Registered Nurse (RN), Med Surg

Job Duties

• Systematically and continuously collects, records, and appropriately communicates data regarding the patient's health status, integrating knowledge of age specific parameters
• Performs initial physiological needs assessment within established time frames
• Accurately completes the admission assessment form within 24 hours of patient's admission.
• Derives appropriate nursing diagnosis from identified problems of the individual based on data collected
• Reassess and documents the patient's total needs per established unit policy
• Routinely reviews assessment data, identifies educational needs, and initiates discharge planning

• Directly supervises and evaluates the job performance of assigned team members, exercising skill in planning and delegating.
• Performs appropriate treatments as ordered by the physician in an accurate and timely manner; following established policy and procedures.
• Follows infection control procedures and universal precaution guidelines in all aspects of patient care.
• Reports immediately any finding of vital signs, behaviors, subjective complaints or objective observations that may indicate patient health deterioration.
• Initiates emergency resuscitative measures according to ACLS guidelines and/or established protocols.
• Completes reports, charging, clinical forms, and quality reviews accurately, legibly and within established timelines.
• Reviews articles, manuals, minutes, and policies needed or requested to be knowledgeable and remain current.
• Exercises decisions making and prioritizing skills as a response to constant changes in work load and care demands.
• Administers medications as prescribed, monitors for adverse effects; and documents in compliance with P/P regulations.

• Evaluates and documents patient responses to all interventions and procedures carried out both on a physical and psychological basis
• Consults, re-evaluates, and revises multi disciplinary plan of care based on patient's progress and behaviors
• Documents medication administration per unit policy
• Assesses and documents the effectiveness of all PRN medications within l hour of administration
• Documents changes from baseline assessment
• Documents verbal orders on the physician order sheet and ensures co-signature in a timely manner per policy
• Accurately and legibly documents using hospital approved abbreviations, appropriate signatures, titles, error corrections and black ink
• Appropriately documents and completes occurrence form in a timely manner
• Assures completeness of nursing documentation on the medical record at the time of discharge

• Utilizes assessment data to develop an educational plan in conjunction with the patient, significant others, and/or other disciplines to effectively meet the identified needs
• Actively participates in patient education by appropriately utilizing available resources and adjusting it to meet the patient's individual needs and level of understanding
• Evaluates and documents patient and/or significant others response to education given
• Documents discharge teaching information given
• Considers patient's cultural and religious practices, emotional barriers, physical/cognitive limitations, and language when planning educational interventions and documents on educational record consistently

• Initiates plan of care reflecting the assessment of the immediate physiological needs of the patient within established time frames
• Develops plan of nursing care in conjunction with the individual and/or significant others and includes expected outcomes appropriate for the nursing diagnosis and unique patient/family needs
• Prioritizes and prescribes appropriate nursing measures to achieve the expected outcomes
• Evaluates, modifies, and updates the nursing care plan based on observable patient responses and attainment of patient outcomes within established time frames
• Organizes, plans and documents discharge needs in the care plan

Education

Associate's degree in nursing from an accredited institution required, bachelor's preferred

Additional education requirements
Graduate of an approved Nursing Program (BSN preferred)

Certification & Licensures
BLS Required
ACLS Required

Additional Certification & Licensures details
Active Tennessee RN license or compact state.
BLS required by hire date
ACLS, CPI and Chemotherapy and Biologic Administration Competency required within 90 days of hire date.

Experience

Must be able to demonstrate knowledge of human growth and development necessary for assessment, range of treatment and care of patients ranging from adult through geriatrics. Knowledge of hospital and department policies