Registered Nurse-Acute Care

Registered Nurse - Acute Care

Reports To : Director of Nursing Status : Non-Exempt

Location : Crook County Medical Services District

POSITION SUMMARY

Assess patient health problems and needs, develop and implement nursing care plans, and maintain medical records. Administer nursing care to ill, injured, convalescent, or disabled patients. May advise patients on health maintenance and disease prevention or provide case management. Acts as a resource to co-workers. Maintains positive attitude and string problem solving skills.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Essential duties and requirements include the following (Other duties may be assigned) :

• Effectively utilizes the nursing process. Completes admission history on all admits on shift.
• Plans nursing care with achievable goals. Completes preliminary care plans on all admissions. Updates and adds to care plans for patients assigned to care during shift. Patient problems are identified and documented on the patient's individualized care plan.
• Implements patient care plans and provides care according to standards and established procedure. Identified patient problems, goals, and plan of care reflects knowledge of clinical conditions and current trends in therapy and care.
• Evaluates the care delivered to patients, their responses to that care and documents care in Nurses notes.
• Promotes continuity of patient care in written care plans, nurses' notes, shift report, and communication with other departments.
• Discharge planning is initiated on all admits during shift of admission. Completes discharge planning as appropriate on all patients discharged during shift. Provides discharge instructions and education as appropriate and arranges for follow up care as needed.
• Documentation is appropriate, timely and complete.
• Work is organized and prioritized.
• Identified patient / family educational needs are documented on the patient care plan and discharge planning worksheet.
• Educational materials and demonstrations are provided and patient / family response to education is documented on the patient's medical record.
• Acts as a liaison among patients' families and physicians.
• Implements the orientation process by acting as preceptor to new employees.
• Assists coworkers as necessary. Assures that patient care is not interrupted because of out of stock or out of date items. Stock levels are periodically reviewed for adequate supply, current dates, and appropriate items and needs for additional items / adjusted levels are communicated appropriately.
• Keeps coworkers informed of pertinent information on patients every shift change.
• Communicates information appropriately to coworkers, superiors, physicians, providers, and families.
• Maintains professional accountability for own actions.
• Provides support to the Director of Nursing on upgrading the quality of nursing care by assisting with policy and procedure changes, achievement of goals for acute care and serving as a resource person. Demonstrates an attitude of helpfulness and cooperation.
• Maintains professional accountability. Cooperates in a positive manner to implement change to ensure compliance with the Standards of Nursing Practice and implementation of the Nursing Process and policies and procedures. Changes affecting nursing care are implemented in a positive manner.
• Meets identified educational goals by attendance at in-services and education programs.
• Sets professional goals and reviews and updates goals annually.
• Adheres to infection control, employee health, fire and safety, hazardous materials, and quality improvement principles and attends these in-services. Maintains current Hepatitis B immunity, TB testing and other vaccines as recommended by state or facility. Practices exposure control measures.

Attends training and meetings as scheduled.

SUPERVISORY RESPONSIBILITIES

Certified Nursing Assistants

Licensed Practical Nurses

QUALIFICATIONS

Education

Knowledge, Skills and Abilities