Registered Nurse-Medical Surgical Unit

Registered Nurse-Medical Surgical Unit

The Staff Nurse Inpatient-Kishwaukee reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

• The Registered Nurse performs established procedures in accordance with hospital and the department of patient care services philosophy, policies, and standards.  Care is provided with consideration to developmental needs and abilities.  The RN uses the nursing process to ensure the delivery of high-quality evidence-based nursing care to the patient and family

Responsibilities:

• According to hospital and unit specific guidelines and standards of practice, completes an assessment for each assigned patient reflecting age specific physical, psychological, emotional, spiritual, cultural, and environmental variables affecting the patient. Recognizes signs of abuse/neglect.
• Assesses patient/family educational needs, abilities, learning preferences, and readiness to learn
• Anticipates potential problems including those related to the patient’s disease entity, adjustment to disease, physical complications, knowledge deficit, discharge needs, and family support
• Develops and updates nursing plan of care based on patient assessment and nursing diagnosis with input from interdisciplinary team members and patient/family/significant others; patient/family education and discharge planning needs are assessed and included in the plan of care
• Initiates and coordinates effective communication with physicians and/or other healthcare providers by reporting and recording pertinent observations and reactions regarding patient/family/significant others
• Assesses patient response to treatment regime, recognizes and analyzes the cause of patient’s symptoms and changing condition and initiates appropriate nursing interventions
• Prioritizes the care needs for assigned patients by demonstrating ability to readjust priorities with changing patient status or unit activity
• Actively participates in discharge planning from time of admission as evidenced by documenting patient teaching, patient/family understanding of plan, and timely referrals, etc.
• Applies Standards of Care in the provision of safe patient care, with consideration given to normal characteristics of growth and development throughout the life span, consulting with team and clinical development coordinator, as needed (see Standards of Care). Follows OSHA standards according to guidelines and policies/procedures
• Appropriate age-specific interventions are identified, implemented, and documented in a safe and timely manner; documentation and practice reflects patient’s response to interventions
• Includes the patient/family/significant other as active participants in the development of the plan of care, the care given, and in teaching
• Administers prescribed medications and performs treatments in a safe manner utilizing knowledge of standards of care in administration of medications. Utilizes medication administration time as opportunity to educate patient/family about medications
• Provides pain management for patient as well as comfort and support to patient/family/significant other
• Follows hospital policy in reporting potential abuse/neglect.
• Anticipates patient needs and coordinates patient care activities with other hospital departments, healthcare providers, and agencies in the community
• Performs re-assessment of patient according to patient condition, standards of practice, and hospital policy
• Consistently evaluates patient diagnostic data in a timely manner and intervenes appropriately
• Comprehensively and accurately documents treatments, assessments, and patient’s response to nursing actions and interventions/medical regime
• Communicates patient’s status changes to shift charge nurse, physician, and/or other healthcare team members as appropriate
• Evaluates patient’s and family’s response to teaching plan including level of understanding, acceptance, and compliance
• In consultation with members of the interdisciplinary team, initiates patient care conferences and revises plan of care based on patient response to interventions.
• Evaluates the quality of care provided including nursing assessments and plan of care