As an integral part of the interdisciplinary team, the Registered Nurse utilizes the nursing process to provide therapeutic care to patients.
Requirements
- Follows policies and procedures
- Demonstrates ability to access online manuals
- Transfers learned scientific knowledge into practical application in applying the Nursing Process
- Interprets assessment information and formulates Nursing Diagnoses
- 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
- 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
- Ensures complete MD order per policy
- Assures patient monitoring per policy
- Ensures Restraint Audit Form is completed each shift
- 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
- Collaborates with Case Manager and/or physician regarding discharge planning
- Ensures all transfer paperwork is completed
- Ensures belongings are sent with patient
- Utilizes patient care equipment appropriately and safely according to manufacture guidelines
- Communicates effectively with all members of the healthcare team
- Shift to shift report
- Physician Rounds
- Patient/family interactions
- MDP Rounds
- Hand-Off reports
- Facility E-mail
- Student/New employee/Contract employee
- 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
- Demonstrates the ability to manage patients with THA
- Demonstrates the ability to manage patients with TKA
- Demonstrates the ability to manage patients with spinal surgery
- Demonstrates the ability to maintain isolation precautions, respiratory and nutrition care specific to cystic fibrosis patients
- Demonstrates the ability to manage medications and maintain protective isolation precautions for patients with abdominal organ transplants
- Institutes safety precautions and skin care for patients with hepatic encephalopathy
- 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
- Demonstrates the ability to manage high acuity patients requiring specialized monitoring and care
- Status post open heart, heart transplant, lung transplant
- Status post liver/kidney transplants, orthopedics, hepatobiliary, general surgeries
- Status post thoracic-forgut, gastric bypass, neurology, neurosurgery
- Demonstrates the ability to manage advanced therapeutic modalities
- Ventilator care
- Arterial/CVP lines
- Ventricular assist devices
- Lumbar drains
- Initiates, performs and terminates all dialysis treatments according to policy and dialysis standards of care
- Reviews all orders and labs prior to initiating treatments
- Informs patient of treatment plan
- Completes all documentation completely and according to policy on the dialysis treatment record
- Performs all pre-treatment safety checks
- Performs appropriate machine maintenance according to dialysis policies and procedures
- Checks charts for dialysis orders prior to arriving on the unit with the dialysis equipment
- Calls physicians for orders early in the shift when orders for dialysis have been placed, but no treatment orders are written
- Engages patients in therapeutic interactions
- Maintains therapeutic milieu
- Assesses and monitors for patient safety including: Contraband assessment upon admission, change of shift and prn
- Initiates and participates in treatment planning
- Monitors locked doors into and out of the unit
- Logs in Visitors and assesses for contraband
- Follows patients’ legal status q shift and communicates with Department of Mental Health and other agencies as required
- Administers psychotropic medications only after proper consent and documentation
- De-escalation techniques as an effort to prevent the need for behavioral restraint/seclusion
- Applies behavioral restraint/seclusion when appropriate
- Continuously monitors patients for safety (or delegates as appropriate)
- Ensures physician assessment of patient within 1 hour of application of restraint/seclusion and then at least every 8 hours
- Obtains physician orders per policy
- Notifies Manager of all behavioral restraint incidences
- Contacts significant other as allowed by patient
- Completes debriefing, with patient if appropriate, after the incident
- Accurately identifies patient that fit Core Measure criteria
- Completes Core Measure Documentation
- Identifies and participates in data collection and process improvements related to Nurse Sensitive Quality Indicators
- Participates in professional hospital/nursing activities
- Relief Charge Nurse
- Nursing committees/councils
- Hospital Teams
- Unit Based Projects
- Research
- Published peer review article
Benefits
- Paid Time Off
- 401k Matching
- Health Insurance
- Dental Insurance
- Vision Insurance
