Registered Nurse - Med Surge

About the Role: Registered Nurse - Med Surge

As a Registered Nurse - Med Surge at Northwell Health, you will deliver comprehensive patient care by meticulously assessing and diagnosing patient conditions, developing individualized care plans, and evaluating patient responses to treatment. This role emphasizes active participation in patient education and discharge planning, alongside collaborating with, coordinating, and guiding designated care team members to achieve patient goals.

Key Responsibilities

• Develops and evaluates plan of care: Systematically and continuously assesses patient's knowledge base and physical, psychosocial, and spiritual health through interviews, physical examinations, and data collection. Consults with the multidisciplinary health care team regarding nursing assessment findings. Creates written, individualized plans of care based on priority of patient problems, anticipated length of stay, input from patient and family, and other members of the health care team. Communicates pertinent information and changes in patient status to appropriate members of the care team and other health care providers, as necessary. Collaborates with team members to make changes in the plan of care, as necessary.
• Provides and/or delegates patient care according to the plan of care and established protocols: Utilizes clinical resources in implementing patient care and provides rationale for patient care decisions. Conducts clinical rounds, provides emergency care, and administers medications to patients. Operates equipment required for patient care according to manufacturer's recommendations. Performs and assists with procedures and treatments on unit including, but not limited to, changing dressings, feeding patients, and providing pre/post-operative care. Practices and monitors infection control standards. Promotes and provides patient safety in accordance with state and federal guidelines.
• Documents patient care, as required on all appropriate forms: Enters date and time of entry and signs name legibly on patient's chart. Completes Nursing Admission Assessment within 24 hours after admission. Documents patient's response to interventions and plan of care on the Progress Notes. Performs vital signs and pain score at least every four hours. Completes Transfer Assessments on patients transferred out of the unit and Perioperative Assessments on patients scheduled for surgery or procedures. Completes Frequent Observations and the Intake/Outtake Record according to established protocols. Initiates and completes health care referrals in collaboration with the interdisciplinary team.
• Provides patient education: Identifies patients' learning needs upon admission. Informs and educates patient and family to enable participation in their care and decision-making. Develops and implements a teaching plan of care. Conducts patient teaching conferences. Documents patient teaching.
• Participates in Quality Improvement process: Participates in developing and implementing unit goals and objectives. Attends in-service programs on new products and equipment used on unit. Completes occurrence reports according to policy and unit-based audits, as assigned. Participates in identifying problems requiring investigation and in developing and implementing corrective action plans for the unit.
• Participates in unit staff meetings and unit based clinical conferences, as scheduled: Represents the clinical unit on committees, as assigned. Submits annual record of continuing educations and self-assessment of clinical performance.
• Performs the responsibilities of charge nurse and preceptor according to established protocols, as assigned: Performs related duties, as required.

Qualifications

• Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred.
• Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010, and obtain a BSN degree within five (5) years of employment date.
• Current license to practice as a Registered Professional Nurse in New York State.
• BCLS, ACLS or PALS, required.

Key Skills/Competency

• Patient Assessment
• Care Planning
• Medication Administration
• Infection Control
• Patient Education
• Electronic Health Records (EHR)
• Team Collaboration
• Critical Thinking
• Emergency Care
• Quality Improvement