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Registered Nurse

Location: Pearland
Posted on: January 8, 2021

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 standardsResponsibilities 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/Resident identification and allergy bands (if applicable) are present.
  • Functional assignments are complete
  • Emergency situations are recognized, and appropriate actions is instituted.
  • All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguishers, etc.)
  • Patient/Resident Education/Discharge Planning
  • The Patient/Resident and family are involved in the planning of care and treatment (documented on the plan of care.)
  • Patient/Resident and/or family are provided with information related to all interventions and activates as indicated.
  • Discharge/Death summaries are complete and accurate.
  • Transfer forms are complete and accurate.
  • Active participation in patient/resident care management is evident.
  • Adherence to Facility Procedures.
  • Facility policy and procedure manuals or reference materials are utilized as needed.
  • Procedures are performed in accordance with facility policies and procedures.
  • Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
  • Safety guidelines established by the facility (i.e. proper needle disposal), are followed.
  • Documentation.
  • The patients/residents full name and room number are present on all chart forms. Allergies are noted on chart cover.
  • Only approved abbreviations are utilized
  • Vital signs are completed timely and recorded accurately.
  • I&O summaries are recorded and added accurately and timely.
  • Progress notes are timed, data and signed with full signature and title.
  • Unit flowsheets are completed accurately and timely (i.e. wound care records, treatment records, IV therapy records, etc.)
  • Medication Administrations/Parental Therapy Records.
  • Medication start and discontinue dates are documented.
  • Medications are charted correctly with names, dose, route, site, time and initials of nurse administering.
  • Vitals (pulse and blood pressure) are obtained and recorded as appropriate.
  • Medications that are not administered are circled with a reason noted and the physician is notified if appropriate.
  • Appropriate notes are written for medications not given and responsive actions are taken.
  • Name and title of nurse administering medication is documents.
  • Patient's/Resident's medication records is labeled with full names, room number, date and allergies.
  • Policies and procedures a=for medication administration and counting of narcotics are followed.
  • All parenteral fluids including additives are charted with time and date started, time infusions complete, site of infusion and signature of nurse.
  • All parenteral fluids are administered according to the ordered infusion rate.
  • Parenteral intake is accurately recorded on the unit flow sheet or I&O records.
  • IV sites are monitored, and catheters are changed according to facility policies and procedures.
  • IV bags and tubing's are changed according to facility policies and procedures.
  • Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.) and facility policies and procedures.
  • Coordination of care.
  • Tests are scheduled and preps are completes as indicated.
  • Co-workers are informed of hanged in patient/resident condition or f and other changes occurring in the unit.
  • Information is relayed to other members of the health care team (i.e. physicians, respiratory therapy, physical therapy, social services, etc.)
  • Unit activities are coordinated (i.e. changing patients/residents' rooms for admissions, coordination transfer/discharge forms etc.)
  • Leadership.
  • Equitable care assignments are made prior to shift that are appropriate in meeting patient/resident needs.
  • Staffing needs are communicated to the nursing supervisor.
  • Assistance, direction and education are provided to unit personnel and families
  • Problems are identified, data is gathered, solutions are suggested and communications regarding the problems/concerns are appropriate.
  • Transcription of all orders is checked
  • All work areas are neat and clean.
  • Communication.
  • Change of shift report is complete, accurate and precise.
  • Incident Reports are completed accurately and in timely manner.
  • Professionalism.
  • Decisions are made that reflect knowledge and good judgment and that demonstrates an awareness of patient/resident/family/physician needs.
  • Awareness of wpm limitation is evident and assistances is sought when necessary.
  • Dress code is adhered to
  • Committee meetings (if assigned) are attended, Reports related to the committee are given during staff meetings.
  • Responsibility is taken for own professional growth. All mandatory and other in-services are attended as required.
  • Organizational ability and time management is demonstrated.
  • Confidentiality of patient/resident is respected at all times (i.e. when answering telephone and/or speaking to co-workers.)
  • Professional behavior is demonstrated at all times.
  • Human Relations.
  • A positive working relationship with patients/resident's, visitors and facility staff is demonstrated.
