1. Utilizes the nursing process for the performance of patient care, to assess, plan, intervene, and evaluate patient care to achieve prioritized patient outcomes according to the RN scope of practice.
- Performs complete admission assessment.
- Performs comprehensive nursing assessments in an efficient and effective manner.
- Conducts full body system analysis.
- Administers and performs nursing assessment in accordance with the applicable patient type, which may include: Acute, Observation, ER, SNF and Outpatient.
- Reviews, discusses and implements health care provider orders appropriately and acts appropriately if there are questions.
- Responds to call lights and patient needs in a timely fashion.
- Recognizes abnormal symptoms/changes in patient condition, establishes priorities and takes appropriate action.
- Serves as a patient advocate.
- Performs patient rounding for all patient assignments.
- Evaluates patient progress toward desired outcomes prior to discharge.
- Demonstrates personal accountability in the delivery of patient care in a competent, professional and compassionate manner.
- Provides intravenous interventions.
2. Collaborates with health care providers to coordinate medical and nursing management of patient care.
- Promotes team concept through effective communication regarding patient condition, patient care plan and patient satisfaction with appropriate individuals that are involved in the patient's care.
- Works effectively with ancillary areas as part of the team approach to patient care.
- Directs patient support team members effectively and appropriately.
- Demonstrates initiative and flexibility in the provision of patient care.
- Informs and involves Lead Nurse or Nurse Manager regarding patient care issues in a timely and appropriate manner.
- Assists in making patient assignments, coordinating admissions, and meeting staffing needs for unit.
- Collaborates with the interdisciplinary team.
- Completes patient and family education throughout the patient's stay and at discharge.
3. Performs emergency treatment as required in accordance with RN scope of practice.
- Initiates or assists in patient care in an effective and responsive manner as each situation requires.
- Triages each emergency situation appropriately and involves other resources as appropriate.
- Administers and performs emergent care in accordance with the applicable patient population type, which may range from newborn to geriatrics.
- Follows emergency policies, procedures and protocols in an effective manner.
4. Performs and maintains documentation.
- Documents accurate and ongoing assessments of patient status that reflect nursing interventions, patient responses, patient teaching and status of outcomes at discharge.
- Completes shift end check prior to leaving duty.
5. Communicates effectively.
- Communicates and collaborates effectively with other health team members regarding patient condition, nursing plan of care, patient satisfaction needs and recommendations for meeting identified outcomes.
- Follows approved shift report format when communicating patient information.
- Identifies and recognizes abnormal symptoms/changes in patient condition, established priorities, and takes appropriate action. Appropriately, reports condition changes to medical provider.
6. Promotes and ensures patient and staff safety in all aspects of responsibilities.
- Administers medications, treatments and procedures in a timely and safe manner according to health care provider orders and nursing policy, including appropriate performance of standard precautions, using two patient identifiers, and performing patient risk assessments every shift.
- Utilizes proper body mechanics, transfer and lifting techniques to minimize fall risk to patient and injury to self.
- Implements infectious disease controls as appropriate including isolation procedures, proper use of hand hygiene and gloves.
- Follows proper procedures for wasting narcotics and disposal of sharps and hazardous materials.
7. Performs in a Lead Nurse capacity, as assigned or requested by department leader.
- Oversees care delivery and staffing needs and assignments on the nursing unit.
- Provides secure pharmacy coverage.
- Demonstrates knowledge of treatments, policies/procedures, and equipment.
- Responds to Patient/Family concerns and provides immediate interventions when possible.
- Adapts to changes in workload and completes assignments while maintaining quality care.
- Initiates and performs duties that need to complete although not directly assigned.
8. Performs other duties as assigned.