Registered Nurse Medical Surgical

Registered Nurse

Performs all responsibilities and duties required by unit as specific to the scope of service. Implements procedures and theories related to the specific area of practice. Maintains up-to-date and accurate documentation of nursing care provided to assure the integration of information for use by the healthcare team. Completes initial assessment upon patient admission and develops appropriate plan of care in accordance with unit standards and that is based on patient and family needs. Implements plan of care, nursing interventions, and patient care procedures. Modifies plan of care based upon continuous evaluation. Takes responsibility for patient and employee safety by reporting and/or correcting safety hazards and incidents. Communicates with others directly and in private when necessary to resolve issues. Offers constructive feedback to assist in the professional development of peers and confers with colleagues to expand knowledge base. Identifies own learning needs and takes initiative to begin appropriate solution. Fulfills all requirements of departmental competencies. The RN performs or assists with the following therapies utilizing proper techniques: IV Access (Peripheral), IV Access (Central Line, PICC, and/or Infusaport), IM; SQ Injections. (Neonatal, Pediatric, Adolescent, Adult, Geriatrics). The RN is skilled and knowledgeable in setting up and assisting with unit procedures, equipment and therapy (Chest Tube Insertion and Management; Sequential Compression Device; Blood Glucose Monitor; PCA Machine; Thorocentesis and Paracentesis; TPN; Thrombolytic Therapy; Kangaroo Pump; Central Line Insertion). The RN responds to emergency situations and functions as an effective team member (Pediatrics, Adolescents, Adults, Geriatrics). Focusing on patient satisfaction by utilizing patient whiteboards, patient rounding and bedside reporting. The RN will demonstrate competency in delivery of care by reviewing, transcribing and implementing orders in a timely manner, communicate the response to treatment while involving the patient, family and significant other in decisions making. Receives patient Bedside Shift Report from an RN at the beginning of each shift, ensuring the inclusion of the patient input, visual validation of a safe patient room environment at the time of shift change and updating of the patient communication board found in each patient room. Delegates patient care tasks/responsibilities to assigned HCT's and validates completion of delegated tasks throughout the shift. Completes and documents basic RN patient care activities such assessments, interpretation of vital signs, ensure physician order completion, admission/discharge of patients, hourly rounding completion on each assigned patient, care plan documentation and patient education meets documentation standards. RN will provide patient medications utilizing the patient 5 Rights: Right Patient, Right Medication, Right Route, Right Dose and Right Time. Maintains patient safety as the highest priority level: ensuring safety measure compliance such as fall precautions, pressure ulcer prevention, isolation precautions and patient ambulation safety. Maintains a positive attitude at all times on unit that promotes a healthy work environment and a healing patient environment. Keeps a diligent focus on prompt answering of patient call lights to ensure effective triage and completion of patient requests/medical needs. Uses critical thinking to evaluate the overall patient condition and uses nursing judgment to identify and act on changes in patient status. Effectively communicates within the health care team to promote interdisciplinary collaboration, effective patient care coordination and patient safety.