Med Surg - Registered Nurse

Position Summary:

The registered nurse is accountable for the provisions of nursing care to all patients in the hospital and to prescribe, delegate and coordinate that care as part of the daily responsibility. The registered nurse will also participate in unit management, staff orientation and self-development.

1. Nursing Skills and Process: Assessment, Care planning, Education, Admission and Discharge, Documentation

Assessment

1. Collects relevant patient data or reviews data collection on admission and ongoing to assure holistic assessment.
2. Assesses the demands of the patient's illness on the patient and the patient's potential for adaptation.
3. Performs and demonstrates a complete, systematic assessment, age appropriate of all patient systems and focused assessments as needed.
4. Recognition of abnormal assessments and appropriate intervention and follow up.
5. Reports abnormal assessments, lab values, reports and patient changes to Charge Nurse and Provider.
6. Continuously analyzes patient data to identify patient's needs using Nursing Diagnosis.

Care Planning

1. Initiates, individualizes and updates patient care plans based on patient diagnosis, needs, safety risks and changes in patient condition.
2. Initiates and participates in team care planning/conferences.
3. Evaluates and documents patient's progression toward patient care plan goals.
4. Takes responsibility for assuring patients needs are being met.

Education

1. Assesses patient and family learning needs and barriers. Adjusts education techniques to meet the needs of patients and families.
2. Educates patient and patient's designated caregiver in self-care, treatments, procedures, disease, symptom management, etc. Uses available resources and assures that education needs are met for all patients.
3. Educate patients, families and caregivers as needed on required Hospital Admission Education: infection prevention, fall risk, pain management, new medications, and current patient medications as needed.

Admission and Discharge

1. On admission performs a thorough systems, pain, and safety assessment and identifies patient's and family's needs.
2. Initiates discharge planning on admission and preparing the patient/family for timely discharges including transfer and discharge sheets and assures that discharge planning has been done that meets the patient's/ family's needs.
3. Initiates collaboration with physicians and other team/department care givers to plan for patient's current and discharge needs.
4. Orients patients and families to the environment and the expected care plan.

Documentation

1. Documents all patient assessment and interventions in the electronic medical record per policy.
2. Documentation is timely, accurate, concise, and objective.
3. Nursing Responsibility
   1. Performs nursing skills according to REHC policies and procedures using proper body mechanics and universal precautions.
   2. Act as a positive advocate to support patients and families.
   3. Implements physician orders correctly and in a timely manner.
   4. Serves as a teacher, mentor and positive role model to others.
   5. Keeps current in nursing knowledge. Attends 80% of mandatory meetings.
   6. Attends educational offerings that enhance knowledge in current role at REHC.
   7. Attends educational offerings which contribute to the overall mission of REHC.
   8. Performs patient hand-off report at shift change and at any other patient transfer. Hand-off report is clear, concise, accurate and objective.

Organizational Skills

1. Manages multiple patient care assignments, prioritizes care to meet patient needs in an efficient method.
2. Completes assignments within expected time frames.

Communication

1. Identifies self to patients and others, explains procedures and uses positive communication techniques. (AIDET)

Collaboration

1. 1. Participates in rounds with physicians and other team/department care givers to plan for patient's current and discharge needs.
   2. Assists REHC to maintain compliance with DNV rules and regulations.
   3. Recognizes when standards are not being met, completes the appropriate event report and make changes that effectively brings the organization into compliance.
   4. Assists in other Departments as assigned and helps other staff to assure all patients are having their needs met.
   5. Utilizes each staff member's expertise and delegates appropriately according to patient needs and acuity.
   6. Assists in orientation of staff with courtesy and respect including skill development, problem solving and decision-making.
   7. Takes an active role in assuring that new employees are oriented in all aspects of the job, evaluating progress, and devising learning opportunities that meet the needs of the new employee.
2. Unit Responsibility
   1. Initiates decision making with and in the absence of the Charge Nurse.
   2. Maintains equipment properly and reports any issues.
   3. Implements changes based on quality improvement findings.
   4. Supports the philosophy and objectives of the department of nursing.
   5. Promotes and influences a positive atmosphere in the department of nursing.
3. Relationship Management
4. Follows all aspects of the Standards of Behavior
5. Receives no patient/family/staff dissatisfaction comments annually.
6. Adheres to the Patient's Bill of Rights and follows the REHC confidentiality policy.

Orthopedic Center of Excellence skills as listed below to include Hip, Knee, Shoulder and Spine procedures.

1. 1. Education per current DNV requirements as defined by CR. 5 DNV regulatory guidelines. Education to include eight hours on hire and annually.
   2. . Provide care for patients suffering from arthritis, injuries, fracture, and osteoporosis including birth defects which may affect the bone or muscles and care for patients undergoing a joint- replacement surgery and orthopedic surgical procedures including shoulder surgery and spine surgery.
   3. Admission and pre-operative prep of the patient for surgery
   4. Educate patients on their care plan, pain management plan including pre and post-operative medications and pain scales, incentive spirometer, prevention of DVT, incisional care, elimination,
   5. Educate patients on steps to take to manage pain and how to avoid post-surgical infections
   6. Instruct and reinforce patients, families and caregivers on appropriate assistive device and precautions (hip or knee precautions)
   7. Ongoing assessments for pre and post-operative pain, surgical complications, and surgical site infection
   8. Ongoing assessment of patient stability and activity tolerance for standing, transferring and ambulating with or without assistive devic.