The Registered Nurse delivers care to patients utilizing the nursing process by demonstrating appropriate assessment, planning, intervention, implementation and evaluation of the patient’s care as evidenced by patient/staff observation.
Assess the patient; collect and document the patient’s current health status and medical history. Make accurate and ongoing assessment of patient’s status and respond appropriately.
Plans/Implementations; sets priorities for nursing action in a logical sequence according to patient’s needs and formulates a plan of care. The plan of care is initiated on patients admission based on all aspects of the initial assessment. Plans include physiological, psychosocial and environment factors; patients/significant other education and patients discharge planning.
Evaluates; performs ongoing assessment and revises plan of care based on new data and patient’s condition.
Documents accurate and ongoing assessment of patient status. Documents patient care that reflects nursing intervention, patient responses to care provided, patient needs, problems, capabilities, limitations and progress toward goals. Documentation includes evidence of appropriate patient/significant other teaching and the understanding of these instructions is noted in electronic medical record.
Communicates with the physician regarding patient needs, nursing assessments and recommendations on a daily basis and as needed as evidenced by patient feedback and Nurse Manager observation.
Collaborates with other nurses and health team members to ensure the patient’s well-being as evidenced by staff/patient feedback.
Teaches patient/significant other appropriate health information in a timely manner and shares written informational material as evidence by patient feedback and Nurse Manager observation.
Performs direct patient care utilizing established procedures, policies and standards as evidenced by patient/staff feedback and Nurse Manager observation.
Administers medication according to policy and procedure.
Administers IV’s according to policy and procedure.
Observes and documents patient’s response to pertinent medications.
Demonstrates ability and appropriate technical skills when administering treatments and procedures in accordance with physician’s orders and policy and procedure (completed in a timely manner).
Demonstrates necessary skills and knowledge to provide care for patients according to unit specific competencies.
Demonstrates ability to handle emergency situations in a prompt, precise and professional manner.
Provides personal patient care to offer comfort and for the well-being of the patient, acknowledging physiological and psychological needs.
Performs indirect patient care utilizing established procedures, policies and standards as evidenced by patient/staff feedback and Nurse Manager observation.
Gives a thorough, concise bedside shift report at change of shift. Communicate pertinent information to the appropriate person in a timely manner.
Maintains a clean, neat and safe environment for the patient and staff according to policy and procedure as evidenced by staff/patient /feedback and Manager observation. Also evidenced by Allen County Regional Hospital patient satisfaction scores.
Ensures that supplies and equipment necessary for patient care are stored in an organized and efficient manner.
Demonstrates correct and safe technique in the use of equipment according to specific product information.
Follows appropriate procedure for obtaining and returning or cleaning/disposing of equipment and supplies.
Participates in economical utilization of supplies and ensures that equipment is maintained in a clean and safe manner.
Maintains professional and technical knowledge by attending educational offerings; reviewing professional publications; establishing personal networks; participating in professional societies.
HIPPA Competency-Maintains patient confidence and protects operations by keeping information confidential
Protects patients and employees by adhering to infection-control policies and procedures, medication administration and storage procedures, and controlled substance regulations.
The Registered Nurse coordinates and delegates duties to other health care personnel, such as Certified Nurse Aides, Unit Clerks and Patient Care Techs.
Adheres to Hospital/Nursing Service policies as evidenced by Nurse Manager.
Labor & Delivery RN will initiate and evaluate fetal heart monitoring and monitor the progress of laboring mothers.
Notify physician when appropriate for progress or concerns.
Assist mother and labor coach with breathing exercises and pain management in accordance to birth plan and hospital policy.
Assist physician in administering care during labor: artificial rupture of membranes, initiation of internal fetal monitoring or intrauterine pressure catheter, initiation of IV medications, amnioinfusion, sterile vaginal exams or other procedures.
Assist anesthesia with the administration of spinal or epidural anesthetic.
Prepare patient for vaginal or Cesarean Section delivery.
Perform immediate post-delivery care of mother and infant: determine Apgar scores, stabilization of newborn, assist physician with resuscitation, perform fundal massage, monitor vital signs and lochia, promote infant/parent bonding.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.