The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation. Provides direct patient care within the scope of practice. The Registered Nurse also directs and guides patient/family teaching and activities of other nursing personnel while maintaining standards of care in the Unit. The Registered Nurse is directly responsible and accountable for the care given to his/her assigned patients; He/She communicates with the physician about changes in the patient’s clinical condition including hemodynamic monitoring, results of diagnostic studies and abnormal results and symptomatology. Is able to respond quickly and accurately to changes in condition and/or response to treatment. Maintains patient privacy and confidentiality. Responsibilities
Ensures consistently that all clinical alarms are set and are audible at all times.Collaborates with and assists the Department Director on age-specific issues, clinical practice, unit operations, human resource management and/or regulatory requirements.Serves as a resource to staff in area of clinical and managerial expertise.Serves as a role model and provides positive influence to facilitate change, managing interpersonal concerns through chain of command in a professional manner.Responsible for the delivery of direct and indirect patient care through the nursing process of assessment, planning, and implementation, and evaluation for neonates, pediatrics, adolescents, adults and older adults.Coordinates the care of the patient with the physician, directs and guides other personnel while maintaining standards of professional nursing.Works with other departments to provide a continuum of care and co-workers to provide continuous, quality patient care, efficient patient flow and unit maintenance and organization. Fosters positive interpersonal relationships with staff and members of other departments.Follows medication reconciliation policy consistently and ensures compliance of same by all licensed staff.Ensures Crash Cart, including defibrillation function, have been checked per protocol and after each code, ensures appropriate items are immediately replaced and crash cart checklist is complete with appropriate signatures.Demonstrates knowledge of and compliance with information contained in Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guideline), appropriate use of personal protective equipment (i.e., gloves, masks, goggles) and hand hygiene techniques.Gives thorough, detailed efficient change of shift report to oncoming charge nurse to ensure consistency in the plan of care and assignment of nursing personnel. Uses the SBAR communication methodology in all reporting.Assists physicians with special tests and procedures in the unit. Uses Universal Protocol "time out" on all patients for any invasive bedside procedures and ensures staff compliance.Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility.Completes pain assessment and reassessment with in the timeframe after giving pain medications and upon discharge or transfer of patients.Detects and reports medication errors and ADRs according to Hospital Policy. Safely and accurately administers medications and documents properly in EMAR system.Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.Initiates and titrates and safely monitors all IV medications and blood components. Uses two patient identifiers consistently when drawing labs, giving medications or performing any procedures on a patient and blood components.Initiates discharge and patient /family education planning, with proper documentation on the patient record or electronic medical record (EMR).Completes documentation of medications given to the patient on medication administration (EMR). Ensures medication reconciliation upon admission, transfers and dismissals.Mentors staff by demonstrating empathy and respect for patients by explaining all procedures, providing privacy and allowing patients to express emotional needs.Demonstrates and fosters an awareness and understanding of the hospital continuous quality program including Core Measures as appropriate to the unit. Ensures staff implements and complies with standardized core measure procedures and/or regulatory mandates. Ensures all regulatory requirements are being met per hospital protocol.Assumes leadership responsibility, supervises and evaluates co-workers work performance, assists in orienting new personnel, and assures that nursing care is carried out in accordance with departmental standards and physician orders.Demonstrates ability for conflict resolution with employees and/or patients.Utilizes the chain of command to ensure appropriate care of resolution of any issues pertaining to patient/staff well being or safety.Makes frequent unit rounds to ensure safety, appropriate staffing and detecting any issues that require intervention. Resolving issues as able and requesting assistance when needed.Documents evidence of nursing care in the patient’s medical record (EMR) based upon the nursing process in a legible, concise, timely and complete manner.Demonstrates empathy and respect for patients by explaining all procedures, providing privacy and allowing patients to express emotional needs.Role models professional nursing to all department personnel assisting with orientation and training of new employees and retraining of others.Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling. Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques. Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.Supervises Patient Care Team to ensure that patients, families, visitors, physicians and other employees are treated with courtesy and respect.Completes patient profiles, initial height & weight, vital signs, and allergies upon admission.Assumes leadership responsibilities by assisting with staff meetings, providing agenda items, educational opportunities, and items needing to be addressed for corrective actions. Attends and holds the meeting along with or in place of the Director when needed.Works with other departments to provide a continuum of care and co-workers to provide continuous, quality patient care, efficient patient flow and unit maintenance and organization. Fosters positive interpersonal relationships with staff and members of other departments.Ensures completion of patient profile.Performs all other duties as assigned or required.Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques.Reviews and implements new orders and keeps physician informed of changes in patients clinical status. Follows protocol consistently regarding telephone/verbal orders, CPOE and the use of "read back." Does not use unacceptable abbreviations in documentation.QualificationsCurrent and valid Texas RN License.Current BLS (AHA) upon hire and maintain current.Current ACLS (AHA) within 1 year and maintain current.Prefer minimum of one (1) year as a staff nurse in an acute care hospital.Bachelor of Science degree in Nursing (BSN), preferred.Behavioral Violence Prevention (BVP) certificate within six (6) months of hire and maintain current.
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Electronic Medical Record
Arm Hand Steadiness
Conducting Physical Examinations