Registered Nurse, Med​/Surg

• Location 2800
  
  E. ROCK HAVEN ROAD,HARRISONVILLE, MO, 64701,United States
• Job Category PROFESSIONALS, RN, Medical Surgical
• Employee Type PRN

Job Code 523

CASS REGIONAL MEDICAL CENTER

Job/Position Description

Department Name:
Med/Surg

Title:

Registered Nurse

EEOC Classification:
Professional/Non-Exempt

PART ONE: DIMENSION AND DESCRIPTION
Primary Purpose

To provide quality Patient care following the standards using the nursing process in order to maintain a safe environment to provide patient and family education and to provide proper documentation for billing.

Formal Policy-Setting Responsibilities

Formally responsible for making recommendations regarding policies associated with the job’s purpose and essential responsibilities.

Routine Decision Making

Alterations in patient assessment; determines patient educational requirements; determines when to contact the physician.

Formal Supervisory Responsibility

No formal supervisory responsibility.

Required Knowledge

Nursing process; critical care; medications and treatments; growth and development; disease processes; interpretation of lab results.

Required Skills and Ability

Good communication skills; assessment skills; time management skills; computer skills; clinic skills; problem solving skills; and knowledge of hospital policies and procedures.

Unusual Working Conditions

Risk of blood, body fluid contamination. Risk for injury from aggressive, combative or disoriented patients.

Education and Certification/ Registration Required for the Position

RN degree required, BSN preferred; current licensure in the state of Missouri; BLS required; NIH Stroke Certification required. PALS, ACLS, preferred.

Age Specific Competencies

May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

PART TWO: ESSENTIAL RESPONSIBILITIES AND TASKS
A. Performs the assessment phase of the nursing process. (20% of time)

• Assesses all assigned patients at start of shift.
• Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four hours of arrival to the medical surgical unit.
• Assesses data relative to age specific needs for every patient within four hours of patient’s arrival to the unit or at start of shift.
• Repeats assessment and documents on abnormal patient findings at least once and PRN during shift.
• Assesses patient/family learning needs within four hours of arrival to the unit or at start of shift.
• Completes appropriate pain assessment at start of shift and as needed.
• Assesses the patient's and family's learning needs every shift.

B. Performs the planning phase of the nursing process. (10% of time)

• Completes an individualized care plan based on patient diagnosis and assessment with each admission.
• Reviews and updates care plan each shift and PRN.
• Collaborates with interdisciplinary team to facilitate the plan of care after the physician writes orders.
• Interprets significance of abnormal patient findings after assessing patient on admission and as condition changes.
• Updates white boards each shift, to include personalized patient goals and pain control.
• Utilizing the “AIDET” model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals, and compliments at least one member of the patient care team each shift.

C. Performs the implementation phase of the nursing process. (15% of time)

• Implements patient care through team approach each shift.
• Documents and reports significant abnormal patient findings to the charge nurse/physician immediately.
• Is knowledgeable of location, care and operation of medical surgical equipment each shift.
• Acts rapidly, effectively and manages self and others during emergency situations.
• Administers IV's and medications as ordered within one hour of time scheduled according to the five rights on every patient.
• Ensures all physician orders are correctly recorded on EMAR and in computer when acknowledging each order.
• Accurately and correctly wastes used portions of…