Registered Nurse
Company: THE MEDICAL RESORT
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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