Rn Clinical
1 month ago
As an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients. The Registered Nurse is accountable for the coordination of patient care and education to the patient and family in accordance with the standards, policies, and practices in a compassionate, supportive, and therapeutic environment.
**Essential Duties**:
- Follows policies and procedures; demonstrates ability to access online manuals.
- ASSESSMENT - Appropriately completes Nursing Assessment upon patient admission, at each shift and with change of condition. - Completes patient acuity by 0200/1400 daily.
- DIAGNOSIS - Interprets assessment information and formulates Nursing Diagnoses.
- PLAN - Develops Plans of Care with individualized interventions. - Documents expected/projected patient outcomes. - Reviews/Revises/Updates Plans of Care daily based on evaluation and interpretation of patient outcomes. INTERVENTION - Administers medication and IV therapy appropriately at prescribed intervals. - Completes patient care procedures correctly per policy at prescribed intervals. - Delegates tasks based on others’ scope of practice and competency. - Acts as patient advocate. - Manages restraint use per policy Attempts alternative non-restraint measures first. Assures complete MD order per policy. Ensures MD assessment per policy. Assures patient monitoring per policy.
-Ensures Restraint Audit Form is completed each shift. DOCUMENTATION - Documentation is complete and correct on all flow sheets and chart forms: Admission Assessment Pain scale assessment and reassessment before and after intervention Daily flow sheet Restraint flow sheet Diabetes flow sheet Educational flow sheet Kardex Care Plan Risk Assessment & Reassessment upon Fall MAR Equipment & Supplies Intra and Inter Facility Transfer Forms Belonging Tracking Form Ensures orders are transcribed and signed off prior to the end of the shift.
-Completes 12h/24h chart checks EDUCATION - Provides patient/family education as needed Room/unit orientation Plan of Care Identifies knowledge deficits related to diagnoses and care
-Uses and provides MICROMEDEX information to patients and families.
- TRANSFER & DISCHARGE - Collaborates with Case Manager and/or physician regarding discharge planning. - Ensures all transfer paperwork is completed. - Ensures belongings are sent with patient. EQUIPMENT - Utilizes patient care equipment appropriately and safely according to manufacture guidelines IV pump Feeding pump PCA pump Epidural pump Sequential compression device Wound VAC
-Heating pad/pump COMMUNCATION - Communicates effectively with all members of the healthcare team including patient and family: Shift to shift report Physician Rounds Patient/family interactions MDP Rounds Hand-Off reports Facility E-mail
-Student/New employee/Contract employee
- ORGANIZATION - Manages time effectively. Able to organize and prioritize responsibilities. - Takes meal breaks without incurring overtime. - Completes shift on time. OBSERVES REGULATORY AGENCY REQUIREMENTS: - National Patient Safety Goals Patient identifiers Unapproved abbreviations Universal Protocol (Procedural Time Out) Hand-Off Medication Reconciliation Clinical Alarms Other - Hazardous waste management Biohazard Medication Sharps - HIPAA - OSHA requirements (i.e. no food or drink in clinical areas) - JCAHO - continuous survey readiness Critical Values Write Down Read Back Follow up Telephone order Appropriate Documented Signed, Timed and Dated Stamped Entered into unit log Maintains safe practice in the work environment Correct body mechanics Electrical safety Infection Control Procedures
-Hand Washing
- MANAGEMENT OF THE CARE OF MEDICAL SURGICAL PATIENTS - (6N) Demonstrates the ability to manage patients with THA. - (6N) Demonstrates the ability to manage patients with TKA. - (6N) Demonstrates the ability to manage patients with spinal surgery - (6S) Demonstrates the ability to maintain isolation precautions, respiratory and nutrition care specific to cystic fibrosis patients. - (6S) Demonstrates the ability to manage medications and maintain protective isolation precautions for patients with abdominal organ transplants - (6S) Institutes safety precautions and skin care for patients with hepatic encephalopathy. MANAGEMENT OF THE CARE OF PATIENTS IN THE INTENSIVE CARE UNIT/S - Demonstrates the ability to manage complex critically ill patients. Neurosurgery, thoracic-forgut, gastric bypass, orthopedic. Liver/kidney/pancreas transplants, hepatobiliary. Open heart, heart and lung transplants. - Demonstrates the ability to manage advanced therapeutic modalities. Hemodynamic monitoring. Continuous renal replacement therapy (CRRT, CVVHD). Ventriculostomy, intracranial pressure monitoring.
-Ventricular assist devices, balloon pumps. MANAGEMENT OF THE CARE OF PATIENTS IN THE STEPDOWN/TELEMETRY UNITS - Demonstrates the ability to manage high acuity patients requiring specialized
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