Within the RN scope of practice as defined by the Oregon State Board of Nursing, applies the nursing process to the care of patients. Teaches patients and significant others. Documents patient care in the medical record. Collaborates with the interdisciplinary team to effectively coordinate overall care of the patient.
PRINCIPLE DUTIES AND RESPONSIBILITIES
• Assesses patients, as appropriate to the scope of care the nurse will provide. Assessments may include: physical, psychosocial, learning needs and barriers, needs related to age/culture, discharge planning.
• Establishes nursing diagnoses based on results of assessments and in collaboration with the interdisciplinary team.
• Plans care according to identified diagnoses and needs. Updates plan of care as appropriate.
• Implements/performs individualized care, based on nursing care plan and the nurse’s role with the patient. This care may include but not be limited to:
o Assisting with activities of daily living, including fall risk management and safe patient handling.
o Medication administration
o Skin assessment/wound care
o Pain management
o Operation/manipulation of biomedical and other patient care and testing equipment, including but not limited to infusion pumps, patient transfer equipment, cardiopulmonary monitors, invasive catheters and drains, thermoregulation devices, measurement devices, medication dispensing cabinets, external therapeutic devices.
o Assisting the physician and other licensed, independent practitioners with invasive and non-invasive procedures.
o Teaching patients and their families about current illness, medical tests, medication, general healthcare, illness and disease prevention, and wellness promotion.
o Providing appropriate assignment, supervision, and direction to unlicensed assistive personnel in order to ensure optimum patient care.
o Providing interdisciplinary coordination and facilitation of overall care.
• Documents patient assessments, interventions, care, and teaching in the electronic medical record. Documents in paper format, as necessary. Documentation is complete, concise, timely, and legible.
• Evaluates care provided, communicates patient status and results of care to the interdisciplinary team.
• Proficiently identifies and interprets cardiac rhythm strips; thoroughly knowledgeable regarding cardiac monitoring system and defibrillator functions.
Equipment utilized in the unit/dept.: Bedside barscan of medication. All documentation is electronic (Soarian) except for traumas, codes and some other misc situations.
Shift or schedule requirements: Will not work alone, No call is required, Weekend work is required
Specific training and orientation program: The first day consists of 1/2 a day of partnering with a RN and documentation of Soarian and the second half of the day is shadowing a RN. There is no patient assignment on the first day.