RN - PSH

Registered Nurse

The Registered Staff Nurse is responsible for the ongoing assessment, health and well-being of patients assigned to their care. Utilizes critical thinking and decision making skills to supervise nursing staff (Certified Nurse Aides, Unit Clerks, Patient Care Technicians, Students, etc.) on his or her shift. The Registered Staff Nurse provides medical/surgical and emergency nursing care to patients by performing the following duties in accordance with hospital approved policies and procedures.

The Registered Staff Nurse works under the direct supervision of the Charge Nurse during their assigned shift. The Registered Staff Nurse is also supervised by the Nursing Department Leadership related to their scope of responsibility.

Duties and responsibilities include:

• Reviewing the patient's chart becoming familiar with the orders for the patient including but not limited to medications, lab orders and results, radiology orders and results, activity, diet, consultation orders etc. and utilize these tools to provide initial and ongoing patient assessment and care planning activities.
• Being knowledgeable regarding discharge plan for patients.
• Assurance of basic patient care activities are completed on all patients. This includes am care (bathing, linens changed, fresh water, daily weights, etc.) or pm cares (face washed, teeth brushed, back rub, etc.)
• Explaining procedures, treatments to patient to allay apprehension, verify understanding and gain cooperation.
• Explaining procedure, treatment and medication delays to patients and families as soon as possible after notification of delay.
• Serving as a patient advocate by clarifying and confirming communications from hospital personnel.
• Following all Universal Precautions and Blood-borne Pathogen protocols as outlined by hospital policy.
• Initiating Isolation precautions as appropriate for safety of patient, staff and visitors.
• Assurance that needed supplies are available in the various nursing areas.
• Providing for the emotional/physical comfort and safety of patients through the development, implementation, and revision of the nursing care plan.
• Responding to life saving situations based upon nursing standards, policies, procedures, and protocol.
• Providing appropriate individualized teaching regarding medical/surgical condition, treatment, pertinent lab/x-ray results, medications, diet, pain management, and potential food, drug and herbal interactions.
• Beginning the shift by attending and receiving report from the staff who have worked the proceeding shift. Asking questions for clarification of the staff that have been caring for the patient.

• Documenting patient assessment in patient chart. Especially notes any changes in condition, vital signs, weight, level of consciousness, etc.
• Reviewing chart to verify medication orders, lab requests, radiology orders, consults, etc. are properly transcribed and have actually been ordered.
• Verifying and noting medical providers' orders.
• Completing and documenting on new patient admission information including signed consents, complete history, complete admission assessment, completed health screenings, patient belongings list, orientation to room and nursing floor routine.
• Utilizing admission and daily assessment data to initiate and update appropriate plan of care.
• Giving a patient report to the oncoming shift that includes patient identifiers, diagnosis/surgical procedure(s) and date. Pertinent treatments, mental status, diet, activity, ability, abnormal assessment findings, skin issues, pain management, safety issues, significant events and plan/goals.
• Assurance that timely, accurate and complete documentation in patient record.
• Insuring that timely, accurate, and complete billable supply charges are placed on patient charge sheet located in patient room.

• Review of Medication Administration Record to plan assigned patient medication and treatment administration times.
• Administers…