Overview:
The Registered Professional Nurse is responsible and accountable for prescribing, delegating and coordinating all nursing care as defined by The New York State Nursing Practice Act. Comprehensive Medical/Surgical nursing care focuses on helping each patient to achieve their optimum health potential. This is achieved within the framework of the nursing process. The Medical/Surgical Registered Professional Nurse is responsible and renders services to Adult Medical/Surgical patients ranging from 18 years and older.

Responsibilities
In accordance with professional nursing standards and practices, the Medical/Surgical nurse will provide nursing care to all patients with medical and surgical diagnoses.

The Medical/Surgical Nurse is responsible and accountable for the nursing care of the patients.

Assessment:
-Assesses patient’s physical, social and behavioral, mental status through direct observation, interview, and medical record review.
-Utilizes observational skills to assess patient’s needs.
-Documents a nursing assessment to include psychosocial, environmental factors, educational level and needs.
-Obtains and reviews available data base and any data collected by other members of the health team (medical/surgical/other history, physical exam mental status, therapist reports and community referrals).
-Identifies medical problems resulting from mental illness and use of medications.
-Communicates findings with other members of the health team. (Social Worker, Case managers, therapist, physician).

Planning
-Identifies and addresses needs for admission based on acute medical/surgical diagnoses and presenting physical/psychological symptoms
-Identifies and addresses patient level of education, learning needs.
-Makes appropriate referral to other disciplines and documents same.

Intervention/Implementation:
-Management of clinical skills in the provision of nursing care and management of the patient including but not limited to:

--Identification of symptoms
--Management of the disease entity
--Treatment modalities
--Administration of medications

-Intervenes appropriately in medical/surgical emergencies utilizing non-violent crisis intervention.
-Utilizes infection control procedures; collaborates with the infection control department in preventing and controlling infection control.
-Practices infection control: personal hygiene; hand washing; and dress code
-Provides for psychosocial and educational needs of all medical/surgical patients.
-Provides health teaching and medication instructions.
-Ensures that all procedures are performed based on established standards of care
-Demonstrates competency in performing all procedures within the scope of practice and in accordance with OBHS.
-Investigates and communicates all required information regarding unusual occurrences or patient care incidents.
-Acts as a patient advocate.

Evaluation:
-Revises the patient’s plan of care based on evaluation of the interventions and expected outcomes in collaboration with other members of the health care team.

Qualifications

Education:
-Bachelor’s degree in Nursing.

Experience:
-Minimum three (3) years' medical-surgical nursing experience preferred.

Knowledge and Skills:
-Ability to communicate effectively in English both verbally and in writing

Licenses, Certifications:
-Current NY State RN License required.
-Basic Cardiac Life Support (BCLS) required.

Physical Requirements:
-Involves standing, walking, sitting, talking, hearing and bending.
-May include some repetitive motions.
-Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.