MAJOR DUTIES AND RESPONSIBILITES:
A. Assesses clients upon admission and throughout treatment utilizing observational and interviewing skills.
B. Assessments demonstrate application of knowledge of nursing practices.
C. Pertinent observations are communicated to the nurse manager and other members of the multi-disciplinary team.
D. Reviews overall client status by reviewing physician orders, client treatment plan, and multidisciplinary notes as applicable.
Performance Is Satisfactory When:
A. Nursing assessment is completed within 24 hours of admission.
B. Clients are reassessed at regular intervals and findings are documented in the client's medical record.
C. Assessments include all pertinent objective and subjective data.
D. Actual and potential client problems are identified and prioritized.
E. Client needs relative to health or education are identified and addressed.
A. Helps to develop an individualized treatment plan using nursing diagnosis, in conjunction with client, family and multidisciplinary team.
B. Identifies short and long term measurable goals, including discharge planning, consistent with client care standards, nursing practice, and policies and procedures.
C. Encourages multidisciplinary input into the treatment plan.
Performance is satisfactory when:
A. Establishes client goals that are measurable, attainable, and in accordance with standards of care.
B. Contribution to multidisciplinary treatment plans is based upon assessment data and supported by applicable nursing practices.
C. Client treatment plans are individualized, complete, and updated in a timely manner.
D. Attends treatment-planning meetings.
E. Helps to provide education to Milieu Counselors.
A. Provides direct nursing care based on client treatment plan.
B. Maintains a safe and therapeutic milieu.
C. Documents on all appropriate client care topics, events and interventions in a timely, concise, clear and complete manner.
D. Implements unit program on a daily basis.
E. Administers medications in accordance with nursing policy and procedures.
F. Communicates with the attending physician and follows directives per physician's order.
Performance is Satisfactory when:
A. Promotes safety in the environment by reducing the risk of accident, injury, or other trauma
B. Plans measurable nursing interventions to address clients' physical, psychosocial, and spiritual needs.
C. Ensures that all documentation is complete and refers to measurable, relevant, and realistic goals.
D. Organizes, develops, and evaluates plans for the prevention and management of crisis situations in the nursing area.
E. Responds effectively to unit or client crisis situations, mobilizing organizational resources as needed.
F. Assists in referral resources related to nursing needs after discharge.
G. Accurately administers medications and observes for results and side effects, accurately documents and reports accordingly.
H. Communicates courteously, appropriately, consistently, and therapeutically with clients, family members, and external customers.
I. Performs or delegates all nursing procedures ordered by physician in accordance with nursing standards.
A. Evaluates and documents the clients' response to medication regiment as related to the overall effectiveness of treatment.
B. Evaluates the effectiveness of care and modifies nursing components of the client's treatment plan accordingly.
Performance is Satisfactory when:
A. Evaluates client's medical status, need for PRN medications, or other interventions.
B. Evaluates the Treatment plan to determine client's responses to treatment on documents accordingly in the client's medical record.
C. Collaborates with all treatment team members and referral sources to evaluate and revise the treatment plan and discharge plan based on client/family needs.
A. Promotes the concept and image of professional nursing practice.
B. Provides for clients' rights and dignity.
C. Demonstrates professional behavior in clinical setting.
D. Supports facility policies and procedures.
G. Demonstrates knowledge of adolescent development and behaviors.
H. Utilizes proper grievance procedures.
Performance is Satisfactory when:
A. Acts as a client advocate by utilizing the Client's Bill of Rights.
B. Demonstrates consideration and respect toward clients, peers, supervisory staff, therapists, and physicians.
C. Observes the ANA Code of Ethics, including confidentiality, in all aspects of employment.
D. Practice occurs in accordance with written nursing and administrative directives including facility policies and procedures.
E. Communicates effectively with staff.
F. Participates in multidisciplinary treatment team meetings as assigned.
G. Demonstrates ability to adapt to changes in unit environment: change in staffing, client volume, acuity, and type.
H. Demonstrates basic knowledge of the legal consequences of nurse's actions.
VI. Therapeutic Crisis Intervention Requirements
A. Demonstrates proficiency at Therapeutic Crisis Intervention training by attaining a passing score.
B. Demonstrates proficiency at Therapeutic Crisis Intervention training by attaining a passing score on the Life Space Interview (LSI) portion of Therapeutic Crisis Intervention testing.
C. Demonstrates proficiency at Therapeutic Crisis Intervention training by attaining a passing score on all of the physical skills tests (e.g. standing hold, small person hold, prone restraint as a team leader, prone restraint as a team assistant and prone restraint as a third person).
D. Must successfully demonstrate in practice the proper techniques of Therapeutic Crisis Intervention. Must successfully demonstrate knowledge of proper Therapeutic Crisis Intervention.
E. May have oversight or direct other staff in special treatment procedures.
F. All nurses are required to complete the appropriate nursing component of the Seclusion / Restraint processobtain a physician's order for the intervention as soon as safety permits, continuously monitor a client in restraint or seclusion, assess clients as soon as the client is removed from restraint or seclusion and one hour after the intervention was initiated, and document in the client's record their care provided during the seclusion or restraint.
G. Within Desert Hills policy and procedures implements seclusion or restraint with sound professional judgment while effectively providing safety to the client and staff.
H. The nurse follows the special treatment procedure as outlined in the policy and procedure.
VII. Other duties as assigned
A. Demonstrates evidence of continued development within field.
B. Identifies own learning needs and selects opportunities for self-growth and career advancement.
C. Attends in-service, continuing education, or college credit.
E. Other duties as directed by Director of Nursing and as needs of facility dictate.
QUALIFICATIONS AT ENTRY
Graduation from an accredited school of Nursing. Current State of New Mexico Nursing License as a Registered Nurse.
Minimum of three years nursing experience in an adolescent psychiatric facility. Ability to read and write at a high school graduate level, analytical skills, time management, problem-solving skills, organizational skills.
MACHINES, TOOLS, AND EQUIPMENT USED ON JOB:
Telephone *Copy Machine *Blood Pressure Cuff *Stethoscope
File Cabinets *Syringes *Copy Machine *Telephone
Shelving *Thermometer *Scales
PHYSICAL AND MENTAL REQUIREMENTS OF JOB:
Ability to stoop, kneel, crouch, crawl, reach, stand, walk, run, push, pull, lift, grasp, and be able to perceive the attributes of objects such as size, shape, temperature, and/or texture by touching with skin. Ability to express and exchange ideas via spoken during activities in which staff must convey detail or important spoken instructions to others accurately, sometimes quickly and loudly.