Registered Nurse; RN- Labor & Delivery

Job Description

Perform an age‑specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborate with physicians and other health team members to coordinate and implement procedures and treatments. Use leadership skills and clinical judgment to coordinate patient care and direct/delegate activities of the patient care unit team.

• Assess the patient’s physiologic health status.
• Conduct patient interview, explain policies and procedures, review chart, and answer questions courteously.
• Assess gastrointestinal, cardiovascular, respiratory, renal, and neurological health status.
• Determine mobility, sensory deficits, prostheses use, and skin condition; adjust plan of care accordingly.
• Assess level of pain and implement pain management.
• Communicate and document patient’s physiologic health status and plan of care.
• Assess patient’s psychosocial health status.
• Elicit perception of care and expectations.
• Determine coping mechanism, knowledge level, and comprehension ability.
• Identify cultural/ethnic requirements to reduce anxiety and ensure satisfaction.
• Communicate and document psychological status and care plan; coordinate support group, counseling, and social services.
• Develop criteria for measuring patient outcomes; identify actual/potential problems.
• Identify teaching needs based on psychosocial and developmental assessment; develop outcome statements and individual goals.
• Formulate plan of care and establish priorities to achieve expected outcomes; identify care activities.
• Coordinate cost‑effective use of supplies, equipment, and medication.
• Document plan of care and collaborate with physicians and other team members.
• Implement the plan of care.
• Maintain vigilance over patient care to ensure safety precautions are followed.
• Exercise professional skills related to the plan of care.
• Reassess patients as needed and appropriately revise plan of care.
• Administer prescribed treatments correctly.
• Use equipment necessary for patient care properly.
• Provide emotional support to patient and significant others.
• Apply scientific principles in performing procedures safely, timely, and efficiently.
• Make accurate observations during treatments/procedures; report and record appropriately.
• Keep accurate documentation of treatment, activity, condition, and responses to interventions.
• Use appropriate documentation methods per policy.
• Act rapidly and effectively during emergencies, managing self, patients, and staff.
• Provide a calm, quiet, restful atmosphere; communicate effectively with family or caretakers.
• Participate in discharge planning and coordinate referrals as appropriate.
• Provide discharge instructions to patient and significant other.
• Measure effectiveness of care and document results.
• Perform variance analysis related to outcome data for performance improvement.
• Design, implement, and evaluate systems to improve care in the unit.
• Collaborate with other care team members to plan and carry out treatment regimens; provide direction to team members.
• Collaborate with the appropriate physician on patient’s plan of care; accurately interpret and implement treatment regimen.
• Assist the physician during treatments or diagnostic procedures.
• Keep the Patient Care Manager/designee and/or physician abreast of changes in condition or treatments.
• Delegate assignments to Patient Care Associate, Support Care Associate, and Clerical Service Associate, ensuring timely completion.
• Perform grade I–IV decubitus care.
• Perform preventive skin care measures, simple dressings, warm/cold compresses, and irrigations per facility procedure.
• Administer medications correctly and safely; identify medication action, dosage, side effects, and implications.
• Meet standard on medication administration examination.
• Prepare local solutions and IV drips.
• Administer and document medication correctly; administer IVP medication per policy.
• Educate patients and significant others related to drug and food interactions.
• Participate in patient and family education; explain patient’s condition.
• Communicate assessment data orderly by recording,…