The Registered Nurse provides professional nursing care to a group of patients within an assigned Immediate Care unit of the hospital in support of medical care directed by physician(s). S/he is responsible to be clinically competent; deliver care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interact with patients, significant others, and other healthcare staff while maintaining standards of professional nursing.
The Registered Nurse assumes responsibility and accountability for the nursing care given, but assigns tasks to others who perform under his/her direction. Nursing care is individualized to meet the changing needs of each patient from age fourteen (14) until the end of life and is based on knowledge, skills, and standard of care. Nursing care is organized through the utilization of the nursing process and a written plan of care.
Duties & Responsibilities:
1. Provide the initial individualized patient care based on standards of nursing care for patients through a written nursing care plan.
2. Assess each patient on admission and on an on-going basis to determine patient needs.
3. Note normal vs. abnormal data to recognize life threatening factors; biophysical needs and the patient’s ability to participate in his/her care; psychological, spiritual, and environmental needs; and risk and/or safety factors, limitations, and capabilities.
4. Follow policy related to patients in restraints.
5. Teach and learn needs in relation to the patient’s health status in anticipation of discharge.
6. Administer prescribed medications and treatments in accordance with approved nursing techniques.
7. Prepare equipment and aid physicians during treatment and examination of patients.
8. Maintain awareness of comfort and safety needs of patients.
9. Observe patients and record significant conditions and reactions. Notify supervisor or physician of patient’s condition and reaction to drugs, treatment, and significant incidents.
10. Take temperature, pulse, blood pressure, and other vital signs to detect deviations from normal readings and assess the condition of the patient.
11. Have 1:1 sessions with assigned patients and document meeting.
12. Follow policy related to narcotic count.
13. Respond to life saving situations based upon nursing standards, polices, procedures, and protocol. Remain calm and resourceful during crisis and emergency situations.
14. Document nursing history and physical assessment for assigned patients.
15. Initiate a patient education plan, as prescribed by the physician and/or hospital policy, considering the individualized needs of the patient, including patient and family instructions.
16. Develop an individualized written plan of care as a measure of organizing patient care and as a communication tool.
17. Identify measurable goals, share plan of care and goals with the patient, family members, and staff.
18. Update and maintain the written plan of care via written instructions identifying nursing interventions required.
19. Incorporate available services which are required to meet individual needs of the patient.
20. Carry out physicians’ orders; make appropriate assignments and follow-up; set priorities; and perform basic nursing skills.
21. Perform advanced nursing skills based on competency in practice determined by the skills inventory.
22. Give shift reports.