Registered Nurse

Spring Lake Village

Summary: Shift RN

The Staff Registered Nurse (RN) functions independently in performing nursing care through assessment, planning, intervention and evaluation of safe therapeutic care for patients' overt and covert needs and/or complications of treatment during his or her assigned shift.

Also leads and directs ancillary members of the health care team.

Responsibilities:

• Completes appropriate written history/assessment on residents' clinical record within 4 hours of admission, including details from interviews with family, responsible parties and other nurses and physicians.

• Legibly documents symptoms that indicate risk on the clinical record; incorporates nursing diagnostic data into written assessments.

• Documents information from family, other nurses and physicians in the written assessment.

• Prepares documents reflecting knowledge of expectations included in the Minimum Data Set (MDS); contributes in an appropriate and timely manner to the MDS.

• Documents identified problems; develops and contributes to the care plan using nursing diagnosis; adds resident teaching needs and discharge planning to clinical records.

• Uses resources and involves resident and/or family when formulating a written plan of care.

• Incorporates the medical plan into the interdisciplinary plan for care.

• Updates the Kardex and care plans using nursing diagnosis and outcome criteria.

• Follows time frames when carrying out medical/nursing plan of care.

• Communicates changes and responses to care in shift report.

• Documents and sets priorities for care of residents based on need and resident preference.

• Safely performs and documents nursing interventions required by the resident assignment and consistent with scientific principles and facility policy.

• Carries out and documents medical and nursing care plans for residents; coordinates resident care activities with other members of the healthcare team.

• Responds to information or data indicating acute risk to resident; initiates and documents action to reduce or correct the risk.

• Explains tests, procedures and disease progression to resident and/or family.

Instructing and informs resident or family of skills essential to understand and cope with illness and to promote optimal health or, if indicated, the discharge process; assesses and records family level of understanding on the clinical record.

• Ensures that resident is reassessed as status requires.

Documents resident response to care in clinical record.

• Regularly evaluates effectiveness of nursing intervention per the intended goals; revises care plans accordingly.

• Participates in resident care conferences.

• Provides formal and informal teaching activities to promote staff education and knowledge.

• Communicates identified learning needs of others to resources able to meet learners' needs.

• Assists in orientation of new staff; shares knowledge, experiences a...