Job Summary: The Registered Nurse of the Acute Care Unit delivers quality nursing care according to the standards within the ANA Standards of Clinical Practice and Maine Nurse Practice Act. Also, demonstrates competence in: nursing assessment, diagnosis, planning, implementation and evaluation; exhibits leadership skills, and teamwork. Promotes patient advocacy, and supports learning needs of staff and students, collaborates with other disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes. Also, supports the organization's vision and mission. Utilizes knowledge of patient's age and culture as well as learning needs in the provision of patient care, maintains organizational and unit requirements, and promotes a collaborative and cooperative environment with emphasis on customer service.
Complete admission assessment and recognize actual and potential health problems.
Admission assessment completed within 8 hours of admission (provisions made/documented i.e. Functional/Cognitive Status).
Complete nursing assessment on assigned patients promptly and adequately, within an hour, to ensure patient safety and continuity of care.
Performs medication list verification upon admission.
Continuously assess patient response to illness intervention and use of critical thinking to problem solve. Document completely and accurately.
Interpret clinical and diagnostic data with evidence of recognition of deviation from norm (differentiate between clinically significant and insignificant data); expedite intervention.
Takes appropriate action when assessment and/or lab and diagnostic data is abnormal or significant.
Prioritize individual patient needs, and document care provided to patient.
Initiate problem list and adjust as patient's needs change, within 24 hours of admission, adjust problem list as goals are met and/or new problems occur.
Support multidisciplinary involvement in the plan of care; communicate with case manager and other disciplines addressing patient needs, problems, and response to interventions, and document interactions.
Administer care according to established nursing standards and hospital policy; actions reflect use of critical thinking, knowledge of nursing science and good judgment.
Complete medically ordered interventions, follow orders when appropriate, withhold actions on questionable orders when seeking clarification in a timely manner. Collaborate with charge level RN/supervisor to seek clarification. Review and update Medact routinely.
Participates in Interdisciplinary Team meetings (IDTs).
Maintain accountability for safe administration of medication and IV therapy according to nursing standards and hospital policy. Administer accurately, following the "5 rights" and any safe medication practices implemented. Patient response observed, reported, and documented. Site observed and site care given as per policy, document appropriately.
Recognizes adverse/critical changes in patient condition and acts appropriately to initiate intervention. Administers supportive care until help arrives, or orders received. Demonstrates correct use of paging and fire alarm system. Able to function (unless medically exempt) as an effective member of the code team.
Recognizes patient Bill of Rights and privacy practices, treating all patients with respect, and compassion.
Ensures that informed consent is obtained prior to procedures, evaluate patient understanding, concerns and issues relating to age, culture and life stage of the patient.
Maintain a current professional Maine Registered Nurse License with no lapse in re-licensing status.
Maintains current BLS and ACLS.
Education, Skills, Experience Requirements:
Maintain accountability for competency in, and willingness to perform in a minimum of two nursing units.
Meet a minimum of 15 hours per year of continuing education (hours submitted to the Health Education Department for recording).
Meet the unit's annual competency training requirements.
Complete Basic Rhythm course within one year.