The Licensed Vocational Nurse/ Registered Nurse is responsible for assessing clients in an inpatient drug and alcohol detoxification program and administering medication. The Nurse works directly with the Nurse Manager, Executive Director, other clinical staff and medical staff and to ensure nursing components of the organization are appropriately coordinated.
ESSENTIAL JOB FUNCTIONS:
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Performing, completing, and validating assessments, utilizing proper grammar, spelling, and complete sentences without using unapproved abbreviations.
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Informing personnel (i.e. psychiatry, and dietician) of new admissions when appropriate.
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Administering and documenting vital signs, CIWAs, COWS, fall assessments/precautions, seizure precautions, suicidal/homicidal assessments, nutritional assessments, pain scales, anxiety scales, craving scales, standard and infection control precautions.
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Observation, documentation, audit functions, education, and record keeping of all observed/inventoried/destroyed/prescribed medications.
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Assessment of patients with addiction and mental health conditions, and assisting in ascertaining clinical medication management.
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Administering medications via oral, sublingual, inhalation, auricular, topical, vaginal, and rectal routes and performing scheduled and PRN vitals as appropriate.
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Entering medication orders into the electronic medical record.
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Manages the Medication Administration Record, documenting administration, efficacy, and first response.
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Provides direct patient care to a diversified patient population, across continuum of care.
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Collaborates with staff in assessing patient, family age-specific nursing needs and develops plan of care for complex high-risk patients.
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Provide assistance to Utilization Review in communicating pertinent nursing information.
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Work closely with physicians to provide education and counseling for clients and other organizational health care providers on optimal use of medicines (e.g., proper use, avoidance of over medication).
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Provide nursing care adapted to the individual patient needs based on the nursing process, which includes assessment, planning, implementation and evaluation.
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Direct patient care, including the reporting of observed changes in mental status and/or physical condition, response to emergencies, safety risks.
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Documents nursing incidents and medication errors.
- Ensures to use the utmost of care in protecting the confidentiality of client records in accordance with state and federal laws.
JOB SKILLS AND ABILITY
- Knowledge of resident rights and provision of treatment that promotes resident dignity, independence, individuality, strengths, privacy, and choice.
- Able to meet the unique needs of our resident population, taking into consideration diagnosis and trauma informed care.
- Ability to maintain appropriate boundaries with residents.
- Ability to communicate effectively, using non-judgmental words and behaviors, using person-centered language, and engages in active and reflective listening.
- Recognizes, respects, and adapts to diversity, differences, and cultural traditions of residents.
- Knowledge and application of confidentiality requirements and HIPAA.
EDUCATION AND EXPERIENCE:
- Must be graduate of an approved nursing program with a current professional licensure from the State of Texas Board of Nursing.
- Should be experienced as a staff nurse preferably in the field of chemical dependency and/or behavioral health.
