Registered Nurse - Ambulatory; OB​/GYN

Overview

Performs an age specific plan of care for designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.

• Conducts patient interview, explains policies and procedures to patient/significant others, reviews patient’s chart and answers questions correctly and courteously; assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status; determines mobility, sensory deficits, prostheses use, and skin condition; adjusts plan of care as appropriate; assesses level of pain and pain management; communicates/documents patient’s physiologic health status and plan of care.
• Assesses patient’s psychosocial health status; elicits perception of medical/nursing care and expectations of care; determines coping mechanism, knowledge level, and ability to comprehend; identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction; communicates and documents psychological status and care plan of support groups, counseling services, and social services.
• Identifies patient outcome; develops criteria for measurement of patient outcomes; identifies actual/potential patient problems; identifies patient’s need for teaching based on psychosocial and developmental assessment.
• Develops patient outcome statements and establishes individualized patient goals; identifies care activities and establishes priorities necessary to achieve expected outcomes; coordinates cost-effective use of supplies, equipment and medication to achieve outcomes; documents the plan of care and collaborates with physicians and other health team members.
• Implements the plan of care; maintains constant vigilance over patient care to ensure safety; follows safety precautions; exercises professional skills related to the plan of care; reassesses patients as needed and revises plan of care; correctly administers prescribed treatments; correctly uses equipment; provides emotional support to patient and significant other; applies scientific principles in performing procedures; carries them out safely, timely and efficiently;
  
  makes accurate observations of patient’s conditions during treatments/procedures; reports and records findings; keeps accurate documentation of patient’s treatment, activity and condition, and patient responses to interventions; uses department-approved documentation methods; acts rapidly and effectively during emergencies; provides a calm, quiet, restful atmosphere; communicates effectively with the patient’s family or caretakers; participates in planning for discharge and coordinates referrals as appropriate;
  
  provides discharge instructions to patient and significant other; evaluates care provided for patient outcome.
• Demonstrates ability to measure effectiveness of care provided and documents outcomes; performs variance analysis related to outcome data for performance improvement; designs, implements, and evaluates systems to improve care in the unit; maintains accurate documentation of patient’s treatment, activity and condition; uses appropriate documentation methods according to departmental policy.
• Collaborates with other care team members in planning and carrying out treatment regimens; provides direction to other members of the care team; collaborates with the appropriate physician on patient’s plan of care.
• Accurately interprets and implements treatment regimens as prescribed by the Physician; assists the Physician during treatments and/or diagnostic procedures; keeps the Patient Care Manager/designee and/or physician abreast of changes in patient’s condition and/or treatments as appropriate; uses clinical judgment in delegating assignments in providing patient care, ensuring assignments are completed in a timely fashion.
• Performs grade I-IV Decubitus Care; performs preventive skin care measures; applies…