Registered Nurse - MedSurge PRN

Description

ORGANIZATIONAL DESCRIPTION

The Registered Nurse (RN) performs those activities for which the RN has been prepared through education and training. The RN provides nursing supervision in the planning for and provision of nursing care to patients and directs and evaluates care given by other licensed nurses and personnel and within scope of practice. The RN provides education, assesses needs, plans for, implements, evaluates and documents care being provided by nursing staff to each patient. The RN is responsible both for nursing care directly provided by that nurse and the care provided by others under her/his supervision.

INTERACTION

Primarily Interacts with: administration, physicians, employees, clinical and non-clinical departments, patients, visitors, and volunteers.

PRIMARY FUNCTIONS

• •Utilize the nursing process by demonstrating appropriate assessment, planning, implementation, and evaluation of the patient's care.
• •Assess the patient; collect and document the patient's current health status and medical history. Complete and/or review Admission Data Record as defined by policy. Make accurate and ongoing assessment of patient's status and respond appropriately.
• •Plan/Implement; set priorities for nursing actions in a logical sequence according to patient's needs and formulate a plan of care by the appropriate selection of Nurse Practice Standards.
• •The Plan of Care is initiated on patient admission based on all aspects of the initial assessment. Plan includes physiological, psychosocial, and environmental factors: patient/significant other education and patient discharge planning.
• •Evaluate; perform ongoing assessment and revise plan of care based on new data and patient's condition.
• •Document accurate and ongoing assessment of patient status. Document patient care which reflects nursing intervention, patient response to care provided, patient needs, problems, capabilities, limitations, and progress toward goals. Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record.
• •Communicate with the physician regarding patient needs, the nursing assessments, and recommendations.
• •Collaborate with other nurses and health team members to ensure the patient's wellbeing.
• •Teach patient/significant other appropriate health information in a timely manner and share written informational material.
• •Perform direct patient care, utilizing established procedures, policies, and standards as evidenced by client/staff feedback and Operations Coordinator observation.
• •Administer medications according to policy and procedure
• •Administer IV's according to policy and procedure.
• •Observe and document patient's response to pertinent medications.
• •Demonstrate ability and appropriate technical skills when administering treatments and procedures in accordance with physician's orders and policy and procedure (done within a timely manner).
• •Demonstrate necessary skills and knowledge to provide care for patients according to policy and procedure.
• •Demonstrate necessary skills and knowledge to provide care for patients according to division/unit specific competencies.
• •Demonstrate ability to handle emergency situations in a prompt, precise, and professional manner.
• •Provide personal patient care to provide comfort and well-being to the patient, acknowledging physiological and psychological needs.
• •Perform indirect patient care, utilizing established procedures, policies, and standards.
• •Give a thorough, concise report at change of shift.
• •Demonstrate accurate and timely documentation according to hospital policy.
• •Maintain a clean, neat, and safe environment for patient and staff according to policy and procedure.
• •Demonstrate correct and safe technique in the use of equipment according to specific product information.
• •Follow appropriate procedure for obtaining and returning or cleaning/disposing of equipment and supplies.
• •Assist patients, family members or other clients with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
• •Answer and refer telephone calls or other inquires to ensure accurate and timely communications are facilitated.
• •Systematically evaluate the quality and effectiveness of nursing practice.
• •Participate in quality of care activities as appropriate to the individual’s position, education, and practice environment.
• •Utilize the results of quality of care activities to initiate changes in practice.
• •Utilize the results of quality of care activities to initiate changes throughout the health care delivery system, as appropriate.
• •Evaluate his/her own nursing practice in relation to professional practice standards and relevant statues and regulations.
• •Engage in performance appraisal on a regular basis, identifying areas of strength as well as areas for professional/practice development.
• •Seek constructive feedback regarding his/her own practice.
• •Take action to achieve goals identified during performance appraisal.
• •Acquire and maintain current knowledge in nursing practice.
• •Participate in ongoing education activities related to clinical knowledge and professional issues.
• •Seek experiences to maintain clinical skills.
• •Seek knowledge and skills appropriate to the practice setting.
• •Demonstrate an integration of knowledge and clinical competence.
• •Contribute to the professional development of peers, colleagues, and others.
• •Share knowledge and skills with colleagues and others.
• •Provide peers with constructive feedback regarding their practice.
• •Mentor novice nurses and those new to the specialty.
• •Contribute to an environment that is conducive to clinical education of nursing students, as appropriate.
• •Decision and actions on behalf of patients are determined in an ethical manner.
• •Assume the role of patient advocate.
• •Deliver care in a nonjudgmental and nondiscriminatory manner that is sensitive to diversity.
• •Deliver care in a manner that preserves/protects patient autonomy, dignity, and rights.
• •Collaborate with the patient’s significant others, and health care providers in providing patient care.
• •Communicate with the patient’s significant others and health care providers regarding patient care and nursing’s role in the provision of care.
• •Maintain confidentiality consistent with the rules and regulations of state and federal government.
• •Consult with health care providers for patient care, as needed.
• •Make referrals, including provisions for continuity of care, as needed.
• •Consider factors relating to safety, effectiveness, and cost in planning and delivering patient care.
• •Promote a safe and therapeutic environment for the recipients and providers of nursing care.
• •Integrate components of the nursing process: assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
• •Individualize care and set priorities to address the patient’s physical, psychological, educational, and social needs.
• •Articulate the plan of care to other members of the health care team to promote collaborative efforts in achieving outcomes.
• •Document the integrated components of the nursing process to show responses to interventions.
• •Foster the development, regular review, and revision of evidence-based practice guidelines and organizational policies and procedures.
• •Participate in the integration of caring into the practice environment.
• •Demonstrate maturity and accountability for job performance. Support the philosophy, objectives and goals of the department and assesses areas of personal and professional growth.
• •Demonstrate good judgment and analytical ability in preparing work for review.
• •Promote confidence and uses complete discretion when discussing information.
• •Maintain calm and effective behavior during stressful situations.
• •Inspire confidence from callers, visitors, co-workers by remaini