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Registered Nurse
2 months ago
Highfield Gardens Care Center -
Registered Nurse (RN) Responsibilities:
Charting Complete and file required record keeping forms/chart upon resident's admission, transfer, and/or discharge.
Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
Receive telephone order from physical and record on the physician' order form. transcribe physician's order to residents chart medex treatment/care plan as required.
Chart nurses' in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.
Fill out complete accident/incident reports. Submit to the director as required. Chart all reports of accidents/incidents involving residents.
Follow established procedures.
Record new/changed diet orders.
Forward information to the Dietary Department.
Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor.
Fill out and complete the transfer form in accordance with established procedures.
Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established procedures.
Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
Registered Nurse (RN) Drug Administration Functions:
Prepare and administer medication as ordered by the physician.
Verify the identity of the resident before administering the medication/treatment
Ensure that prescribe medication for one resident is not administered to another
Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents.
Report needs to the Nurse Supervisor.
Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
Ensure that narcotic records are accurate for your shift.
Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.
Notify the attending physician's of automatic stop order prior to the last dosage being administered.
Dispose of drugs and narcotics as required, and in accordance with established procedures
Registered Nurse (RN) Administrative Functions:
Confer with the nursing Supervisor/or other licensed nursing personnel regarding dermatologic disorders of residents in the facility.
Consult with the car Planning Team concerning assessment evaluation and assist in planning and developing the skin care treatment to be performed for the resident. Initiate requests for consultation or referral.
Respond to requests from the resident, physician, or nursing staff
Examine the resident and his/her records and charts, and discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision, or direction.
Perform administrative duties such as completing medical form, reports, evaluation, studies, charting, etc.
Implement and maintain established policies and procedures relative to skin care treatments.
Interpret these to the physician, resident family members and public as appropriate.
Make a written and oral report/recommendations to the attending physician, Medical Director, or nursing supervisor the status and care of the resident.
Identify, manage, and treat specific skin disorders and secondary lesions, abrasions, foot problems such as corns and calluses, decubitus ulcers, bacterial, parasitic and viral skin infections, scaling popular diseases, and benign tumors.
Provide assessment and diagnostic service to resident.
Perform an assessment evaluation using technique including observation, inspection, and palpation
Complete weekly physical dermatologic examination on the resident and record the results with the assessment.
Provide therapeutic services confer with the Care Planning Team in the development of the care plan.
Provide, within established protocols and under the supervision of the physician, treatment for uncompleted dermatologic disorder as directed by the attending physician or Medical Director
Ensure that resident with decubitus ulcer receive appropriate prophylaxis and treatment, such as daily inspection, turning and activity, a well-planned diet, and maintain a clean and dry bed.
Give direct physical and psychological nursing care in emergencies, as well as in the presence of illness or disability in order to maintain life, provide comfort, reduce stress, and enhance the resident's ability to cope.
Work with other health agencies and family members in the physical and emotional transitions of admission, care, and discharge of residents as necessary.
Assist in resident rehabilitation activities.
Where required, perform range of motion, assist in ambulation, provide emotional support.
Monitor the results of physical therapy activities.
Provide preventive health care services.
Make recommendations to residents concerning nutrition, prevention of common skin disorders, etc.
Provide information to residents' family members of prevention techniques and other ways to maintain or improve the general health and psychosocial status of the resident.
Attend and participate in continuing education programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status
Assist in monitoring the inventory of medications, medical supplies and equipment to ensure and adequate supply of skin care products are on hand to meet the needs of residents.
Be familiar with and use as appropriate all items of personal protective equipment offered by facility, including, but not limited to, mask, gown, gloves, and back brace to be worn while lifting.
Participate in employee performances evaluation, and making recommendations to the Nurse Supervisor concerning employee disposals, transfers, etc.
Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work. Report absentee call-in to the Nurse Supervisor.
Review and evaluate your department's work force and make recommendations to the Nurse Supervisor.
Develop work assignments and/or assist in completing and performing such assignments.
Provide leadership to nursing personnel assigned to your unit/shift.
Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignment accordance with acceptable nursing standards.
Report problem areas to the Nurse Supervisor.
Ensure that all nursing assistant are enrolled in or have graduated from an approved nursing assistant training program.
Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
Meet with your shift's nursing personnel on a regularly schedule basis, to assist in identifying and correcting problem areas, and/or to improve services.
Ensure that department personnel, resident and visitors follow the department's established policies and procedure at all times.
Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments with the facility to ensure that nursing services and activities can be adequately maintain to meet the needs of the residents
Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
Review complaints and grievances made or filed by your assigned personnel.
Make appropriate reports to the Nurse Supervisor as require or as may be necessary.
Follow facility's established procedures
Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
Receive/give the nursing report upon reporting in and ending shift duty hours.
Report occupational exposures to blood/body fluids, infectious materials and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and incidents.
Registered Nurse (RN) Nursing Care Functions:
Inform nursing personnel of new admission, their expected time of arrival, room assignment, etc.
Ensure room are ready for new admissions.
Greet newly admitted resident upon admission.
Escort them to their room as necessary.
Participate in the orientation of new residents/family members to the facility.
Make rounds with physicians as necessary
Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with in established procedures.
Consult with the resident's physician providing the resident's care treatment, rehabilitation, etc., as necessary.
Review the resident's chart or specific treatments, medication orders, diets etc., as necessary.
Implement and maintain established nursing objectives and standards.
Make periodic check to ensure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident's physical and emotional status
Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure.
Cooperate with and coordinate social and activity programs with nursing service schedules.
Notify the resident's attending physician when the resident is involved in an accident or incident.
Notify the residents attending physician and next-of-kin when there is a change in the resident's condition.
Carry out restorative and rehabilitative programs, to include self-help, and care.
Inspect the nursing serve treatment areas daily to ensure that they are maintained in a clean and safe manner.
Administer professional services such as; catheterization, tube feedings suction, apply and changing dressing/bandages, packs, colostomy, and drainage bags, taking blood giving massages and range of motion exercises care for the dead/dying etc., as required
