RN - PSHGC

Job Description

Job Description

Title:  Registered Nurse  Department:  Nursing

General summary

The Registered Staff Nurse is responsible for the ongoing assessment, health and well‐being of patients assigned to their care. Utilizes critical thinking and decision making skills to supervise nursing staff (Certified Nurse Aides, Unit Clerks, Patient Care Technicians, Students, etc.) on his or her shift. The Registered Staff Nurse provides medical/surgical and emergency nursing care to patients by performing the following duties in accordance with hospital approved policies and procedures. The Registered Staff Nurse works under the direct supervision of the Charge Nurse during their assigned shift. The Registered Staff Nurse is also supervised by the Nursing Department Leadership related to their scope of responsibility.

Duties and responsibilities

• Uphold Nursing “Code of Ethics” (ANA)
• The Registered Staff Nurse will provide general patient care by:

a. The Registered Staff Nurse will review the patient’s chart becoming familiar with the orders for the patient including but not limited to medications, lab orders and results, radiology orders and results, activity, diet, consultation orders etc. and utilize these tools to provide initial and ongoing patient assessment and care planning activities.

b. Is knowledgeable regarding discharge plan for patients.

c. Assures basic patient care activities are completed on all patients. This includes am care (bathing, linens changed, fresh water, daily weights, etc.) or pm cares (face washed, teeth brushed, back rub, etc.)

d. Explains procedures, treatments to patient to allay apprehension, verify understanding and gain cooperation.

e. Explains procedure, treatment and medication delays to patients and families as soon as possible after notification of delay.

f. Serves as a patient advocate by clarifying and confirming communications from hospital personnel.

g. Follows all Universal Precautions and Blood‐borne Pathogen protocols as outlined by hospital policy.

h. Initiates Isolation precautions as appropriate for safety of patient, staff and visitors.

i. Assures needed supplies are available in the various nursing areas.

j. Provides for the emotional/physical comfort and safety of patients through the development, implementation, and revision of the nursing care plan.

k. Responds to life saving situations based upon nursing standards, policies, procedures, and protocol.

l. Provides appropriate individualized teaching regarding medical/surgical condition, treatment, pertinent lab/x‐ray results, medications, diet, pain management, and potential food, drug and herbal interactions.

m. Begins the shift by attending and receiving report from the staff who have worked the proceeding shift. Asks questions for clarification of the staff that have been caring for the patient.

3. The documentation of patient information will be completed by:

a. Documents patient assessment in patient chart. Especially notes any changes in condition, vital signs, weight, level of consciousness, etc.

b. Reviews chart to verify Medication orders, lab requests, radiology orders, consults, etc. are properly transcribed and have actually been ordered.

c. Verifies and notes medical providers’ orders.

d. Completes and documents on new patient admission information including signed consents, complete history, complete admission assessment, completed health screenings, patient belongings list, orientation to room and nursing floor routine.

e. Utilizes admission and daily assessment data to initiate and update appropriate plan of care.

f. Gives a patient report to the oncoming shift that includes. Patient identifiers, diagnosis/surgical procedure(s) and date. Pertinent treatments, mental status, diet, activity, ability, abnormal assessment findings, skin issues, pain management, safety issues, significant events and plan/goals.

g. Assures timely, accurate and complete documentation in patient record.

h. Insures that timely, accurate, and complete billable supply charges are placed on patient charge sheet located in patient room.

4. Completes Medication Administration responsibilities as demonstrated by:

a. Review of Medication Administration Record to plan assigned patient medication and treatment administration times.

b. Administers prescribed medications and treatments in accordance with approved nursing techniques.

c. Observes patients for therapeutic and/or adverse reactions to medications or treatment. Reports adverse reactions to medical provider responsible for patient.

d. Assures accurate narcotic count and resolves discrepancy before leaving shift.

e. Wastes narcotics immediately or as soon as possible with a second nurse to prevent diversion activity.

5. The patient will be assessed by:

a. A visual assessment on each assigned patient will be performed within a minimum of one hour after receipt of report and a complete physical assessment will be performed on each assigned patient within a minimum of two hours after receipt of report during an assigned shift.