Registered Nurse (RN) Job Description
As a Registered Nurse, you will deliver care to patients in a long-term acute care and or rehabilitation setting. Observe and provide ongoing assessment of client and family circumstances. Drive preventive, rehabilitative and therapeutic measures. Teach and oversee safety precautions; medication actions and interactions; appropriate health care measures. Administration of medications, treatments and other modalities as ordered by the attending provider. Document accurately and submit timely the nursing notes, according to agency standards Responsibilities although not all inclusive, below are examples of what you will be responsible for in this role: • Works using the guidelines established by the Nurse Practice Act, facility Policies and Procedures, and sound nursing judgement. • Assess, plans and evaluates nursing care delivered to patients/residents requiring long-term, and/or rehabilitation care. • Delivers nursing care to patients/residents requiring long-term and/or rehabilitative care. • Implements the patients/residents plan of care and evaluates the patient/resident response. • Directs and supervises care provided by other nursing personnel. • Provides input in the formulation and evaluation of standards of care. • Maintains knowledge of necessary documentation requirements. • Maintains knowledge of equipment set-up, maintenance and use (i.e. monitors, infusion devise, drain devices, etc.) • Maintains confidentiality and compliance with painted/resident rights, relating to all patient/resident/personnel information. • Provides patient/resident/family/caregiver education as appropriate and/or directed. • Conducts self in a professional manner in compliance with unit and facility policies. • Works shifts, holidays and weekends as scheduled. • Initiates emergency support measures, including CPR as appropriate and protects patients/residents from injury/harm. • Assessment: • Admission and routine resident observations/transfer notes are complete and accurately reflect the patient/resident’s status. • Documentation of the observations is complete and reflects knowledge of unit documentation policies and procedures. • Nursing history is present in the medical records for all patient/residents. • Assessment identifies changes in the patients/residents physical and/or psychological condition (i.e. changes in lab, data, vital signs, mental status). • Planning of Care • Nursing care plans and initiated/reviewed/individualized on assigned patients/residents in accordance with facility policies and procedures. • Pertinent nursing problems/concerns are identified and communicated to appropriate personnel for correction. • Goals are stated. • Appropriate nursing interventions orders are formulated. • Evaluation of Care • The effectiveness of nursing interventions, medications, etc., is evaluated and documented in accordance with facility policies and procedures. • Care Plans: • Evaluation of care plan is performed and documented in accordance with facility policies and procedures. • The care plan is revised as indicated by the patients/resident’s status and in accordance with facility policies and procedures. • General Patient/Resident Care. • Patient/Resident is approached in a kind, gentle and friendly manner. Respect for the patient/resident’s dignity and privacy is consistently provided. • Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided. • Independence by the patient/resident in activities of daily living encouraged to the extent possible. • Treatments are complete as indicated and documented in accordance with facility policy and procedure. • Safety concerns are identified, and appropriate actions are taken to maintain a safe environment. • Side-rails and height of bed are adjusted • Patient/resident call light and equipment is within reach. • Restraints, when used are maintained properly. • Rooms are neat and orderly. • Patient/R