Behavioral Healthcare, Inc. - "Your doorway to Choice, Hope and Recovery"

March 2, 2010

PRN Registered Nurse Gainesville

Posting Description

Salary : $26.00 / hour + Shift Diff.

The Registered Nurse is responsible for identifying client alterations in health, assessing the client's responses to actual and potential health problems and prescribed treatments, and providing appropriate nursing interventions to return the client to baseline health with appropriate physician orders. Whenever possible, the client, family/significant others is integrated in the care provided. The RN functions within the interdisciplinary team model to provide a safe, therapeutic environment and support the client in reintegration to the community.

The RN performs assessments and other activities as recognized by the Board of Nursing and supervises and directs the care provided by Licensed Practical Nurses (LPN), psychiatric technicians, and unit secretaries in activities appropriate to their licensure and experience. The RN coordinates the care provided by the interdisciplinary team

OSHA Statement: This position has potential for exposure to blood and body fluids.

General Clinical Responsibilities

• A. Performs initial physical assessments and performs ongoing re-assessment. Assesses and collects data to determine client stability, safety, and pain status on admission Integrates assessment findings with previously reported or documented information to determine changes in the client's status Assesses client cultural and religious practices, education level, readiness to learn and utilizes the information to plan care Recognizes interrelationships between assessment findings, medications, and lab findings Follows up abnormal assessment findings, changes in status, and lack of response to therapy
• B. Initiates Treatment Plan and Nursing Care Plan. Plans and coordinates initial and ongoing care based on assessments and re-assessments Treatment goals are client-centered, specific, and measurable Incorporates the client, family/significant other, developmental and age-appropriate needs Provides client and family/significant other education and discharge preparation as appropriate
• C. Implements care based on assessment of client status and progress toward desired outcomes. Implements the Treatment Plan and Nursing Care Plan Initiates, verifies, and carries out physician orders transcribing to the Medication Administration Record as appropriate Initiates independent nursing actions that demonstrate accountability for progress toward outcomes Provide support to the client, family/significant other as needed Implements appropriate interventions for changes in client behavior Assumes leadership role in crisis or emergency situations Provides education on milieu, medication, adaptive and coping techniques, and discharge needs Documents all assessments, evaluations, and interactions as per policy and procedure
• D. Evaluates care based on the client's progress toward desired outcomes. Evaluates client condition related to identified problems and goals of treatment Identifies unexpected responses to treatment or other alterations in client condition that requires treatment and communicates with appropriate physician Revises treatment plan as necessary based on assessments
• E. Collaborates with other members of the team to assess progress toward goals.
• F. Organizes assignments based on client needs and available resources and provides leadership to the nursing team Identifies clients whose needs require constant monitoring Facilitates adjustments in assignments according to acuity and census Delegates tasks appropriately and follows up to ensure completion Works with Nurse Manager and HR Staffing to provide appropriate staffing based on census and acuity
• G. Contributes to a safe and therapeutic environment for clients, visitors, and staff Identifies clients at risk for self-harm or harm to others and institutes appropriate measures to reduce risk Manages milieu to promote safety Assesses and corrects or reports environmental safety hazards Responds to client or family/SO concerns promptly and completes Client Concern reports Completes Unusual Occurrence reports and/or Medication Variance Reports as needed and appropriate
• H. Demonstrates professional development, accountability, and leadership in the performance of professional nursing practice. Keeps current with continuing education as required by license or as required by the position Utilizes resources as needed to accomplish goals Participates in QI activities and incorporates results in daily practice Ensures compliance with HIPAA

Clinical Responsibilities

• Transcribes verbal or telephone orders received from the physician and verifies such by "read-back".
• Transcribes physician orders to the medication administration record (MAR).
• Performs Nursing Physical assessment.
• Performs breath testing for alcohol.
• Performs vital signs.
• Performs fingerstick for glucose evaluation.
• Evaluates point-of-care urine drug screens.
• Administers medications as ordered by a physician.
• Provides wound care as ordered by a physician.
• Educates and orients client and family to the unit milieu and structure.
• Provides confidentiality in all interactions with clients, to the extent possible, in the clinical setting.
• Provides for interactions with family, to the extent possible, under HIPPA regulations.
• Ensures that necessary safety precautions are taken based on the client's condition and facility policy.
• Intervenes as necessary to prevent injury to staff or other clients.
• Provides accurate documentation of client interactions and interventions.
• Initiates upon admission, and updates, Kardex & Shift Report.
• Utilizes seclusion and restraint as warranted and provided for in the Baker Act.

Human Resource Staff at Meridian Behavioral Healthcare, Inc.

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