Registered Nurse BSN

Overview

Provides professional nursing care for assigned patient(s) in one or more patient care departments according to State Board of Nursing Practice Act, American Nursing Association Code of Ethics and standards of practice and professional performance. Responsible for assessment, diagnosis, outcomes identification, planning, implementation and evaluation for patients served. As an active participant in decisions related to patient care and nursing practice, serves as instructor, colleague, researcher, advocate and leader. Must demonstrate competency in assuring quality care, Process Improvement, patient and employee safety, collaboration, consultation and professional development. Assumes responsibility for planning, organizing, delegating and evaluating patient care rendered by LPNs, technicians, medical receptionists and other staff

Assessment: Involves the patient, family, other healthcare providers in collecting and prioritizing patient health information (PHI). Uses appropriate evidence - based assessment techniques and tools. Documents relevant data in the appropriate format. Performs initial and ongoing assessments. Notifies physician of significant changes in patient status, including critical results. Interprets and documents PHI for determining plan of care. Identifies and documents patient/family learning and discharge needs. Incorporates information from other resources in assessment and planning care of the patient. Assesses discharge barriers on admission and when appropriate. • Nursing diagnosis: Identifies and documents the diagnoses, problem list or issues based on assessment. Validates the diagnoses, problem list or issues with the patient, family, and others when appropriate. • Outcomes Identification: Involves the patient, family, and other healthcare providers in identifying and documenting expected outcomes & timelines. Defines expected outcomes in terms of the patient, patient values, ethical and cultural considerations, environment, situation and continuity of care. • Planning: Involves the patient, family and other healthcare providers in developing and documenting a plan of care that is culturally sensitive, to include discharge and learning needs. Updates the care plan to address each of the identified diagnoses, problems or issues and assures plans are achievable and patient-centered. Utilizes the plan to assure continuity of care. Integrates evidence based practice and research affecting care in the planning process. • Implementation: Provides/ documents age appropriate care into a culturally sensitive manner. Provides nursing care based on patient-focused outcomes and are evidence based standards of care. Safely administers patient care, medications and treatments in accordance with standards of practice. Recognizes and responds appropriately to emergency situations