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
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