Travel Nurse RN 1,456 per week in Muncie,

A Registered Nurse (RN) - Clinical Decision Unit (CDU) is responsible for providing high-quality nursing care to patients who require observation and assessment for short-term medical conditions that do not necessarily require full admission to the hospital. The CDU is a specialized unit where patients are monitored to determine whether they need to be admitted, discharged, or transferred for further care. The RN in this role plays a critical part in patient triage, ongoing assessment, and ensuring timely interventions to support clinical decision-making.

Key Responsibilities:

Patient Assessment and Monitoring:

Perform initial and ongoing comprehensive assessments of patients admitted to the CDU, including vital signs, medical history, current symptoms, and any potential risk factors.
Monitor patients' condition continuously, assessing for changes that may require immediate intervention or more intensive care.
Document nursing assessments, vital signs, laboratory results, and interventions in the electronic health record (EHR) accurately and promptly.

Clinical Decision Support:

Assist physicians and clinical staff in determining whether a patient should be admitted, discharged, or transferred to a higher level of care based on observations and assessments.
Participate in patient care rounds and provide input regarding patient status and any developments in their condition that may influence discharge or admission decisions.
Ensure that patients meet the criteria for discharge when appropriate, coordinating with the healthcare team to ensure proper follow-up care and instructions.

Patient Education and Communication:

Educate patients and their families about their medical conditions, the purpose of observation, and what to expect while in the CDU.
Provide guidance on post-discharge care, follow-up appointments, and any lifestyle modifications or treatments needed to manage their condition.
Communicate effectively with patients, families, and the healthcare team, ensuring that patients understand the rationale for their stay in the CDU and their discharge instructions.

Medication Administration and Management:

Administer prescribed medications as per physician orders, including oral, intravenous, and intramuscular medications.
Monitor for any side effects, allergic reactions, or adverse effects of medications, promptly notifying the physician if concerns arise.
Ensure proper medication reconciliation during admission and discharge, making sure that prescribed medications align with the patient's health plan and history.

Observation and Diagnostic Testing:

Assist with or perform basic diagnostic tests and procedures such as blood draws, EKGs, and vital sign monitoring to assist in patient evaluation.
Collaborate with laboratory staff, radiologists, and other clinical professionals to facilitate the completion of necessary diagnostic tests in a timely manner.
Track patient progress through observation and testing, helping to determine if further intervention is required or if discharge is appropriate.

Safety and Infection Control:

Follow established infection control protocols to prevent the spread of infections in the CDU.
Maintain patient safety at all times, ensuring a safe and secure environment, including preventing falls and minimizing the risk of complications.
Assist with the safe handling and disposal of medications and medical equipment, ensuring the unit remains clean and sterile.

Emergency Response and Critical Care:

Respond promptly to any signs of patient deterioration or emergencies, such as changes in vital signs, difficulty breathing, or significant pain.
Provide basic life support (BLS) and advanced cardiac life support (ACLS) interventions as required, until further care can be provided.
Coordinate with emergency department (ED) or intensive care unit (ICU) teams for potential transfers if a patient's condition worsens.

Collaboration with Healthcare Team:

Work closely with physicians, nurse practitioners, physician assistants, and other healthcare professionals to develop and adjust care plans based on the patient's condition.
Attend patient care rounds and contribute to the decision-making process regarding diagnosis, treatment, and discharge plans.
Collaborate with case managers and social workers to arrange follow-up care, home health services, or referrals as needed for patients being discharged from the CDU.

Documentation and Reporting:

Document patient assessments, progress, interventions, and outcomes in a timely and accurate manner in the patient's medical record.
Report any significant changes in the patient's condition to the healthcare provider immediately and assist in adjusting care plans as necessary.
Ensure accurate reporting for discharge instructions, follow-up appointments, and any necessary medical equipment or prescriptions.

Quality Improvement and Professional Development:

Participate in ongoing education to maintain licensure, stay current on best practices, and improve nursing care.
Contribute to quality improvement initiatives by identifying potential process improvements to increase the efficiency and quality of care provided in the CDU.
Stay informed about new clinical guidelines, policies, and procedures that can improve patient outcomes.

Skills & Qualifications:

Education:

Bachelor of Science in Nursing (BSN) preferred; Associate Degree in Nursing (ADN) may be considered.
Current state licensure as a Registered Nurse (RN).

Experience:

Previous experience in an emergency department (ED), urgent care, or acute care setting preferred, as the RN in the CDU must have expertise in managing a wide range of medical conditions.
Experience in triage, patient assessment, or observation settings is a plus.

Certifications:

Basic Life Support (BLS) certification required.
Advanced Cardiac Life Support (ACLS) certification may be required or preferred, depending on the facility.
Trauma Nursing Core Course (TNCC) certification is desirable in some facilities.

Skills:

Strong critical thinking and clinical decision-making skills to assess and respond to changing patient conditions.
Excellent communication skills, particularly in educating patients and working within a multidisciplinary healthcare team.
Ability to manage a diverse set of clinical tasks simultaneously while maintaining attention to detail.
Compassionate care approach to improve patient experience, especially when dealing with uncertain diagnoses or outcomes.