LPN - Med/Surg

Primary Purpose: To provide prescribed medical treatment to patients, quality nursing care and comfort to patients, while promoting teamwork and to provide proper documentation for billing. Perform other duties as assigned.

Formal Policy-Setting Responsibilities: No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.

Routine Decision Making: Changes in patient assessment and what observations need to be reported immediately.

Formal Supervisory Responsibility: No formal supervisory responsibility.

Unusual Working Conditions: Risk of blood, body fluid contamination. Risk of injury related to poor body mechanics. Risk for injury from aggressive, combative or disoriented patients. Potential exposure to hazardous drugs and chemicals.

Age Specific Competencies: May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs.); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

Essential Responsibilities and TasksAssists with the implementation phase of the nursing process. (20% of time)

• Implements patient care through team approach each shift.

• Documents and reports significant findings to the charge nurse/provider/ manager immediately.

• Is knowledgeable of location, care and operation of Medical Surgical equipment each shift.

• Acts rapidly, effectively and manages self and others during emergency situations.

• Administers medications within scope of care, as ordered, within one (1) hour of time scheduled according to the five rights on every patient.

• Observes all provider orders each shift and as needed.

• Accurately documents the IV starts, tubing changes and administration of all medications prior to the end of the shift.

• Ensures all provider orders are reviewed on the EMAR.

• Accurately and correctly wastes unused portion of controlled substances within a timely manner.

• Attaches patient's name band, fall risk, allergy band, etc. immediately after patient's arrival and upon bands being removed.

• Ensures fall protocol is followed on each patient.

• Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.

• Bedside report to be performed each shift with the off-going nurse.

• White boards to be updated during shift change and throughout the shift. To include personalized patient goals and pain control.

Assists with performing the assessment phase of the nursing process. (15% of time)

• Assists with assessing all assigned patients each shift and as needed.

• Assists with assessing data relative to age specific needs for every patient each shift and as needed.

• Repeats assessment on abnormal patient findings at least once and as needed.

• Assesses the patient's & family's learning needs every shift and as needed.

• Completes appropriate pain assessment at the start of shift and as needed.

Assists with performing the planning phase of the nursing process. (5% of time)

• Reviews and updates care plan each shift and as needed.

• Collaborates with interdisciplinary team to facilitate the plan of care after the provider enters orders.

• Interprets, under the supervision of a registered nurse, the significant abnormal patient findings after assessing the patient and as condition changes.

• Updates white boards each shift, to include personalized patient goals and pain control.

Assists with performing the evaluation phase of the nursing process. (10% of time)

• Evaluates each assigned patients’ response to care each shift and as needed.

Provides patient and family education. (15% of time)

• Provides patient's and/or family's education based on assessments and re-assessments each shift.

• Uses terminology appropriate to patient/family's knowledge base and age specific needs each shift.

• Re-assesses patient and family's learning needs and abilities each shift and as needed.

• Documents education provided including subject taught, method of teaching, who was taught and comprehension of information each shift.

• Provides and documents patient and family follow-up instructions at discharge.

Maintains a safe and comfortable unit. (10% of time)

• Ensures alarms on any assigned areas are audible to alert staff, each shift.

• Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem.

• Completes a requisition for repair and sends electronic work request before the end of the shift, pass on any issues to the next shift for follow up and provides a copy to the manager before the end of shift.

• Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification.

• Utilizes correct method of barcode scanning patient identification bracelets for medication administration via EMAR 97% of the time.

• Utilizes correct method of barcode scanning patient medications or medication administration via EMAR 95% of the time.

• Provides thorough handoff communication to the next shift, including bedside shift report.

Demonstrates accountability to the nursing process through documentation. (15% of time)

• Documents time and date on each provider order.

• Documents assessments at least every shift and as needed.

• Documents according to the plan of care at least once per shift and as needed.

• Documents clearly the implementation of specific intervention, including details of methods used, with the time of implementation and evaluation of patient response.

• Utilizes only approved abbreviations in patient documentation each shift.

• Documentation follows hospital and departmental policies for frequency and content.

Develops and promotes performance improvement initiatives. (10% of time)

• Plans, develops and evaluates self-objectives, annually.

• Participates in planning ways to solve problems and make improvements in the Medical Surgical unit, quarterly, and as needed.

• Participates in implementing planned changes and activities to improve the Medical Surgical unit quarterly, and as needed.

• Evaluates planned changes and activities to improve the Medical Surgical unit, quarterly, and as needed.

• Attends unit staff meetings 5= 100%, 4= 81% - 99%, 3= 75% - 80%, 2= 50% - 74%, 1= <49% annually.

ESSENTIAL PHYSICAL REQUIREMENTS

• Heavy Work: Lifting 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 50lbs.

PHYSICAL DEMANDS

• Lifting: Raising or lowering an object from one level to another (includes upward pulling).

• Carrying: Transporting an object, usually holding it in hands or arms or on the shoulders.

• Pushing: Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).

• Pulling: Exerting force upon an object so that the object moves toward the force (includes jerking).

• Hearing: Ability to determine audible communication.

• Stooping: Bending the body downward and forward by bending the spine at the waist.

• Kneeling: Bending the legs at the knees to come to rest on the knee or knees.

• Crouching: Bending the body downward and forward by bending the legs and spine.

• Reaching: Extending the hands and arms in any direction.

• Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).

• Fingering: Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).

• Repetitive Motions: Substantial movements (motions) of the wrist, hands, and/or fingers.

• Feeling: Perceiving such attributes of objects and materials as size, shape, temperature, or texture by means of receptors in the skin, particularly those of the finger tips.

• Speaking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

• Seeing: Obtaining impressions through the eyes of the shape, size, distance, motion, color or other characteristics of objects.

• Acuity, far - clarity of vision at 20 feet or more.

• Acuity, near - clarity of vision at 20 inches or less.

• Depth perception - ability to judge distance and space relationships so as to see objects where and as they actually are.

• Field of vision - area seen up and down or to the right or left while eyes are fixed.

• Accommodations - adjustment of the lens of the eye to bring an object into sharp focus.

• Color vision - the ability to identify and distinguish colors.

WORKING CONDITIONS

• Inside: Worker spends approximately 75% or more of time inside.

• Wet: Contact with water or other liquids.

• Hazards: Situations in which the individual is exposed to the definite risk of the bodily injury.

• Infectious Disease: Risk of exposure to biohazard us materials, blood, body fluid contamination.