Must have an Active Registered Nurse license in the State of Texas
Available Shifts: PRN All Shifts (6am-2pm, 2pm-10pm, 10pm-6am)
Position Summary:
To plan and deliver nursing care to patients/residents requiring long-term care or rehabilitative care.
Essential Duties and Responsibilities:
Works using the guidelines established from the Nurse Practice Act, facility Policy and Procedures, use of your nursing judgement.
Assess, plan and evaluate nursing care delivered to patients/residents requiring long-term or rehabilitation care.
Implement the patient/residents plan of care and evaluate the patient/resident’s response.
Directs and supervises care given by other nursing personnel.
Provide input in the formulation and evaluation of standards of care.
Maintain knowledge of necessary documentation requirements.
Maintain knowledge of equipment set-up, maintenance and use (i.e. monitors, infusion devices, drain devices, etc.).
Maintain confidentiality and patient/resident rights, regarding all patient/resident and personnel information.
Provide patient/resident, family/caregiver education as directed.
Initiate emergency support measures (CPR, protecting patients/residents from injury)
Assessment:
o Admission and routine resident observations/transfer notes are complete and accurately reflect the patient/resident’s status
o Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
o Nursing history is present in the medical record for all patients/residents
o Assessment identifies changes in the patient/resident’s physical or psychological condition (Changes in lab data, Vital signs, mental status).
Planning of Care:
o Nursing care plans are initiated/reviewed/individualized on assigned patients/residents monthly and PRN.
o Pertinent nursing problems are identified.
o Goals are stated.
o Appropriate nursing orders are formulated.
Evaluation of Care:
o the effectiveness of nursing interventions, medications, etc. is evaluated and documented in the progress notes.
Care Plans:
o Evaluation of care plan is noted monthly or as indicated.
o the care plan is revised and indicated by the patient/resident’s status.
General Patients/Resident Care:
o Patient/Resident is approached in a kind, gentle, and friendly manner. Respect for the patients/resident’s dignity and privacy is consistently provided.
o Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
o Independence by the patient/resident in activities or daily living in encouraged to the extent possible.
o Treatments are completed as indicated.
o Safety concerns are identified and appropriate actions are taken to maintain a safe environment.
o Assist/Grab-bars and height of bed are adjusted.
o Patient/Resident call light and equipment is within reach.
o Restraints, if ordered by a Physician, are maintained properly.
o Rooms are neat and orderly.
Functional assignments are completed.
Emergency situations are recognized and appropriate action is taken.
All emergency equipment can be readily located and operated (Emergency Oxygen Supply, Drug Box, Fire Extinguisher, AED/Crash Cart, etc.)
Patient/Resident Education/Discharge Planning:
o the patient/resident and family are involved in the planning of care and treatment (documented on the plan of care).
o Patient/resident and/or family are provided with information related to all intervention and activities as indicated.
o Discharge/Death summaries are complete and accurate.
o Transfer forms are complete and accurate
o Active participation in patient/resident care management is evident
Adherence to Facility Procedures:
o Facility procedure manuals or reference materials are utilized as needed.
o Procedures are performed according to methods outlined in procedure manual.
o Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
o Safety guidelines established by the facility (i.e. proper needle disposal) are followed.
Documentation:
o the patients/resident’s full name and room number are present on the chart forms. Allergies are noted on the chart cover.
o Only approved abbreviations are utilized.
o TPR graphic is completed properly and timely
o I&O summaries are recorded and added correctly
o Blood pressure graphic is completed accurately and timely
o Progress notes are timed, dated and signed with full signature and title
o Unit flow-sheets are completed properly (i.e., Wound Care Records, Treatment Records, IV Therapy Record, etc.)
Medication Administrations/ Parenteral Therapy Record
o Dates that medications are started or discontinued are documented
o Medications are charted correctly with name, does, route, site, time and initials of nurse
o Pulse and BP are obtained and recorded when appropriate
o Medications not given are circled, reason noted and physician notified if applicable
o Appropriate notes are written for medication not given and actions taken.
o Name and title of nurse administering medication are documented
o Patient/residents medication records are labeled with full name, room number, date and allergies.
o the procedure for administration and counting of narcotics is followed
o All parenteral fluids are charted with time and date started, time infusion completed, sit of infusion and signature of nurse.
o All parenteral fluids are administered according to the ordered infusion rate.
o Parenteral intake is accurately recorded on the unit flow sheet or I&O record.
o IV sites are monitored and catheters changed according to unit policy
o IV bags and tubing are changed according to unit policy
o Appropriate actions are taken related to identified IV infusions problems (infiltration, phlebitis, poor infusion, etc.) policy
Coordination of Care:
o Tests are scheduled and preps are completed as indicated
o Co-workers are informed of changes in patient/resident condition or of any other changes occurring on the unit.
o Information is relayed to the member of the Health Care Team (i.e. physicians, respiratory therapy, physical therapy, social services, etc.)
o Unit activities are coordinated (i.e. changing patients/residents’ room for Admission Coordination transfer/discharge forms, etc.)
Leadership:
o Equitable care assignments are made prior to shift that are appropriate to patient/resident’s needs
o Staffing needs are communicated to the nursing supervisors
o Assistance, direction, and education is provided to unit personnel and families.
o Problems are identified, data is gathered, solutions are suggested, and communications regarding the problem is appropriate.
o Transcriptions of all orders is checked
o All work areas are neat and clean
Communication:
o Change of shift report is complete, accurate and concise.
o Incident reports are completed accurately and in a timely manner.
o Staff meetings are attended, if on duty, or minutes read initialed if not on duty.
Cost Awareness:
o Supplies are used appropriately
o Charge stickers (or charge system) are utilized appropriately
o Minimal supplies are stored in resident room
o Discharged medications are returned to the pharmacy or destroyed in a timely manner
o Floor-stock medications are charged and re-stocked
o Participates in the identification of staff educational needs.
o Serves as a preceptor, as delegated, for new staff
o Maintains patient/resident care supplies, equipment and environment
o Participates in the development of unit objectives
o Participates in the quality assessment and improvement process and activities.