JOB SUMMARY: The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation. Provides direct patient care within the scope of practice. The Registered Nurse also directs and guides patient/family teaching and activities of other nursing personnel while maintaining standards of care within the Medical/Surgical Unit. The Registered Nurse is directly responsible and accountable for the care given to his/her assigned patients. He / She communicates with physician about changes in the patient’s clinical condition including cardiac monitoring, results of diagnostic studies and symptomatology. Is able to respond quickly and accurately to changes in condition and/or response to treatment.
EDUCATION, EXPERIENCE, TRAINING
DUTIES AND RESPONSIBILITIES
Recognizes signs of abuse and reports appropriately to the hospital social worker and/or Child /Adult Protective Services. Familiar with the EMTALA Regulations.
Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling.
Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to 1) Appropriate use of lifting devices and equipment, 2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation, 3) Use of lifting devices to handle patients safely.
Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
Uses two patient identifiers consistently when drawing lab, administering medications and performing procedures. Follows medication reconciliation policy consistently.
Does not use unacceptable abbreviations in documentation (uses read back on all telephone orders.) Monitors authentication and validation of telephone orders within 24 hours by the physician.
Ensures consistently that all clinical alarms, i.e. cardiac monitors are set with the appropriate parameters for the patient and are audible at all times.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines), and demonstrates appropriate use of personal protective equipment (e.g., gloves, gowns, masks, goggles) and hand hygiene techniques.
Gives thorough, detailed efficient change of shift report or upon patient intra-department transfer to ensure consistency in the plan of care. Uses the SBAR communication methodology in all reporting.
Assists physicians with special tests and procedures in the unit. Uses universal protocol “time out” on all patients for any invasive/bedside procedures.
Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e. suction and oxygen immediately available when needed.
Completes pain assessment and reassessment consistently within the time frame after giving pain medications and upon discharge or transfer of patients.
Completes documentation of medications given to the patient on the medication administration record (MAR) and narcotic sheet.
Initiates discharge and patient / family education planning with proper documentation on the patient record in Medi-Tech.
Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
Formulates, maintains and updates a goal directed plan of care on patients which is prioritized and based on patient outcomes.
Detects and reports medication errors and ADR’s according to hospital policy. Safely and accurately administers medications and documents properly on the MAR in a timely manner.
Complies with all regulatory requirements for clinical pathways, clinical assessments, interventions and documentation
Performs all other duties as assigned or required.
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