Registered Nurse (RN)

Nursing Care Position

To plan and deliver nursing care to patients/residents requiring long-term or rehabilitative care.

Essential Duties and Responsibilities

1. Works using the guidelines established from the Nurse Practice Act, facility policies and procedures, and nursing judgement.

2. Assesses, plans and evaluates nursing care delivered to patients/residents requiring long-term or rehabilitation care.

3. Delivers nursing care to patients/residents requiring long-term or rehabilitative care.

4. Implements the patient/residents plan of care and evaluates the patient/resident response

5. Directs and supervises care given by other nursing personnel.

6. Provides input in the formulation and evaluation of standards of care.

7. Maintains knowledge of necessary documentation requirements.

8. Maintains knowledge of equipment set-up, maintenance and use, i.e. monitors, infusion devices, drain devices, etc.

9. Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.

10. Provides patient/resident/family/caregiver education as directed.

11. Conducts self in a professional manner in compliance with unit and facility policies.

12. Works rotating shifts, holidays and weekends as scheduled.

13. Initiates emergency support measures (i.e., CPR, protects patients/residents from injury)

14. Assessment

A. Admission and routine resident observations/transfer notes are complete and accurately reflect the patient=s/residents status.

B. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.

C. Nursing history is present in the medical record for all patients/residents

D. Assessment identifies changes in the patient=s/residents physical or psychological condition (i.e., changes in lab data, vital signs, mental status).

15. Planning of Care

A. Nursing care plans are initiated/reviewed/individualized on assigned patients/residents monthly and PRN.

1. Pertinent nursing problems are identified.

2. Goals are stated.

3. Appropriate nursing orders are formulated.

16. Evaluation of Care

A. The effectiveness of nursing interventions, medications, etc., is evaluated and documented in the progress notes.

B. Care Plans:

1. Evaluation of care plan is noted monthly or as indicated.

2. The care plan is revised as indicated by the patients/residents status.

17. General Patients/Resident Care

A. Patient/Resident is approached in a kind, gentle and friendly manner. Respect for the patients/resident dignity and privacy is consistently provided

B. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.

C. Independence by the patient/resident in activities or daily living is encouraged to the extent possible.

D. Treatments are completed as indicated.

E. Safety concerns are identified and appropriate actions are taken to maintain a safe environment.

1. Side-rails and height of bed are adjusted

2. Patient/residents call light and equipment is within reach

3. Restraints, when used are maintained properly.

4. Rooms are neat and orderly.

5. Patient/resident identification and allergy bands (if applicable)are present.

6. Functional assignments are completed.

7. Emergency situation are recognized and appropriate action is instituted.

8. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.)

18. Patient/Resident Education/Discharge Planning

A. The patient/resident and family are involved in the planning of care and treatment (documented on the plan of care.)

B. Patient/resident and/or family are provided with information related to all intervention and activities as indicated.

C. Discharge/death summaries are complete and accurate.

D. Transfer forms are complete and accurate.

E. Active participation in patient/resident care management is evident.

19. Adherence to Facility Procedures

A. Facility procedure manuals or reference materials are utilized as needed.

B. Procedures are performed according to method outlined in procedure manual.

C. Body substance precautions and other appropriate infection control practice are utilized with all nursing interventions.

D. Safety guidelines established by the facility (i.e., proper needle disposal), are followed.

20. Documentation

A. The patients/residents full name and room number are present on the chart forms. Allergies are noted on the chart cover.

B. Only approved abbreviations are utilized.

C. TPR graphic is completed properly and timely.

D. I&O summaries are recorded and added correctly.

E. Blood pressure graphic is completed accurately and timely.

F. Progress notes are timed, dated and signed with full signature and title.

G. Unit flow-sheets are completed properly (i.e., wound care records, treatment records, IV therapy record, etc.).

21. Medication Administrations/ Parenteral Therapy Record

A. Dates that medication are started or discontinued are documented.

B. Medication are charted correctly with name, dose, route, site, time and initials of nurse Administering.

C. Pulse and BP are obtained and recorded with appropriate.

D. Medications not given are circled, reason noted and physician notified if applicable,

E. Appropriate notes are written for medication not given and actions taken.

F. Name and title of nurse administering medication are documented.

G. Patient/residents medication records in labeled with full name, room number, date and allergies.

H. The procedure for administration and counting of narcotics is followed.

I. All parenteral fluids including additives are charted with time and date started, time infusion completed, site of infusion and signature of nurse.

J. All parenteral fluids are administered according to the ordered infusion rate.

K. Parenteral intake is accurately recorded ion the unit flow sheet or I&O record.

L. IV sites are monitored and catheters changed according to unit policy

M. IV bags and tubing are changed according to unit policy

N. Appropriate actions are taken related to identified IV infusions problems (infiltration, phlebitis, poor infusion, etc.) policy.

22. Coordination of Care

A. Tests are scheduled and preps are completed as indicated.

B. Co-workers are informed of changes in patient/resident condition or of any other Changes occurring on the unit.

C. Information is relayed to the member of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc.,).

D. Unit activities are coordinated (i.e. changing patients/residents room for admissions Coordination transfer/discharge forms, etc.)

23. Leadership

A. Equitable care assignments are made prior to shift that are appropriate to patient/residents needs.

B. Staffing needs are communicated to the nursing supervisors.

C. Assistance, direction and education are provided to unit personnel and families.

D. Problems are identified, data are gathered, solutions are suggested and communication regarding the problem is appropriate.

E. Transcriptions of all orders is checked.

F. All work areas are neat and clean

24. Communication

A. Change of shift report is complete, accurate and concise.

B. Incident reports are completed accurately and in a timely manner.

C. Staff meeting are attended, if on duty, or minutes read and initialed if not on duty.

25. Professionalism

A. Decisions are made that reflect knowledge and