Must have a current RN license in the State(s) of practice.
PRN (as needed)
Position Summaries:
To plan and deliver nursing care to patients/residents requiring long-term care or rehabilitative care.
Essential Duties and Responsibilities:
Position Summary:
To plan and deliver nursing care to patients/residents requiring long-term or rehabilitative care.
Essential Duties and Responsibilities:
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Works using the guidelines established from the Nurse Practice Act, facility Policy and Procedures, use of your nursing judgement.
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Assess, plan and evaluate nursing care delivered to patients/residents requiring long-term or rehabilitation care.
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Implement the patient/residents plan of care and evaluate the patient/residents response.
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Directs and supervises care given by other nursing personnel.
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Provide input in the formulation and evaluation of standards of care.
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Maintain knowledge of necessary documentation requirements.
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Maintain knowledge of equipment set-up, maintenance and use (i.e. monitors, infusion devices, drain devices, etc.).
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Maintain confidentiality and patient/resident rights, regarding all patient/resident and personnel information.
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Provide patient/resident, family/caregiver education as directed.
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Initiate emergency support measures ( CPR, protecting patients/residents from injury)
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Assessment:
o Admission and routine resident observations/transfer notes are complete and accurately reflect the patient/resident’s status
o Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
o Nursing history is present in the medical record for all patients/residents
o Assessment identifies changes in the patient/resident’s physical or psychological condition ( Changes in lab data, Vital signs, mental status).
o Nursing care plans are initiated/reviewed/individualized on assigned patients/residents monthly and PRN.
o Pertinent nursing problems are identified.
o Goals are stated.
o Appropriate nursing orders are formulated.
o The effectiveness of nursing interventions, medications, etc. is evaluated and documented in the progress notes.
o Evaluation of care plan is noted monthly or as indicated.
o The care plan is revised and indicated by the patient/resident’s status.
o Patient/Resident is approached in a kind, gentle, and friendly manner. Respect for the patients/residents dignity and privacy is consistently provided.
o Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
o Independence by the patient/resident in activities or daily living in encouraged to the extent possible.
o Treatments are completed as indicated.
o Safety concerns are identified and appropriate actions are taken to maintain a safe environment.
o Assist/Grab-bars and height of bed are adjusted.
o Patient/Resident call light and equipment is within reach.
o Restraints, if ordered by a Physician, are maintained properly.
o Rooms are neat and orderly.
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Functional assignments are completed.
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Emergency situations are recognized and appropriate action is taken.
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All emergency equipment can be readily located and operated (Emergency Oxygen Supply, Drug Box, Fire Extinguisher, AED/Crash Cart, etc.)
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Patient/Resident Education/Discharge Planning:
o The patient/resident and family are involved in the planning of care and treatment (documented on the plan of care).
o Patient/resident and/or family are provided with information related to all intervention and activities as indicated.
o Discharge/Death summaries are complete and accurate.
o Transfer forms are complete and accurate
o Active participation in patient/resident care management is evident
o Facility procedure manuals or reference materials are utilized as needed.
o Procedures are performed according to methods outlined in procedure manual.
o Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
o Safety guidelines established by the facility ( i.e. proper needle disposal ) are followed.
o The patients/resident’s full name and room number are present on the chart forms. Allergies are noted on the chart cover.
o Only approved abbreviations are utilized.
o TPR graphic is completed properly and timely
o I&O summaries are recorded and added correctly
o Blood pressure graphic is completed accurately and timely
o Progress notes are timed, dated and signed with full signature and title
o Unit flow-sheets are completed properly (i.e, Wound Care Records, Treatment Records, IV Therapy Record, etc)
o Dates that medications are started or discontinued are documented
o Medications are charted correctly with name, does, route, site, time and initials of nurse
o Pulse and BP are obtained and recorded when appropriate
o Medications not given are circled, reason noted and physician notified if applicable
o Appropriate notes are written for medication not given and actions taken.
o Name and title of nurse administering medication are documented
o Patient/residents medication records are labeled with full name, room number, date and allergies.
o The procedure for administration and counting of narcotics is followed
o All parenteral fluids are charted with time and date started, time infusion completed, sit of infusion and signature of nurse.
o All parenteral fluids are administered according to the ordered infusion rate.
o Parenteral intake is accurately recorded on the unit flow sheet or I&O record.
o IV sites are monitored and catheters changed according to unit policy
o IV bags and tubing are changed according to unit policy
o Appropriate actions are taken related to identified IV infusions problems (infiltration, phlebitis, poor infusion, etc. ) policy
o Tests are scheduled and preps are completed as indicated
o Co-workers are informed of changes in patient/resident condition or of any other changes occurring on the unit.
o Information is relayed to the member of the Health Care Team (i.e. physicians, respitory therapy, physical therapy, social services, etc)
o Unit activities are coordinated (i.e. changing patients/residents room for Admission Coordination transfer/discharge forms, etc.)
o Equitable care assignments are made prior to shift that are appropriate to patient/resident’s needs
o Staffing needs are communicated to the nursing supervisors
o Assistance, direction, and education is provided to unit personnel and families.
o Problems are identified, data is gathered, solutions are suggested, and communications regarding the problem is appropriate.
o Transcriptions of all orders is checked
o All work areas are neat and clean
o Change of shift report is complete, accurate and concise.
o Incident reports are completed accurately and in a timely manner.
o Staff meetings are attended, if on duty, or minutes read initialed if not on duty.
o Supplies are used appropriately
o Charge stickers (or charge system) are utilized appropriately
o Minimal supplies are stored in resident room
o Discharged medications are returned to the pharmacy or destroyed in a timely manner
o Floor-stock medications are charged and re-stocked
o Participates in the identification of staff educational needs.
o Serves as a preceptor, as delegated, for new staff
o Maintains patient/resident care supplies, equipment and environment
o Participates in the development of unit objectives
o Participates in the quality assessment and improvement process and activities.
