Rn

3 weeks ago

Weatherford, United States Hilltop Park Rehabilitation and Care Center Full time

**Summary Description**:
To plan and deliver nursing care to patients/residents requiring long-term and/or rehabilitation care.

**Essential Functions and Responsibilities**:

- Works using the guidelines established by the Nurse Practice Act, facility Policies and Procedures, and sound nursing judgment.
- Assesses, plans and evaluates nursing care delivered to patients/residents requiring long-term and/or rehabilitation care.
- Delivers nursing care to patients/residents requiring long-term and /or rehabilitative care.
- Implements the patient/resident plan of care and evaluates the patient/resident response.
- Directs and supervises care provided by other nursing personnel.
- Provides input in the formulation and evaluation of standards of care.
- Maintains knowledge of necessary documentation requirements.
- Maintains knowledge of equipment set-up, maintenance and use (i.e. monitors, infusion devices, drain devices, etc.).
- Maintains confidentiality and compliance with patient/resident rights, relating to all patient/resident/personnel information.
- Provides patient/resident/family/caregiver education as appropriate and/or directed.
- Conducts self in a professional manner in compliance with unit and facility policies.
- Works rotating shifts, holidays and weekends as scheduled.
- Initiates emergency support measures, including CPR as appropriate and protects patients/residents from injury/harm.
- Assessment:

- Admission and routine resident observations/transfer notes are complete and accurately reflect the patient’s/resident’s status.
- Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
- Nursing history is present in the medical record for all patients/residents.
- Assessment identifies changes in the patient’s/resident’s physical and /or psychological condition (i.e., changes in lab data, vital signs, mental status).
- Planning of Care:

- Nursing care plans are initiated/reviewed/individualized on assigned patients/residents in accordance with facility policies and procedures.
- Pertinent nursing problems/concerns are identified and communicated to appropriate personnel for correction.
- Goals are stated.
- Appropriate nursing orders are formulated.
- Evaluation of Care:

- The effectiveness of nursing interventions, medication, etc., is evaluated and documented in accordance with facility policies and procedures.
- Care Plans:

- Evaluation of care plan is performed and documented in accordance with the facility policies and procedures.
- The care plan is revised as indicated by the patient’s/resident’s status and in accordance with facility policies and procedures.
- General Patient/Resident Care:

- Patient/Resident is approached in a kind, gentle and friendly manner. Respect for the patient’s/resident’s dignity and privacy is consistently provided.
- Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
- Independence by the patient/resident in activities of daily living is encouraged to the extent possible.
- Treatments are completed as indicated and documented in accordance with facility policy and procedure.
- Safety concerns are identified and appropriate actions are taken to maintain a safe environment.
- Side-rails and height of bed are adjusted.
- Patient/resident call light and equipment is within reach.
- Restraints, when used, are maintained properly.
- Rooms are neat and orderly.
- Patient/Resident identification and allergy bands (if applicable) are present.
- Functional assignments are completed.
- Emergency situations are recognized and appropriate action is instituted.
- All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.).
- Patient/Resident Education/Discharge Planning:

- The patient/resident and family are involved in the planning of care and treatment (documented on the plan of care).
- Patient/Resident and/or family are provided with information related to all interventions and activities as indicated.
- Discharge/Death summaries are complete and accurate.
- Transfer forms are complete and accurate.
- Active participation in patient/resident care management is evident.
- Adherence to Facility Procedures:

- Facility policy and procedure manuals or reference materials are utilized as needed.
- Procedures are performed in accordance with facility policies and procedures.
- Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
- Safety guidelines established by the facility (i.e., proper needle disposal), are followed.
- Documentation:

- The patient’s/resident’s full name and room number are present on all chart forms. Allergies are noted on the chart cover.
- Only approved abbreviations are utilized.
- TPR graphic is completed accurately and timely.
- I & O summaries are recorded and added accurately and tim

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