Registered Nurse

Job Description

Job Description

Description:

The registered nurse has principal responsibility for the total nursing care, assessment, planning, implementation, and evaluation of each assigned patient. Plans, provides, and documents discharge planning, teaching, and educations patients, family, or others to attain optimal health and continuity of care. Assures that the plan of care is carried out in a safe environment through performance and supervision of subordinate personnel.

Responsibilities

1. Care for clients within the Texas Board of Nursing scope of practice for a Registered Nurse -neonate 1yr, Child/Pediatric 1-11yrs, Adolescent 12-17yrs, Adult 18-55yrs and geriatric -55yrs throughout the facility while communicating positively and respectfully.
2. Perform required tasks without prompting and adjust appropriately to situations.
3. Adhere to the attendance policy.
4. Follow district and department policies.
5. Attend required meetings and in-services.
6. Participate in Hospital District Safety Program and QA Programs.
7. Use time and resources wisely.
8. Maintain HIPAA, keeping patient and hospital confidentiality.
9. Maintain adequate supplies of items needed to perform job; order or report low items to supervisor.
10. Practice proper phone etiquette, identification of self and department.
11. Report adverse events regarding patients, guests or self to supervisor immediately.
12. Oversees LVNs and CNAs.
13. Demonstrates a willingness to learn and practices a team approach.

Essential Functions

Primary Responsibilities for all Units Assigned:

Utilizes the nursing process, completes a comprehensive physical and psychological assessment of patients.

1. Takes nursing histories to provide a basis for developing patient care plans.
2. Completes a thorough nursing assessment and history on admission.
3. Identifies teaching/learning/ discharge needs at the time of admission and throughout stay.
4. Provides an ongoing assessment that accurately reflects overt physiological and psychological needs of patients.
5. Consistently uses input from patient, family, significant other, physician, and healthcare team members.

Using nursing process, plan and provide patient, family care; evaluates patient's response to care and redirects as necessary.

1. Formulates appropriate nursing diagnosis and identifies patient problems from admission database and ongoing assessment.
2. Establishes patient outcome goals that are realistic, specific, measurable, and progressive.
3. Develops and implements nursing orders that are specific and measurable.
4. Initiate interdisciplinary communication and incorporate recommendation.
5. Consults with patients, family and others to formulate care plans that reflect concern for holistic patient needs.
6. Assess and evaluates patient response/outcome and makes appropriate modifications to the care plan.
7. Reviews and updates care plan on a timely basis to reflect patient's status throughout hospitalization.

Implements and monitors appropriate nursing care to meet patient's needs.

1. Identifies expected outcomes for planned nursing intervention and ensures vital information is passed between shifts.
2. Administers medications according to policy including IV's, blood, and blood components as prescribed.
3. Knows actions, indications, contraindications, precautions, adverse reactions, dosage, and route of administration on all drugs prior to administering to patient.
4. Verifies medication administration accuracy and performs the required checks on the medication administration record.
5. Gives exchange report to other health care personnel providing accurate complete information on each patient at the change of shift when transferring patient to another unit and at intervals during the shift.
6. Assesses patients at the beginning of the shift for acuity of patient needs/problems and establishes priority in which work activities are consistently completed by the end of the shift.
7. Performs basic nursing competently to include but not limited to: intake and output, vital signs, physical assessment, urine testing, specimens/cultures, dressing changes, neurological assessments, personal hygiene for the patient, skin care, glucose monitoring, airway/suctioning, basic oxygen administration, nasogastric tubes, tube feedings, urinary catheterization, drains, enemas, and intravenous catheterization.
8. Recognizes, evaluates, and interviews appropriately in a life-threatening situation.
9. Recognizes variance of diagnostic tests, vital signs and assessments that should be reported to the physicians and notifies physicians in a time frames appropriate to the variance.
10. Functions proficiently in all unit nursing modalities.

Participates in the health care educational needs for the patient, family, or significant other regarding patient care needs, disease prevention, and health maintenance measures.

1. Develops and implements an individualized teaching and discharge plan at admission and throughout hospitalization.
2. Initiates and documents progressive patient, family, or significant other teaching on admission and throughout hospitalization.
3. Act as liaison between patient, physician, family, or significant other, and other health disciplines.

Maintains accurate and timely records according to hospital policy and procedures.

1. Documents ongoing assessment within timeframe determined by policy which accurately reflects overt physiological and psychological needs of patient.
2. Accurately documents on each shift the nursing patient care activities and the patient's response to nursing interventions and delegated medical management.
3. Maintains a patient care plan that is current and reflects individual needs or preferences of patients.
4. Documents teaching completed and patient, family, or significant other response in the patient record.
5. Documents interdisciplinary recommendations for plan of care.
6. Transcribes and or cosigns physicians’ orders completely and accurately according to hospital policy and practice.
7. Completes all appropriate transfer and discharge forms.
8. Other duties as assigned withing the RN scope of practice.

Professional Education Requirements

1. Graduate of an accredited School of Professional Nursing.
2. Current Texas RN license or Compact RN license required.
3. BLS
4. ACLS
5. ENPC/PALS
6. TNCC, preferred.
7. STABLE, preferred.
8. NRP, preferred.
9. Nova Strip Glucose Monitoring Certificate

Skill Requirements

1. Effective oral and written communication skills
2. Computer Skills
3. Listening Skills

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1. Extended periods of sitting/standing/walking
2. Manual dexterity
3. Pushing
4. Pulling
5. Lifting/carrying >= 50 lbs.
6. Kneeling/bending
7. Visual acuity
8. Hearing acuity