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 Birthplace. Is able to respond quickly and accurately to changes in condition and/or response to treatment. Provides for a safe environment for patients and visitors. Utilizes the chain of command when necessary to ensure patient well-being and appropriateness of care to newborns and mothers during the antepartum and postpartum periods.
Recognizes onset of antepartum, postpartum, neonatal or post-operative complications and emergencies.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines) and demonstrates appropriate use of personal protective equipment (e.g., gloves, gown, masks, and goggles) and hand hygiene techniques.
Gives thorough, detailed efficient change of shift report to ensure consistency in the plan of care. 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.
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, i.e. suction and oxygen immediately available when needed.
Completes pain assessment and reassessment consistently within the time frame after giving pain medications and upon discharge or transfer of patients.
Completes documentation of medications given to the patient on the Medication Administration Record (MAR) and narcotic sheet.
Recognizes signs of abuse and reports appropriately to the hospital social worker or Adult/Child Protective Services. Familiar with the EMTALA Regulations.
Initiates discharge and patient / family education planning with proper documentation on the patient record.
Reviews/implements/processes new orders in a timely manner and keeps physician informed of patient’s status.
Initiates, titrates and safely monitors all medications and blood components. Detects and reports any medication errors/ADR’s per policy.
Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
Formulates, maintains and updates a goal directed plan of care on patients which is prioritized and based on patient outcomes.
Uses two patient identifiers consistently when drawing lab, administering medications and performing procedures
Does not use unacceptable abbreviations in documentation and uses read back on all telephone orders. Reviews and transcribes all telephone orders. Follows telephone read back policy. Monitors authentication and validation of telephone orders within 48 hours by the physician.
Monitors continually infant safety/security levels in the department and notifies security as appropriate.
Promotes a breastfeeding-friendly environment to all nursing mothers.
Determines the patient and family understanding of post-delivery and neonatal care and post-hospital follow-up plans.
Questions the presence of unknown/unauthorized persons in the Perinatal Department and notifies security as needed.
Checks maternal/infant identification bands per policy ensuring parental education regarding the critical importance of bands/security tags.
Utilizes the chain of command to ensure appropriate care or resolution of any issues pertaining to patient well-being or safety.
Responds immediately, efficiently and appropriately to all Code Pink alarms.
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, includes but not limited to 1) Appropriate use of lifting devices and equipment, 2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation, 3) Use of lifting devices to handle patients safely.
Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
Complies with all regulatory requirements for clinical pathways, clinical assessments, interventions and documentation.
Performs other duties as assigned or required.
Must have current and valid license as a Registered Nurse issued by the State.
BLS (AHA) Certificate upon hire and maintain current.
ACLS (AHA) Certificate upon hire and maintain current.
NRP (AHA) Certificate within 30 days of hire and maintain current.
Basic Fetal monitoring within 60 days of hire and maintain current
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