Registered Nurse Tier 1

Overview

The Staff Nurse is accountable for interpreting the plan of medical care, assessment of patients clinical decision-making regarding nursing care, assuring nursing care is provided in a safe and competent manner, providing individualized nursing care, and evaluating nursing care for groups of patients.

The Staff Nurse provides clinical supervision to LPNs, Nursing Aides, and Nursing Service Clerks where applicable.

Responsibilities

MAJOR ACTIVITIES

· Takes report from prior shift and gives report to oncoming shift which includes condition of patients,

diagnosis, treatments, procedures given and required and other aspects of the plan of care.

· Performs assessments and reassessments of patients.

· Reviews ancillary service reports, communicates abnormal results to physicians, and notifies

supervisor and physician when ancillary services are not completed.

· Interprets plan of medical care, evaluates patients, and devises patient plan of care.

· Maintains proper control of medicine, equipment and supplies specific to the assigned unit.

· Plans for discharge of patient considering all available resources and continuum of care needs.

· Refers patients to chaplain, social worker, and agencies as required.

· Provides a safe and secure environment for the patient.

· Implements the patient plan of care by assigning tasks to nursing and non-nursing personnel, and continuously assessing and evaluating patient care and patient's responses to nursing care.

· Performs nursing treatments and procedures and total patient care which may require expert skill and judgment in accordance with established nursing standards

· May accompany physicians when possible on rounds, communicates pertinent information about patient to the physician, and assists the physician with treatments and procedures or delegate if not possible.

· Performs certain special procedures for which specialized training and supervised experience has been received.

· Plans for and provides effective patient and family education.

· Documents pertinent findings, plan of care and evaluation of care in the medical record.

· Assists patients in performing activities of daily living to meet the basic human needs.

· Prepares and maintains reports, charts, records, and forms as required by hospital, state, and federal regulations.

· May accompany patients who are transferred to another medical facility.

· Notifies supervisor, doctor, and/or family/guardian as appropriate when patient's condition changes.

· Observes and evaluates work performed by LPNs, Nursing Aides, and Clerks to validate that treatments and procedures are being performed in compliance with the plan of care and established hospital guidelines.

· Participates in teaching activities for other hospital personnel and nursing students.

· Participates in the orientation of new employees.

· Participates in interdisciplinary team meetings

· Participates in committee meetings as requested.

· Attends in-service programs per contract.

· Assumes responsibility for personal professional development.

· Assists in the development of review and revision of Nursing policies and procedures.

· Respects the dignity and confidentiality of all matters relating to the patients.

· Operates crucial care equipment such as respirators, temporary pacemakers, defibrillators, and other emergency equipment.

· Set-up, maintains, interprets results of cardiac and hemodynamic monitor required and takes action as indicated by nursing practice and hospital procedure.

· Perform such special procedures as endotracheal and tracheostomy suctioning; tracheostomy care; extubation; cardio-pulmonary resuscitation; arterial punctions; care of chest tubes and plerevac; set-up and assistance with peritoneal dialysis, paracentesis, thoracentesis.

· Performs other related duties as required within the scope of the job classification.

SPECIFIC ACCOUNTABILITIES

· Responsible for assessment/reassessment of patients and documentation of nursing intervention.

· Responsible for implementing the patient plan of care.

· Responsible for determining which nursing acts can be delegated and to whom.

· Responsible for providing direction and assistance to those supervised, observes and monitors the activities of those supervised and evaluates the effectiveness of acts performed under supervision.

· Responsible for assuring that the individual performing delegated nursing acts has the necessary educational preparation and validation of competence in order to perform the act in a safe manner.

· Responsible for preparing reports, charts, records, and forms required by hospital, state and federal agencies.

· Responsible for participating in educational programs to further professional growth and development, and assisting in conducting in-service programs.

· Perform other duties as assigned.

DEFINITION: SUPERVISION The provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task has been performed according to established standards of practice [ 201 KAR 20:400 Section 1 (7)].

Qualifications

Education

· Graduation from a State accredited or approved school of nursing. · Must maintain current licensure in state of practice.

Required Skills, Knowledge, and Abilities

Prior to assignment as sole RN provider, the nurse must successfully complete critical care course acceptable to the Director of Nursing and demonstrate mastery of equipment, diagnostic responsibilities, and procedures required of the critical care nurse.

Such course work shall include:

· Cardiopulmonary resuscitation and management of an obstructed airway.

· EKG interpretation.

· Drug therapy, including emergency drug therapy via the I.V. route, or routes normally left to the physician.

· Hemodynamic monitoring.

· Critical care procedures.

The nurse shall be adequately oriented to policies, procedures and equipment. Orientation shall include safety procedures, infection control practices, and performance improvement activities