RN II

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The Registered Nurse will interview patients and significant others and complete a history documentation. Documents signs and symptoms that indicate actual and potential problems. Provides continuity of care by communicating the plan of care and diagnostic data, in accordance with the unit's guidelines. Involves family members and other health care team members in the development of the plan of care as appropriate.

Sets priorities and gives nursing care based on the patient's needs.

• Performs appropriate nursing history and physical upon admission and on an ongoing basis.
• Collects and documents patient data.
  • Interview patients and significant others and completes a history documentation.
  • Documents signs and symptoms that indicate actual and potential problems.
  • Incorporates information in the written assessment from families/significant others and members of the health care team.
  • Assess safety of the patient care environment.
  • Documents patient/family teaching needs in the patient care plan.

• In conjunction with the patient and family, develops individualized patient care plan.
  • Identifies short and long-term goals, including discharge planning consistent with established patient care.
  • Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.
  • Provides continuity of care by communicating the plan of care and diagnostic data through the shift report, in accordance with the unit's guidelines.
  • Involves family members and other health care team members in the development of the plan of care as able and appropriate.
  • Revises the initial patient care plan to the changing needs of the patient.

• Provides direct nursing care based on the plan of care and established priorities.
  • Sets priorities and gives nursing care based on the patient's needs.
  • Implements the medical care plan as delegated.
  • Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).
  • Writes patient discharge plan and makes appropriate referrals.
  • Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.
  • Coordinates the activities of other disciplines of the health team to implement the individual care plan.

• Evaluates and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.
  • Revises plan of care based on evaluation.
  • Documents the response of the patient to the medical care plan.
  • Documents the response of the patient to nursing interventions.
  • Recognizes alterations in physiological and psychosocial status.
  • Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.
  • Documents revision of the goals and plan of care to meet the changing needs of the patient.

• Consistently strives to implement the unit's customer service standards and to exceed the expectations of patients, families, physicians and visitors.
• Unit surveys consistently meet or exceed hospital benchmark.
• Demonstrates customer service commitment to patients by maintaining flexibility in relation to patient assignment, shift assignment and work schedule.
• All interactions are conducted in a professional manner.
• Verbal and written feedback from patients, family members/significant others, medical staff visitors and co-workers indicates behavior conducive to positive guest relations.
• Consistently exhibits appropriate phone protocol, e.g., answers phones promptly and professionally, is courteous and helpful.
• Interacts with other departments for problem resolution and quality patient care.
• Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.
• Makes rounds to assigned patients; anticipates patients' needs and answers/responds to the patients' call lights or paging promptly.

• Employee has the willingness and ability to perform additional duties…