RN - Nights

Position: RN - FT Nights
Location: Salem

POSITION SUMMARY:

The staff nurse is a graduate of an approved school of nursing and is currently licensed to practice as a professional nurse in the state of Kentucky. The Staff Nurse, under supervision of the House Supervisor and Director of Nursing, is responsible for the nursing care of the patients assigned to him/her and as a team leader, directs others in patient care.

He/she should have a thorough knowledge of nursing principles and procedures, knowledge and skill in techniques of good patient care.

PRIMARY RESPONSIBILITIES & AUTHORITIES:

A. Assess physical and mental status, plans, supervises, and evaluates the care of all patients assigned.
1. Able to correctly assess the patient’s physical and mental condition and identify the patient’s needs.
2. Completes assessment of patient on admission and a nursing admission note is recorded on the patient’s record.
3. Initiates on admission a written patient care plan including identified problems/action and discharge plan.
4. Recognizes and interprets signs and symptoms by continually assessing the patient’s condition. This is done both by observation and data collection. Pertinent information must be documented in the patient’s medical record and reported to the physician.

B. Functions as assigned team leader.
1. Responsible for providing care within established standards and policies. Assist with orientation of new personnel.
2. Instructs, guides and assists other nursing personnel in documentation of care to ensure satisfactory nursing practice. Provides instruction and supervision as needed by team members. Must be technically capable of performing and supervising procedures as described in the Nursing Practice Guideline Manual.
3. Assumes responsibility for care of all patients assigned. Closely supervises, assists, and/or cares for the acutely ill patient. Is willing and does as is required in all nursing functions.a. Uses good judgment in assigning the care of the more acutely ill patients to the most qualified nursing team member.

Position:
Registered Nurse — Staff NursePRIMARY RESPONSIBILITIES & AUTHORITIES (cont.):b. Plans work, sets priorities and delegates nursing functions so that work is equitably assigned.
4. Plans, implements and documents patient and family teaching programs.
5. Prepares the patient physically and psychologically for treatments, surgical procedures and diagnostic studies.
6. Assists the physician with examinations and treatments.
7. Make patient rounds with physician.
8. Following instructions initiates I. V. infusions (including blood), administers I. V. medications, does daily I. V. care and follows hospital policy in regard to changing I. V. needles and tubing. Accurately monitors I. V. infusion rates.
9.. Reports pertinent information at the end of the shift to oncoming shift.
10. Administers medication (including I. V. meds), following the Nursing Practice Guidelines in the Nursing Practice Guidelines Manual.
11. Performs and supervises extra duty assignments to see that they are completed.
12. Performs extra duties as assigned by House Supervisor/Charge Nurse or Director of Nursing.

C. Interprets, transcribes, and carries out physicians orders.
1. Physician’s orders are interpreted and transcribed accurately to the Med Act and Medication Administration Record.
2. Initiates all new orders promptly, either personally or by delegating function. All STAT orders are to be initiated immediately.

D. Responsible for accurate documentation and maintaining completed records.
1. Must assess and summarize each patient’s status at least once each twelve hours.a. Summarization must include statement relevant to progress on status of admission disease process.
2. Documentation includes other health problems relative to care.a. Treatments, diagnostic studies, and medications are documented with results and responses.
1. When documenting dressing change include condition of skin, wound,type and amount of drainage and any odor.
2. Use specific descriptive terms in documentation.b. Oxygen therapy must be documented each twelve hours.c. Decubitus care treatment and response each twelve hours.d. Mental status, restraints, bed rails when…