Job Description:
PURPOSE:
To plan and deliver nursing care to patients requiring acute care.
ENVIROMENT:
Lincoln Community Hospital and Nursing Home is a 15-bed Critical Access Hospital co-located with 35-bed Long Term Care Unit. The facility employs 130-200 employees.
ESSENTIAL DUTIES AND RESPONISILITIES:
1) Works using the guidelines established from the Nurse Practice Act, Lincoln Community Hospital and Nursing Home standards, policies and procedures and nursing judgment.
2) Assesses plans and evaluates nursing care delivered to patients requiring acute care.
3) Delivers nursing care to patients requiring acute care.
4) Implements the patient plan of care and evaluate the patient response.
5) Directs and supervises care given by other nursing personnel.
6) Provides assistance to the Nursing Home on an as needed basis.
7) Provides input in the formulation and evaluation of standards of care.
8) Maintains knowledge of necessary documentation requirements.
9) Maintains knowledge of equipment set-up, maintenance and use (i.e., monitors, infusion devices, drain devices, etc.).
10) Maintains confidentiality and patient rights regarding all patient personnel information.
11) Provides patient/family/caregiver education as directed.
12) Conducts self in a professional manner in compliance with unit and facility policy.
13) Works rotating shifts, holidays and week-ends as scheduled.
14) Initiates emergency support measure (i.e., CPR, protects patients/residents from injury.
15) Participates in the identification of staff educational needs.
16) Servers as a preceptor, as delegated, for new staff.
17) Maintains patient care supplies, equipment and environment.
18) Participates in the development of unit objectives.
19) Participates in the quality assessment and improvement process and activities.
EXPOSURE RISK:
The Registered Nurse is at high risk for exposure to blood and body fluids or other potentially infectious materials.
SUPERVISION RECEIVCED:
Receives administrative supervision form the Assistant Director of Nurses or Director of Nurses. At time may receive functional supervision from other Registered Nurses working on the unit.
SUPERVISION EXERCISED:
Exercises functional supervision in specific situations over unit personnel.
MINIMUM PERFORMANCE STANDARDS:
Performance in the following areas is acceptable when:
Assessment:
1) Admission and routine patient observations/transfer notes are complete and accurately reflect the patient's status.
2) Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
3) Nursing history is present in the medical record of all patients/residents.
4) Assessment identifies changes in the patient's physical or psychological condition (i.e., changes in lab data, vital signs, mental status).
Planning of Care:
1) Nursing care plans are initiated/reviewed/individualized on assigned patients weekly and PRN.
a. Pertinent nursing problems are identified.
b. Goals are stated.
c. Appropriate nursing orders are formulated.
2) Nursing kardex is initiated, revised and/or completed.
a. Tests and procedures are marked off when completed.
Evaluation of Care:
1) The effectiveness of nursing interventions, medications, etc., are evaluated and documented in the progress notes.
2) Care plans:
a. Evaluation of care plan is noted weekly or as indicated.
b. The care plan is revised as indicated by the patient's/resident's status.
General Patient Care:
1) Patient is approached in a kind, gentle and friendly manner. Respect for the patient's dignity and privacy is consistently provided.
2) Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
3) Independence by the patient in activities of daily living is encouraged to the fullest extent possible.
4) Treatments are completed as indicated.
5) Safety concerns are identified and appropriate actions are taken to maintain a safe environment.
a. Siderails and height of beds are adjusted.
b. Patient call light and equipment is within reach.
c. Restraints, when used, are maintained properly.
d. Rooms are neat and orderly.
6) Patient identification and allergy bands (if applicable) are present.
7) Functional assignments are completed.
8) Emergency situations are recognized and appropriate action is instituted.
9) All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.).
Patient Education/Discharge Planning:
1) The patient and family are involved in the planning of care and treatment (documented on the plan of care).
2) Patient and/or family are provided with information related to all intervention and activities are indicated.
3) Discharge/death summaries are complete and accurate.
4) Transfer forms are complete and accurate.
5) Active participation in patient care management is evident.
Adherence to the Facility Procedures:
1) Facility procedure manuals or reference materials are utilized as needed.
2) Procedures are performed according to method outlined in procedure manual.
3) Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
4) Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
Documentation:
1) The patient's full name and room number are present on all chart forms. Allergies are noted on chart cover.
2) Only approved abbreviations are utilized.
3) TPR graphic is completed properly and timely.
4) I & O summaries are recorded and added correctly.
5) Blood pressure graphic is completed accurately and timely.
6) Progress notes are timed, dated, and signed with full signature and title.
7) Unit flow sheets are completed properly (i.e., wound care records, treatment records, IV therapy record, etc.).
Medication Administrations/Parenteral Therapy Record:
1) Dates that medications are started or discontinued are documented.
2) Medications are charted correctly with name, dose, route, site, time and initials of nurse administering.
3) Pulse and BP are obtained and recorded when appropriate.
4) Medications not given are circled, reason noted and physician notified if applicable.
5) Appropriate notes are written for medications not given and actions taken.
6) Name and title of nurse administering medication are documented.
7) Patient's/resident's medication record is labeled with full name, room number, date and allergies.
8) The procedure for administration and counting of narcotics is followed.
9) All parenteral fluids including additives are charted with time and date started, time infusion completed, site of infusion and signature of nurse.
10) All parenteral fluids are administered according to the ordered infusion rate.
11) Parenteral intake is accurately recorded on the unit flow sheet or I & O record.
12) IV sites are monitored and catheters changed according to unit policy.
13) IV bags and tubing are changed according to unit policy.
14) Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.).
Coordination of Care:
1) Tests are scheduled and preps are completed as indicated.
2) Co-workers are informed of changes in patient/resident conditions or of any other changes occurring on the unit.
3) Information is relayed to other members of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc).
4) Unity activities are coordinated (i.e., changing patients/residents rooms for admissions, coordinating transfer/discharge forms, etc).
Leadership:
1) Equitable care assignments are made prior to shift are appropriate
