Community Hospital RN-Med Surg, Full Time in Grand Junction, Colorado
ESSENTIAL DUTIES AND RESPONSIBILITIES:
(The following statements are illustrative of the essential functions of the job and do not include other non-essential or marginal duties that may be required. Community Hospital reserves the right to modify or change the duties or essential functions of this job at any time. All responsibilities may not be performed by all incumbents.)
Uphold Nursing ?Code of Ethics? (ANA)
The Registered Nurse will provide general patient care by:
The Registered Nurse will review the patient?s chart becoming familiar with the orders for the patient including but not limited to medications, lab orders and results, radiology orders and results, activity, diet, consultation orders etc and utilize these tools to provide initial and ongoing patient assessment and care planning activities.
Is knowledgeable regarding discharge plan for patients.
Assures basic patient care activities are completed on all patients. This includes am care (bathing, linens changed, fresh water, daily weights, etc.) or pm cares (face washed, teeth brushed, back rub, etc.)
Explains procedures, treatments to patient to allay apprehension, verify understanding and gain cooperation.
Explains procedure, treatment and medication delays to patients and families as soon as possible after notification of delay.
Serves as a patient advocate by clarifying and confirming communications from hospital personnel.
Follows all Universal Precautions and Blood-borne Pathogen protocols as outlined by hospital policy.
Initiates Isolation precautions as appropriate for safety of patient, staff and visitors.
Assures needed supplies are available in the various nursing areas.
Provides for the emotional/physical comfort and safety of patients through the development, implementation, and revision of the nursing care plan.
Responds to life saving situations based upon nursing standards, policies, procedures, and protocol.
Provides appropriate individualized teaching regarding medical/surgical condition, treatment, pertinent lab/x-ray results, medications, diet, pain management, and potential food, drug and herbal interactions.
Begins the shift by attending and receiving report from the staff who have worked the proceeding shift. Asks questions for clarification of the staff that have been caring for the patient
The documentation of patient information will be completed by
Documents patient assessment in patient chart. Especially notes any changes in condition, vital signs, weight, level of consciousness, etc.
Reviews chart to verify Medication orders, lab requests, radiology orders, consults, etc. are properly transcribed and have actually been ordered.
Verifies and notes medical providers? orders.
Completes and documents on new patient admission information including signed consents, complete history, complete admission assessment, completed health screenings, patient belongings list, orientation to room and nursing floor routine.
Utilizes admission and daily assessment data to initiate and update appropriate plan of care.
Gives a patient report to the oncoming shift that includes. Patient identifiers, diagnosis/surgical procedure(s) and date. Pertinent treatments, mental status, diet, activity, ability, abnormal assessment findings, skin issues, pain management, safety issues, significant events and plan/goals.
Assures timely, accurate and complete documentation in patient record.
Insures that timely, accurate, and complete billable supply charges are placed on patient charge sheet located in patient room.
Completes Medication Administration responsibilities as demonstrated by:
Review of Medication Administration Record to plan assigned patient medication and treatment administration times.
Administers prescribed medications and treatments in accordance with approved nursing techniques.
Observes patients for therapeutic and/or adverse reactions to medications or treatment. Reports adverse reactions to medical provider responsible for patient.
Assures accurate narcotic count and resolves discrepancy before leaving shift.
Wastes narcotics immediately or as soon as possible with a second nurse to prevent diversion activity.
The patient will be assessed by:
A visual assessment on each assigned patient will be performed within a minimum of one hour after receipt of report and a complete physical assessment will be performed on each assigned patient within a minimum of two hours after receipt of report during an assigned shift.
Document any assessed changes in patient condition. Notify the Charge RN and medical provider of changes in patient condition as necessary. (Including vital signs, weights etc. that may have been performed by ancillary staff.)
Assess patient?s room for safety issues or needed equipment such as bedside commode, riser on toilet, water glass, holder for dentures or glasses, etc.
Creates or follows Nursing Care plan including patient education plan.
Monitors the patient for any changes in condition. Maintains awareness of comfort and safety needs of patient. Reports any significant changes in patients? condition during the shift to the Charge RN and Medical Provider.
Other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE:
Associate?s Degree from accredited Registered Nurse Program with at least six (6) months of patient care experience is preferred
OR equivalent combination of education and experience.
Current, unrestricted licensure as a Registered Nurse in Colorado