Registered Nurse - Clinical - Medical​/Surgical

Job Summary

The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.

Regular

• Reports risk management concerns using eSRM.
• Annual Blood Borne Pathogens training (if required)
• Performs comprehensive nursing assessment and reassessment.
• Performs age-appropriate admission or transfer assessment, obtains input from family/guardian when appropriate.
• Accurately documents findings.
• Assesses post‑op or post‑invasive procedure patients.
• Assesses and documents education and discharge needs.
• Provides patient reassessment with documentation of observations, changes, responses, procedures, and standards of care.
• Establishes, coordinates, and evaluates a plan of care based on assessment data, patient diagnosis, lab data, tests, orders, protocols, standards, and other relevant information.
• Identifies short‑ and long‑term goals based on patient care needs.
• Formulates nursing interventions to achieve desired patient outcomes.
• Incorporates evidence‑based practice into the nursing care plan and documentation.
• Provides and documents nursing interventions based on assessed needs and changes in patient status.
• Collaborates with health team members for coordination of daily care plans.
• Provides, coordinates, and communicates patient care, including accurate handoff communication reports.
• Administers and documents medications accurately according to policies and procedures.
• Monitors, maintains, and documents accurate IV fluids and parenteral nutrition according to policies and procedures.
• Completes referrals as indicated by assessment data.
• Requests consultation for special needs, equipment, or information for patient and/or family.
• Provides patient/family education and discharge planning per guidelines and protocol.
• Clarifies all physician orders as warranted.
• Acknowledges and implements physician orders accurately and in a timely manner.
• Assists physician with procedures/treatments as requested or delegates to care partner as appropriate.
• Documents readback for all telephone or verbal orders.
• Takes telephone or verbal orders only in emergency situations.
• Recognizes changes in patient condition and takes appropriate nursing actions.
• Involves family/guardian in care and decision‑making as appropriate.
• Recognizes risks for the patient and takes appropriate action.
• Incorporates use of infection control practices in daily care.
• Documents and/or communicates nursing care and changes in patient condition.
• Performs ongoing evaluation of the effectiveness of care based on assessment data, nursing interventions, patient response to medications, treatments, and procedures.
• Evaluates and documents effectiveness of patient/family education.
• Evaluates plan of care and modifies it as indicated.
• Recognizes significant changes in patient clinical parameters and reports immediately to physician and others as indicated.
• Identifies problems, gathers pertinent data, suggests solutions, communicates using appropriate lines of authority, and works toward problem resolution.
• Reports variations from care/treatment following the occurrence reporting policy and procedures.
• Specialized care to patients at high risk for injury:
  • Restraint Care – Initiates/evaluates alternatives to restraint prior to application, applies restraints consistently, monitors patient response, provides specified patient care, consults peers for alternatives, and documents restraint use thoroughly.
  • Pain Management – Assesses pain on admission and reassessments, incorporates patient cultural/spiritual beliefs, implements preventive pain techniques, involves patient/family in the plan, and considers alternative methods such as massage, repositioning, immobilization, and music therapy.
  • Abuse Assessment – Recognizes abuse criteria, reports signs of abuse/neglect to appropriate agencies, and takes actions to support patient safety.
• Adheres to all quality and performance standards, policies, procedures, and protocols.
• Participates in learning experiences that increase professional competence.
• Demon…