RN - ER

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. Perform other duties as assigned.

Formal Policy-Setting Responsibilities:
No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.

Routine Decision Making:
Alterations in patient assessment; determines patient educational requirements; determines when to contact the provider.

Formal Supervisory Responsibility:
No formal supervisory responsibility.

Unusual

Working Conditions:

Risk of blood, body fluid contamination. Risk of injury related to poor body mechanics. Risk for injury from aggressive, combative or disoriented patients. Potential exposure to hazardous drugs and chemicals.

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.

Essential Responsibilities and Tasks Performs the assessment phase of the nursing process. (20% of time)
Assesses all assigned patients at start of shift and as needed.

Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four (4) hours of arrival to the Medical Surgical unit.

Assesses data relative to age specific needs for every patient within four (4) hours of patient’s arrival to the unit, at start of shift and as needed.

Repeats assessment and documents on abnormal patient findings at least once and as needed during shift.

Assesses patient/family learning needs within four hours (4) of arrival to the unit, start of shift and as needed.

Completes appropriate pain assessment at start of shift and as needed.

Assesses the patient's and family's learning needs every shift and as needed.

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 and as needed.

Reviews and updates care plan each shift and as needed.

Collaborates with interdisciplinary team to facilitate the plan of care after the provider 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’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.

Performs the implementation phase of the nursing process. (15% of time)
Implements patient care through team approach each shift and as needed.

Documents and reports significant abnormal patient findings to the charge nurse/provider/manager 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 (1) hour of time scheduled according to the five rights on every patient.

Ensures all provider orders are correctly recorded on EMAR and in computer when acknowledging each order.

Accurately and correctly wastes used portions of controlled substances within a timely manner.

Performs narcotic count according to hospital policy.

Attaches patients name band, fall risk, allergy band etc. immediately after patient’s arrival and upon bands being removed.

Ensures fall protocol is followed on each patient.

Performs the…