working Conditions:
Manual: significant manual skills/motor coord & finger dexterity
Occupational: Significant occupational risk
Physical Effort: Very Heavy effort. May exert up to 50 lbs. force
Physical Environment: Significant exposure to dirt, odors, noise, human waste, etc.
Credentials:RN
Company: Norwalk Hospital Association
Org Unit: 338
Department: Psych Unit
Exempt: No
