RN - MS Tele

Registered Nurse

Responsible to the Unit Manager for the overall nursing practice during the shift assigned. In the absence of the Unit Manager, the RN is responsible to the Nursing Supervisor, Charge Nurse, or the Nursing House Supervisor of the shift. Provides professional nursing care based on current nursing knowledge through the use of the nursing process. This includes the responsibility for assessment of the patient's needs, development of the plan of care to meet those needs, implementation of nursing measures, and evaluation of the effectiveness of the nursing care and other treatment measures.

The nurse collects patient health data by prioritizing data collection based on the patient's immediate condition or needs. Collects pertinent data using appropriate assessment techniques based on the patient's and family's developmental levels, health status, and identified learning needs. Involves the patient, significant others, and other health care providers when appropriate in data collection. Uses a data collection process that is systematic and ongoing. Documents relevant data in a retrievable form.

The nurse analyzes the assessment data in determining diagnoses that are derived from the assessment data. Validates diagnoses with the patient, significant others, and other health care providers. Documents findings in a manner that facilitates the determination of expected outcomes and plan of care. The nurse identifies expected outcomes individualized to the patient. Outcomes are derived from the diagnoses and documented as measurable goals. They are formulated with the patient and other health care providers when possible. Goals are realistic in relation to the patient's present and potential capabilities and attainable within the established time estimate. They are directed toward providing continuity of care.

The nurse develops a plan of care that prescribes interventions to attain expected outcomes. The plan is individualized to meet the patient's developmental and health status needs. It is developed with the patient, significant others, and other health care providers, when appropriate, considering role relationships and interaction patterns of family members. The plan reflects current nursing practice and includes appropriate interventions to meet the patient's and family's identified learning needs. It is documented to provide for continuity of care, including post-discharge.

The nurse implements interventions identified in the plan of care. Interventions are consistent with the established plan of care and implemented to prevent potential developmental and health problems in vulnerable patients and at-risk families. They are directed at assisting patients and families to understand and cope with developmental and traumatic situations during illness. Interventions are implemented in a safe and appropriate manner and documented. The nurse evaluates the patient's progress toward attainment of outcomes by using a systematic and ongoing process. Documents the patient's responses to interventions and evaluates the effectiveness of interventions in relation to outcomes. Uses ongoing assessment data to revise diagnoses, outcomes, and the plan of care as needed. Documents any revisions and involves the patient, significant others, and other health care providers in the evaluation process when appropriate.

The nurse systematically evaluates the quality and effectiveness of nursing practice by participating in quality of care activities as appropriate to the individual's position, education, and practice environment. This may include identifying aspects of care and developing indicators used to monitor the effectiveness of nursing care. Collects data to monitor quality and identify opportunities for improving nursing care. Recommends and implements activities to improve the quality of nursing practice and patient outcomes. Participates on interdisciplinary teams that evaluate clinical practice or health services. Develops policies and procedures to improve quality of care and uses the results to initiate changes in practice and throughout the health care delivery system as appropriate.

The nurse evaluates his/her own nursing practice in relation to professional standards and relevant statutes and regulations. Engages in performance appraisal on a regular basis, identifying areas of strength as well as areas for professional/practice development. Seeks constructive feedback regarding practice and takes action to achieve goals identified during performance appraisal. Participates in peer review as appropriate. The nurse acquires and maintains current knowledge in nursing practice by participating in ongoing educational activities related to clinical knowledge and professional issues. Seeks experiences to maintain clinical skills and demonstrate clinical competency. Seeks knowledge and skills appropriate to the practice setting and related to the designated age-specific populations served. Updates knowledge and clinical skills on an ongoing basis, including but not limited to achieving and maintaining Basic Life Support (BLS) certification within specified time frames.

The nurse contributes to the professional development of peers, colleagues, and others by sharing knowledge and skills. Provides peers with constructive feedback regarding their practice. Contributes to a clinical education environment for nursing students when appropriate.