Clinical Nurse, Med/Surg

Position Summary / Career Interest:

Under the supervision of the nursing department’s management, the RN assumes the responsibility for the nursing processes of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation needed to deliver safe, evidence based care within their scope of practice.  


Responsibilities and Essential Job Functions

• Collects and assesses initial and on-going data about the health status of the patient.
• Initiates and/or revises an individualized plan of care that includes immediate and long-term outcomes for the patient/family and reflects the plan of the entire health care team.
• Carries out interventions safely and in compliance with policy to facilitate achievement of expected outcomes.
• Evaluates patient response to intervention/therapy based upon expected outcomes.
• Provides patient education by explaining procedures, medications and giving instructions at a level the patient can understand.
• Addresses patient’s questions and concerns.
• Verifies patient informed consent when indicated.
• Documents and communicates all required components of patient care.
• Provides care to acutely and critically ill patients, in a highly technical and ongoing monitoring environment.
• Pre Op/PACU GB • Assess patient’s physical, psychosocial, cultural and spiritual needs through observation, interview, review of medical records & clinical data. Evaluates patient’s response and intervenes to ensure optimal patient outcome. • Performs airway management. • Identifies physical symptoms changes and provides appropriate treatment. • Demonstrates established techniques of safe administration of medications and parenteral fluids, according to hospital policies and procedures. • Develop and implement patient plan of care and observe outcomes in accordance with nursing standards and in collaboration with the interdisciplinary team. • Demonstrate competency in a variety of therapeutic/diagnostic interventions including but not limited to IV’s, incision/wound care, medication administration, catheterization and specimen collections. • Demonstrates knowledge of anesthetic drugs, actions, and side effects. Demonstrates ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. • Promote, advocate and collaborate to protect the health and safety and rights of each patient. • Provide patient/family education through assessment of patient/family learning readiness, needs, and ability. Provide teaching and evaluate effectiveness of teaching. • Delegates to non-RN personnel in accordance with State Board of Nursing and hospital policy. • Effectively uses time, personnel, equipment and supplies to provide high quality, cost effective patient care. • Manages resources and patient flow through matching nursing competencies with individualized patient’s and unit needs. • Uses standards of care, hospital policies/procedures and regulatory guidelines to guide practice. • Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. • Precepts/mentors new staff or nursing students as needed. • Seeks out learning opportunities and continuing education. Seeks experiences that reflect current practice in order to maintain skills and competence in clinical practice or role performance. • Use current healthcare research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues. • Maintains professional records that provide evidence of competency and lifelong learning. • Adapts to rapidly changing technology as evidenced by competency in technology and equipment used in the patient care setting. • Thorough and confidential maintenance of patient charts and records. Document ongoing status, interventions, patient response and outcomes in accurate, timely manner. Use information technology to communicate, manage knowledge, mitigate error, and support decision-making. • Utilizes initiative; strives to maintain a steady level of productivity; self motivated. Organizes and manages activities reflecting due consideration for the needs of the department and staff.
• Inpt Nursing GB • Demonstrates applied knowledge base in areas of medical/ surgical patient care, pain assessment and actions of pharmaceuticals and anesthetic agents, laboratory values, safety and legal issues and all emergency equipment. • Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department as outlines in the unit orientation checklist. • Performs assessment/data collection in an ongoing and systematic manner, focusing on physiologic, psychologic and cognitive status. • Formulates a goal directed plan of care, which is prioritized and based on determined nursing diagnosis and patient outcomes. • Implements care in a knowledgeable, skilled, consistent manner in reaching the desired patient outcomes through nursing processes. • Establish priorities of patient care based on essential patient needs and available center resources of time, personnel, equipment and supplies. • Coordinates care delivery and education through collaboration with patient, family and all health care team providers to ensure safe, effective and quality patient care. • Performs documentation on the floor and in the patient record, in a timely, accurate and concise manner. • Reviews and carries out physician orders in an appropriate professional manner. • Performs efficiently in emergency patient situations following established protocols, remaining calm, informing appropriate persons and documenting events. • Follows organizational policies & procedures in providing safe patient care. • Attends all mandatory in services and participates in staff meetings.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelor Degree Nursing

Required Licensure and Certification

• Licensed Registered Nurse (LRN) - Single State - State Board of Nursing
• Basic Cardiac Life Support (BLS or BCLS) - American Heart Association (AHA)

Preferred Licensure and Certification

• Emergency Nursing Pediatric Course (ENPC) - Emergency Nurses Association (ENA)
• Trauma Nurse Core Course (TNCC) - Emergency Nurses Association (ENA)
• Neonatal Resuscitation Program (NRP) - American Academy of Pediatrics (AAP)
• Fetal Heart Monitor (AWHONN, ETC.) - Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
• PALS - Pediatric Advanced Life Support - American Heart Association (AHA)
• Advanced Cardiac Life Support (ACLS) - American Heart Association (AHA)

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.