Registered Nurse (RN) Staff Nurse
Freedom Staffing Services
Chapel Hill, NC, US
Full-time
Purpose
To assure quality nursing care for patient by following physician's orders, state and federal regulations and this Facility's policies and procedures.
Essential Job Functions and Requirements
- Makes walking rounds at the beginning and end of shift while receiving and / or giving report.
- Counts narcotics at beginning and end of shift, always initialing the count sheet appropriately ascertaining accuracy of count.
- Performs fingersticks as ordered by MD scheduled during shift.
- Administers all medications (oral, s.q., I.M., or I.V.) as ordered by M.D. and according to contracted Facility policies.
- May administer up to 60 minutes before or after time ordered. Also, administers (hangs) tube feeding as ordered by M.D.;
starts I.V.'s as ordered.
- Checks critical or "sick" patients frequently and documents findings, changes, etc. in Nurses Notes and notifies supervisor and / or M.D. as necessary.
- Observes patients for symptoms and / or reactions, including general physical and / or mental condition for signs which may be indicative of adverse change.
Reports these to supervisor and / or MD as necessary. Documents in nurses notes and places on charting list and calendar.
Also notifies patient's family as necessary of any significant change in patient's condition.
- Leads, guides, and supervises facility nursing assistants and orderlies.
- Supervises care and treatments performed by facility nursing assistants and orderlies. (Example : Vital signs, ROM, ambulation, rehabilitative programs, etc.
Monitors documentation of care and treatments performed by nursing assistants and orderlies.
- Completes incident reports and calls physician if needed.
- Completes appropriate nursing documentation according to facility policies and procedures. .
- Admits new patients, completing the following : Nurses Admission Record, Nurses Notes, status change slip, dietary requisition, taking off orders, and checking MAR's.
- Transfers and / or discharges patients when ordered by physician.
- Assists physicians with rounds as needed.
- Drapes, remains with and cares for patients during MD rounds, physical examinations, and treatments as necessary.
- Notifies MD of any error administering medication should such occur.
- Documents PRN medications and also the effectiveness or lack of effectiveness appropriately on PRN sheet.
- Performs treatments scheduled during shift and documents appropriately.
- Monitors specific skin tears and / or other skin conditions' and documents at least weekly or more often if warranted.
2 days ago