Responsibilities

The Registered Nurse develops patient care standards; assesses the health needs of patients; and plans, implements and evaluates care for surgical patients. The Registered Nurse utilizes specialized knowledge and skills for direct patient care, for teaching patients and staff, and for evaluating the clinical performance of nursing personnel. The Registered Nurse acts as a resource for all levels in the clinical area.

Essential Functions:

• Assesses and monitors the overall needs of patients and family. Ensures that required documentation is performed in an accurate and timely manner.
• Implements accepted standards of documentation on patient electronic medical records and other hospital forms to ensure that information affecting a patient, significant other or member of the healthcare team is properly recorded.
• Assertively communicates concerns, issues and information through appropriate channels.
• Interprets and correlates diagnostic data with physical findings on an ongoing basis in order to assess the patient and plan appropriate intervention.
• Establishes an appropriate plan of care based on adolescent/adult/geriatric assessment and identified problems within 24 hours in order to provide direction for caregivers.
• Initiates discharge-planning process by identifying post-hospital care needs. Collaborates with healthcare team members to meet those needs.
• Evaluates patient response to nursing intervention in order to revise/update the plan of care.
• Recognizes potential and actual emergency situations promptly, and responds within established guidelines to meet the needs of the patient.
• Initiates and maintains correct sponge, needle and instrument counts.
• Opens sterile supplies, maintains counts and implements surgical asepsis and safety precautions.
• Develops a nursing care plan that integrates surgical intervention and anesthesia management using nursing diagnosis.
• Prepares and identifies surgical specimens.
• Ensures placement of electro-surgical grounding pads.