Job Description

Performs complete prenatal and postpartum assessment using the nursing process of assessment, diagnosis, outcome identification, planning, implementation and evaluation of patient care. Performs a head to toe assessment on infants, children and teenagers. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.

Responsibilities Include:

1. Assesses the patient's physiologic health status

* Conducts patient interview, explains policies and procedures to patient/ significant others, reviews patient's chart and answers questions correctly and courteously;
* Assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status;
* Determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate;
* Assesses level of pain and pain management;
* Communicates/documents patient's physiologic health status and plan of care.

2. Assesses patient's psychosocial health status

* Elicits perception of medical/nursing care and the expectation of care;
* Determines coping mechanism, knowledge level, and ability to comprehend;
* Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction;
* Communicates and documents psychological status and care plan; support group, counseling services, social services.

3. Identifies patient outcome

* Develops criteria for measurement of patient outcomes;
* Identifies actual/potential patient problems;
* Identifies patient's need for teaching based on psychosocial and developmental assessment;
* Develops patient outcome statement (s) and establishes individualized patient goals.

4. Formulates the plan of care and establishes the priorities necessary to achieve expected outcome

* Identifies care activities and establishes the priorities necessary to achieve expected outcome;
* Coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome;
* Documents the plan of care and collaborates with physicians and other health team members.

5. Implements the plan of care

* Maintains constant vigilance over patients care to ensure that safety precautions/needs are followed.
* Exercises professional skills related to the plan of care;
* Reassesses patients as needed and appropriately revises plan of care;
* Correctly administers prescribed treatments;
* Correctly uses equipment necessary for patient care;
* Provides emotional support to patient and significant other;
* Applies scientific principles in performing procedures; carries them out safely, timely and efficiently;
* Makes accurate observations of patient's conditions during treatments/procedures. Reports and records same as appropriate;
* Keeps accurate documentation of patient's treatment, activity and condition, as well as patient's responses to medical and nursing interventions;
* Uses appropriate methods of documentation according to departmental policy;
* Acts rapidly and effectively during any emergency situation, managing self, patients and other employees;
* Provides a calm, quiet, restful atmosphere. Communicates effectively with the patient's family or caretakers;
* Participates in planning for discharge and coordinates referrals, as appropriate;
* Provides discharge instructions to patient and significant other.

6. Evaluates care provided for patient outcome

* Demonstrates ability to measure effectiveness of care provided and documents same;
* Performs variance analysis related to outcome data for performance improvement;
* Designs, implements, and evaluates systems to improve care
* Keeps accurate documentation of patient's treatment, activity and condition;
* Uses appropriate methods of documentation according to departmental policy.

7. Collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team

* Collaborates with the appropriate physician on patient's plan of care;
* Accurately interprets and implements treatment regimen as prescribed by the Physician;
* Assists the Physician during treatments and/or diagnostic procedures;
* Keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient's condition and/or treatments, as appropriate;
* Uses clinical judgment in delegating assignments to the Patient Care Associate, Support Care Associate and Clerical Service Associate in providing patient care, and ensures that assignments are completed in a timely fashion.

8. Performs wound care in accordance with physician orders and agency policy

9. Administers medications correctly and safely

* Correctly identifies medication: action; dosage; side effects and implications for the patient;
* Meets standard on medication administration examination;
* Demonstrates preparation of local solutions;
* Administers and documents medication correctly;
* Educates patients and significant others related to drug and food interactions.

10. Participates in patient and family education

* Provides patient with an explanation of his/her condition as indicated;
* Communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies;
* Recognizes and utilizes health teaching opportunities and resources /materials available for this teaching;
* Provides for early discharge planning and appropriate referrals
* Evaluates the effectiveness of teaching by feedback from patient/ family and documents same.

11. Performs related duties, as required.

Qualifications

* Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred.
* Current license to practice as a Registered Professional Nurse in New York State.
* Minimum one (1) year of experience as an RN in Medicine/Surgery and one (1) year of experience as an RN in MCH, PEDS, PICU or NICU.
* Current Driver's License and/or own transportation available to maintain caseload, schedules and travel to clients' homes.

Registered Nurse (Rn) - Pediatrics/Maternal Child Health Home Care Queens

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