The registered nurse, adheres to the rules and regulations of the Massachusetts Board of Registration in Nursing. is primarily responsible for professional performance and direct patient care. The role encompasses nursing assessment, diagnosis, planning, intervention, evaluation, and coordination of care for patients and their families across the health care continuum. The registered nurse is accountable for clinical, educational, quality and fiscal patient care outcomes using the model of care designed by the nursing department and in accordance with established agency policies, procedures, protocols, guidelines and standards of practice.
ESSENTIAL RESPONSIBILITIES / DUTIES:
STANDARDS OF CARE
Consistently and effectively utilizes all steps of the nursing process in the provision of timely, safe, efficient and appropriate patient/centered care.
- Assesses the patient and family in a systematic and ongoing manner for both overt and covert signs and symptoms in accordance with the standards of clinical nursing practice.
- Collects pertinent data using appropriate assessment techniques.
- Prioritizes data according to the patient’s immediate condition or needs.
- Involves the patient, family/significant others and appropriate health care providers in the collection of data when appropriate.
- Consistently uses clear, concise and effective written/oral communication and complies with departmental policies when sharing/documenting relevant patient care data.
- Identifies emergency/crisis situations, communicates such in a timely manner to appropriate health care team members, and responds appropriately when needed.
Analyzes the assessment data to determine appropriate nursing diagnoses.
- Demonstrates use of critical thinking skills, derives and documents appropriate diagnoses from patient and family assessment data.
Identifies expected outcomes individualized to the patient.
- Derives and documents realistic, appropriate clinical and educational patient-centered outcomes consistent with patient’s diagnoses, capabilities and expectations in accordance to the standards of clinical nursing practice.
- Develops outcomes as measurable goals which include a time estimate for attainment and provides direction for continuity of care.
- Mutually formulates outcomes with the patient, significant others and health care team when appropriate.
Develops a plan of care that prescribes interventions to attain expected outcomes.
Develops and documents an individualized plan of care that reflects the patient’s condition, prioritizes his/her needs, and provides for continuity of care.
- Develops the plan with the client, significant others and appropriate health care providers.
- Develops a plan reflective of current nursing practice standards, policies, procedures, protocols and guidelines.
- Plan reflects effective use of available resources and appropriate internal/external referrals in order to provide comprehensive care to patients and families.
Implements interventions identified in the nursing and medical plan of care.
- Prioritizes patient care interventions based on fluctuating patient and unit needs.
- Demonstrates the knowledge and skills necessary to provide care appropriate to the age groups of patients regularly served. Consults appropriate resources when patients outside regularly served age populations are present.
- Effectively delegates appropriate patient care activities to co-workers with appropriate knowledge and skill level and ensures that co-workers have completed the delegated tasks in a timely manner.
- Provides for a safe, clean unit environment through use of appropriate risk management practices, e.g. labeling and removing broken/expired equipment/materials from service.
- Demonstrates safe technical competence based on patient needs, including but not limited to direct care skills, e.g., phlebotomy, IV insertion, etc., informatics, and equipment monitoring/utilization.
- Implements patient care interventions/treatments and administers medications in accordance with established practice standards, policies, and protocols.
- Educates patient and family regarding current illness, procedures, treatments, plan of care as well as health maintenance, promotion, and illness/injury prevention.
- In emergency/crisis situations, demonstrates effective decision making in accordance with standards of clinical nursing practice, re-prioritizes patient care needs, initiates appropriate response actions, and directs other team members to ensure a complete and coordinated response.
- Documents interventions according to departmental policy.
Evaluates the patient’s progress toward the attainment of clinical and educational outcomes.
- Conducts systematic and ongoing patient reassessments and evaluations.
- Evaluates the effectiveness of interventions in relation to desired outcomes and includes the patient, significant others and appropriate health care providers in the evaluation process as needed.
- Demonstrates use of critical thinking skills through the incorporation of ongoing assessment data in the revision of diagnoses, outcomes and the plan of care.
- Provides follow-up care in person via home visits and via telephone when needed and when appropriate.
- Documents patient’s response to interventions as well as revisions in diagnoses, outcomes and plan of care according to departmental policy.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).