  • Authority is acknowledged and response to the directing of supervisors is appropriate.
  • Time is spent with patient/resident's rather than other personnel.
  • Co-workers are readily assisted as needed.
  • Cost Awareness.
  • Supplies are used appropriately.
  • Charge stickers (or charge system) are utilized appropriately.
  • Minimal supplies are stored in the resident's room
  • Discharge medications are returned to the pharmacy or destroyed in timely manner.
  • Floor-stock medications are charged and re-stocked.
  • Participates in the identification of staff educational needs.
  • Serves as a preceptor, as delegated, for new staff.
  • Maintains patient/resident care supplies, equipment and environment.
  • Participates in the development of unit objectives.
  • Participates in the quality assessment and improvement proves and activities.Required Standards:
    • Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the private, dignity and well-being of al resident in a safe, secure environment.Support, cooperates with, and implements specific procedures and programs for:
      • Safety, including precautions and are work practices, established fire/safety/disaster plans, risk management, and security, report and /or correct unsafe working conditions, equipment repair and maintenance needs.
      • Confidentially and privacy of all data, including patient/resident, employee and operations data.
      • Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and wellbeing of all residents in a safe, secure environment.
      • Compliance with all regularly requirements.
      • Compliance with and enforcement of current law and policy to provide a work environment free from harassment and all illegal and discriminatory behavior.
      • Supports and participates in common teamwork:
      • Cooperates and works together with all co-workers, plans and completes job duties with minimal supervisory direction, including appropriate judgment.
      • Uses tactful, appropriate communications in sensitive and emotional situations.
      • Reports complaints, problems and concerns regarding co-workers, management or residents in accordance with company policy
      • Promotes positive public relations with patients, residents, family member and guests.
      • Completes requirements for in-service training, acceptable attendance, uniform and dress codes including personal hygiene, and other work duties assigned.
      • Agrees to comply with Code of Conduct.Continuing Education:
        • Attends in service and educational programs.Physical Demands:
          • Ability to communicate in English via phone, in writing, and verbally in conversation with different levels of staff, patient families, and any outside customers.
          • While performing the duties of this job, the employee is frequently required to stand and walk. The employee is occasionally required to sit, use hands or fingers, handle of feel, reach who hands and arms, talk or hear, taste or smell. The employee must occasionally lift 50 pounds. Specific vision abilities required by this job include vision, distance vision, peripheral vision, death perceptions, and ability to adjust focus.
          • While performing the duties of this job, the employee is occasionally exposed to blood or other body fluids, fumes or airborne particles and toxic or caustic chemicals. The noise level in the work environment is usually moderate.
          • The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
          • Works in office areas as well as throughout the Facility. Must be able to move about intermittently during working hours including standing, lifting, bending, stooping, twisting, pushing and pulling.
          • Must be able to transfer patients and assists in emergency evacuations.
          • Interacts with patients, family members, staff, visitors, government agencies/personnel, etc., under all conditions/circumstances.
          • Exercises Universal precautions in this hospital environment to protect against the possible exposure to infectious waste, diseases, conditions.Qualifications:
            • Associates Degree in Nursing (Bachelor's in Nursing Preferred)
            • Licensed in the State of Texas as a Registered Nurse
            • Minimum one (1) year of nursing experience in a long-term or acute care setting
            • Excellent communication skills, both verbal and written
            • Exceptional organization skills, ability to prepare and maintain accurate resident charts, reports, and observation
            • Good problem solving and independent thinking skills
            • Knowledge and practicum of basic hygiene and sanitation practicesI acknowledge I have received a copy of the job description and understand the basic requirements I am expected to complete, in addition to all other duties as assigned. I understand the job duties may be altered from these duties based on business needs. I have noted and made my manager and or human resources aware by noting below any accommodations that are required to enable me to perform these duties. I have also noted below any job duties that I am unable to perform, with or without accommodations.

Keywords: THE MEDICAL RESORT, Pearland , Registered Nurse, Healthcare , Pearland, Texas

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