Registered Nurse

The Registered Nurse is responsible for delivering patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation. The Registered Nurse directs and coordinates all nursing care for patients based on established clinical nursing practice standards and collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes.

This position is part of the Massachusetts Nurses Association Bargaining Unit at Cooley Dickinson Hospital.

This position reports to the Nurse Manager/Director and operates within established organizational and departmental policies and procedures.

• Must be able to effectively interact appropriately to an individual's intellectual level and physical ability with infant, pediatric, adolescent, adult and geriatric patients.
• Deliver nursing care according to the standards of care defined within the American Nurses Association (ANA) Standards of Clinical Practice.
• Collect patient health data during admission process and throughout the patient's stay.
• Determine the priority of data collection based on the patient's immediate condition or needs.
• Collect pertinent data using appropriate assessment techniques.
• Involve the patient, significant others and health care providers in data collection when appropriate.
• Ensure that the data collection process is systematic and ongoing.
• Document relevant data in the medical record according to hospital standards.
• Analyze the assessment data in determining diagnoses/patient problems.
• Derive diagnoses/patient problems from the assessment data.
• Validate diagnoses/patient problems with the patient, significant others, and health care providers when possible.
• Document diagnoses/patient problems in a manner that facilitates the determination of expected outcomes and plan of care.
• Identify expected outcomes individualized to the patient.
• Derive outcomes from the diagnoses/patient problems.
• Document outcomes as measurable goals.
• Formulate outcomes mutually with the patient and health care providers, when possible.
• Ensure outcomes are realistic and attainable in relation to the patient's present and potential capabilities and resources available.
• Ensure outcomes provide direction for continuity of care.
• Develop a plan of care that prescribes interventions to attain expected outcomes.
• Individualize the plan to the patient's condition or needs.
• Develop the plan with the patient, significant other, and health care providers, when appropriate.
• Ensure the plan reflects current nursing practice.
• Document the plan according to hospital standards.
• Provide for continuity of care in the plan.
• Implement the interventions identified in the plan of care.
• Interpret and implement physician's orders accurately, safely, and within established time expectations.
• Calculate and administer medications safely.
• Administer Point of Care testing, such as glucose monitoring, bladder scans and urine dipsticks (Childbirth Center only). Establish interventions that are consistent with the plan of care.
• Implement interventions in a safe and appropriate manner.
• Document interventions according to hospital standards.
• Evaluate the patient's progress toward attainment of outcomes.
• Ensure evaluation is systematic and ongoing.
• Document patient's response to interventions according to hospital standards.
• Evaluate the effectiveness of interventions in relation to outcomes.
• Utilize ongoing assessment data to revise diagnoses/patient problems, outcomes, and the plan of care, as needed.
• Document revisions in the diagnoses/patient problems, outcomes, and the plan of care according to hospital standards.
• Involve the patient, significant others, and health care providers in the evaluation process, when appropriate.
• Formulate a discharge plan.
• Begin discharge plan at patient's admission.
• Contribute to, update, and communicate plan throughout hospitalization.
• Collaborate with the patient, significant others, and health care providers to efficiently utilize resources throughout hospitalization and facilitate appropriate discharge.
• Document the discharge plan according to hospital standards.
• Assess patient/family learning needs and facilitate the education process.
• Identify patient/family's willingness and readiness to learn.
• Investigate barriers to patient/family education and develop plan to alleviate barriers in learning process.
• Develop and implement individualized patient teaching plans using appropriate patient education resources, including Care Notes.
• Adjust teaching strategies based on age appropriateness, cultural, and gender issues.
• Incorporate patient/family understanding into practice.
• Utilize education strategies to manage transitions across the continuum of care.
• Systematically evaluate the quality and effectiveness of nursing practice.
• Participate in quality of care activities as appropriate to the individual's position, education and practice environment, including:
• Identification of aspects of…