Registered Nurse - Unit Keys+ - 144

Position Summary

Utilizing the Nursing Process of assessing, planning, implementing and evaluating, the Staff Registered Nurse is responsible for delivery of patient care; managing assigned personnel, and promoting collaboration among the multi – disciplinary health care team

Education

Associates - Required

Experience

2 Years experience; with 1 year minimum in Medical Surgical - Required

License & Certification

Professional License with State of Practice - Required

Core Job Functions

Assessment and documentation of the physical, psycho-social, growth, Functional Independence Measures (FIM) scores, and developmental dimensions of the patient.

Includes patient and other health care team members in developing and implementing plan of care using the medical/ nursing diagnosis. Customizes and prioritizes plan of care and helps to develop problem list as needed. Evaluates long and short term goals including communication of plan of care and evaluation to patient, family, provider as appropriate.

Teach back performed with patients to facilitate patient outcome improvements by increasing knowledge and skills needed to improve healthy behaviors. Elicit information using effective counseling techniques. Identify factors that might affect communication or learning.

Conducts comprehensive holistic wellness and illness assessments and employs evidence-based clinical practice guidelines in care of patients. Provides leadership for collaborative, evidence-based revision of diagnoses and plans of care, to improve patient outcomes. Develops evidence-based clinical interventions and systems to achieve defined patient and system outcomes.

Complies with regulatory guidelines for work area and professional practice standards. Assists with data collection, trouble shooting, and educating staff of performance improvement indicators. Utilizes available safety equipment and processes for patient care.

Care plan developed and implemented with other health care team members. Is a resource for others in the delivery of timely professional communication with physicians regarding Situation, Background, Assessment, and Recommendation format. Is a resource for assuring consistent rounding and communicating including present on admission indicators.

Administers medication utilizing the 5 rights and available safety equipment and processes. Utilizes clinical judgment with patient assessment and prescribed therapies to ensure promotion of goal obtainment. As a leader holds healthcare providers accountable for the standard of care.