Registered Nurse Tier 2

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.

Responsibilities

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, ORT's 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 committee meetings as requested. Attends inservice 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. Performs other related duties as required within the scope of the job classification.