Registered Nurse/Inpatient

Registered Nurse/Inpatient

Job Summary:

The Registered Nurse (RN) manages individualized, goal-directed nursing care through use of the nursing process and the principles of primary nursing in accordance with departmental and hospital policies and procedures. Cares for ages Pediatric through advanced age and end of life.

Essential Functions:

• Assess and diagnose patient and family needs to provide quality care to assigned patients and documents findings in the EMR.
• Perform admission assessment within six hours of admission or in accordance with specific unit standards. Reviews and acknowledges all MD orders for assigned patients.
• Identify and document nursing diagnosis on patients’ plan of care promptly.
• Identify and document patient/family/significant other teaching needs upon admission.
• Identify discharge-planning needs of patient/family/significant other of admission.
• Develop, discuss, and communicate a realistic problem list (plan of care) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs. Plan of care will include nursing diagnosis statement for each identified problem.
• Develop patient/family/significant other teaching and discharge plan as per unit standard.
• Demonstrates proper procedures in all methods of medication administration. Administer blood and blood products competently following hospital policy and procedures.
• Initiate and maintain IV access according to hospital policy and procedures.
• Assess and document IV site q4o or per unit standard, ensures IV site is labeled AAT.
• Evaluate the identified problems, care provided, and patient’s responses are reassessed in order to meet patient and family needs to ensure overall quality of care delivered.
• Reassessment of plan of care is done every shift.
• Assess the patient/significant other’s response to teaching plan in order to evaluate the effectiveness of the plan
• Based on reassessment, plan of care will remain the same or be modified to meet the patient/significant others identified needs.
• Demonstrate a constructive approach during all interactions with staff and nurse leaders toward the organization.
• Perform all responsibilities/duties required by the unit/med-surg division as specific to the scope of service to ensure that the unique nature of the client is addressed.
• Demonstrate knowledge of procedures and theories related to the care of the orthopedic patient.
• Demonstrate knowledge of procedures and theories of PCA and epidural pain management modalities. Consistently documents pre/post pain med assessments.
• Demonstrate knowledge and procedures of theories of capillary blood glucose testing.
• Follow MD orders and accurately documents I & O’s
• Utilizes appropriate PPE and precautions prn