Registered Nurse

Position Goal

The Registered Nurse (RN) performs the functions of assessing, planning, implementing, and evaluating the care for the assigned patients on the unit during a shift. The RN is responsible for meeting the Standards of Practice, which includes managing all assigned personnel, supplies, and equipment on the unit, and for promoting collaboration with all members of the health care team. The individual demonstrates personal and professional responsibility, participates in creating an atmosphere of teamwork and coordination and assumes responsibility for their own professional development.

NURSING PROCESS:
ASSESSMENT
:
Includes appropriate interviewing techniques, systematic physical assessment and interpretation of available data including: past medical history, current medical status, vital signs, lab work, x-rays and other diagnostic tests. It should encompass the spiritual, psychological, physiological, social, and age appropriate needs of the patient.

Consistently, independently conducts a thorough admission interview and systematic physical assessment.

Consistently, independently collects and interprets all appropriate patient data and reviews pertinent findings with anesthesia.

Assesses the need for services of other health care professionals to facilitate the delivery of care.

PLANNING
:
Includes the development of a written plan of care that utilizes the data collected in the assessment process, incorporates the medical plan of care, demonstrates knowledge of resources available, sets priorities and establishes realistic outcomes and discharge planning.

Independently develops/revises an appropriate age specific patient care plan

Attends and participates in patient care conferences, when applicable.

Initiates and coordinates patient care conferences, when applicable

IMPLEMENTATION
:
Includes organization, prioritization and implementation of a safe therapeutic patient care regimen, recognizing the dynamics of changes that may occur and adjusting the plan of care to accommodate those changes. In addition, demonstrates an understanding of medication administration i.e. right patient, drug, route, dose, time, indications, drug interactions and side effects. Also demonstrates knowledge of the proper use, troubleshooting, and maintenance of all equipment utilized to carry out the patient care regimen.

Independently organizes and implements a safe, therapeutic and efficient patient care regimen at all levels of acuity

Sets appropriate priorities and completes assignments independently

Is aware of changing clinical status, anticipates problems and independently adapts plan of care to meet patient needs as clinical status changes and reviews pertinent findings with anesthesia and/or the surgeon.

Demonstrates knowledge of location, operation and care of all equipment/implants (eg. tourniquets, drills, etc) necessary to function on the unit independently. Can trouble shoot minor equipment problems

EVALUATION: Includes a review of the effectiveness of a patient plan of care, based on patient progress, changing clinical status and appropriateness of expected outcomes. As a result of this review, the plan of care is continued; revised or expected outcomes are adjusted.

Evaluates effectiveness of plan of care, based on patient progress versus expected outcomes, and independently revises plan or adjusts expected outcomes.

PATIENT SAFETY

Complies with surgical site verification and time out policies.

Reviews the planned procedure and verifies the surgical consent with the patient.

Verifies surgeon privileges as well as the need for surgical assistant.

Verifies all equipment is functioning and inspects for safety prior to use.

Implements appropriate patient positioning while maintaining proper body alignment for all types of surgical procedures.

Completes all counts accurately.

Verifies the sterility of all items prior to introduction onto the sterile field.

Provides appropriate shielding for both the patient and the surgical team when using X-ray.

Monitors the sterile field for any breaks or potential breaks in sterility.

Documentation
:
Reflects the changes in…