The staff Registered Nurse (RN) is a professional caregiver who assumes responsibility for a group of patients for a designated time frame and provides care to these patients via the utilization of the nursing process, nursing trends, technology, financial and human resources within the philosophy of the institution.
Performs all responsibilities and duties required by unit as specific to the scope of service. Implements procedures and theories related to the specific area of practice. Maintains up-to-date and accurate documentation of nursing care provided to assure the integration of information for use by the healthcare team.
Completes initial assessment upon patient admission and develops appropriate plan of care in accordance with unit standards and that is based on patient and family needs. Implements plan of care, nursing interventions, and patient care procedures. Modifies plan of care based upon continuous evaluation.
Takes responsibility for patient and employee safety by reporting and/or correcting safety hazards and incidents.
Communicates with others directly and in private when necessary to resolve issues. Offers constructive feedback to assist in the professional development of peers, and confers with colleagues to expand knowledge base. Identifies own learning needs and takes initiative to begin appropriate solution.
Fulfills all requirements of departmental competencies.
Receives patient Bedside Shift Report from an RN at the beginning of each shift, ensuring the inclusion of the patient input, visual validation of a safe patient room environment at the time of shift change and updating of the patient communication board found in each patient room
Delegates patient care tasks/responsibilities to assigned HCT’s and validates completion of delegated tasks throughout the shift
Completes and documents basic RN patient care activities such assessments, interpretation of vital signs, ensure physician order completion, admission/discharge of patients, hourly rounding completion on each assigned patient, care plan documentation and patient education
Meets Carle Med/Surg RN documentation standards for each assigned patient
RN will provide patient medications utilizing the patient 5 Rights: Right Patient, Right Medication, Right Route, Right Dose and Right Time
Maintains patient safety as the highest priority level: ensuring safety measure compliance such as fall precautions, pressure ulcer prevention, isolation precautions and patient ambulation safety
Maintains a positive attitude at all times on unit that promotes a healthy work environment and a healing patient environment
Keeps a diligent focus on prompt answering of patient call lights to ensure effective triage and completion of patient requests/medical needs
Uses critical thinking to evaluate the overall patient condition and uses nursing judgement to identify and act on changes in patient status
Effectively communicates within the healthcare team to promote interdisciplinary collaboration, effective patient care coordination and patient safety
Provides competent care for patients who display mild to severe brain injury due to stroke, trauma or surgery; Can specifically identify and respond immediately to neurological changes and/or seizure activity