RN, Med Surg - Days

1. Utilizes the nursing process for the performance of patient care, to assess, plan, intervene, and evaluate patient care to achieve prioritized patient outcomes according to the RN scope of practice.

• Performs complete admission assessment.
• Performs comprehensive nursing assessments in an efficient and effective manner.
• Conducts full body system analysis.
• Administers and performs nursing assessment in accordance with the applicable patient type, which may include: Acute, Observation, ER, SNF and Outpatient.
• Reviews, discusses and implements health care provider orders appropriately and acts appropriately if there are questions.
• Responds to call lights and patient needs in a timely fashion.
• Recognizes abnormal symptoms/changes in patient condition, establishes priorities and takes appropriate action.
• Serves as a patient advocate.
• Performs patient rounding for all patient assignments.
• Evaluates patient progress toward desired outcomes prior to discharge.
• Demonstrates personal accountability in the delivery of patient care in a competent, professional and compassionate manner.
• Provides intravenous interventions.

 2. Collaborates with health care providers to coordinate medical and nursing management of patient care.

• Promotes team concept through effective communication regarding patient condition, patient care plan and patient satisfaction with appropriate individuals that are involved in the patient’s care.
• Works effectively with ancillary areas as part of the team approach to patient care.
• Directs patient support team members effectively and appropriately.
• Demonstrates initiative and flexibility in the provision of patient care.
• Informs and involves Lead Nurse or Nurse Manager regarding patient care issues in a timely and appropriate manner.
• Assists in making patient assignments, coordinating admissions, and meeting staffing needs for unit.
• Collaborates with the interdisciplinary team.
• Completes patient and family education throughout the patient’s stay and at discharge.

3. Performs emergency treatment as required in accordance with RN scope of practice.

• Initiates or assists in patient care in an effective and responsive manner as each situation requires.
• Triages each emergency situation appropriately and involves other resources as appropriate.
• Administers and performs emergent care in accordance with the applicable patient population type, which may range from newborn to geriatrics.
• Follows emergency policies, procedures and protocols in an effective manner.

4. Performs and maintains documentation.

• Documents accurate and ongoing assessments of patient status that reflect nursing interventions, patient responses, patient teaching and status of outcomes at discharge.
• Completes shift end check prior to leaving duty.

5. Communicates effectively.

• Communicates and collaborates effectively with other health team members regarding patient condition, nursing plan of care, patient satisfaction needs and recommendations for meeting identified outcomes.
• Follows approved shift report format when communicating patient information.
• Identifies and recognizes abnormal symptoms/changes in patient condition, established priorities, and takes appropriate action. Appropriately, reports condition changes to medical provider.

6. Promotes and ensures patient and staff safety in all aspects of responsibilities.

• Administers medications, treatments and procedures in a timely and safe manner according to health care provider orders and nursing policy, including appropriate performance of standard precautions, using two patient identifiers, and performing patient risk assessments every shift.
• Utilizes proper body mechanics, transfer and lifting techniques to minimize fall risk to patient and injury to self.
• Implements infectious disease controls as appropriate including isolation procedures, proper use of hand hygiene and gloves.
• Follows proper procedures for wasting narcotics and disposal of sharps and hazardous materials.

7. Performs in a Lead Nurse capacity, as assigned or requested by department leader.

• Oversees care delivery and staffing needs and assignments on the nursing unit.
• Provides secure pharmacy coverage.
• Demonstrates knowledge of treatments, policies/procedures, and equipment.
• Responds to Patient/Family concerns and provides immediate interventions when possible.
• Adapts to changes in workload and completes assignments while maintaining quality care.
• Initiates and performs duties that need to complete although not directly assigned.

8. Performs other duties as assigned.