RN - ER

## Description

**Primary Purpose**: To provide quality Patient care following the standards using the nursing process in order to maintain a safe environment to provide patient and family education and to provide proper documentation for billing. Perform other duties as assigned.

**Formal Policy-Setting Responsibilities:** No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.

**Routine Decision Making**: Alterations in patient assessment; determines patient educational requirements; determines when to contact the provider.

**Formal Supervisory Responsibility:** No formal supervisory responsibility.

**Unusual Working Conditions**: Risk of blood, body fluid contamination. Risk of injury related to poor body mechanics. Risk for injury from aggressive, combative or disoriented patients. Potential exposure to hazardous drugs and chemicals.

**Age Specific Competencies:** May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs.); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

**Essential Responsibilities and Tasks**

**Performs the assessment phase of the nursing process.**

• Assesses all assigned patients at start of shift and as needed.
• Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four (4) hours of arrival to the Medical Surgical unit.
• Assesses data relative to age specific needs for every patient within four (4) hours of patient’s arrival to the unit, at start of shift and as needed.
• Repeats assessment and documents on abnormal patient findings at least once and as needed during shift.
• Assesses patient/family learning needs within four hours (4) of arrival to the unit, start of shift and as needed.
• Completes appropriate pain assessment at start of shift and as needed.
• Assesses the patient's and family's learning needs every shift and as needed.

**Performs the planning phase of the nursing process.**

• Completes an individualized care plan based on patient diagnosis and assessment with each admission and as needed.
• Reviews and updates care plan each shift and as needed.
• Collaborates with interdisciplinary team to facilitate the plan of care after the provider writes orders.
• Interprets significance of abnormal patient findings after assessing patient on admission and as condition changes.
• Updates white boards each shift, to include personalized patient goals and pain control.
• Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.

**Performs the implementation phase of the nursing process.**

• Implements patient care through team approach each shift and as needed.
• Documents and reports significant abnormal patient findings to the charge nurse/provider/manager immediately.
• Is knowledgeable of location, care and operation of Medical Surgical equipment each shift.
• Acts rapidly, effectively and manages self and others during emergency situations.
• Administers IV's and medications as ordered within one (1) hour of time scheduled according to the five rights on every patient.
• Ensures all provider orders are correctly recorded on EMAR and in computer when acknowledging each order.
• Accurately and correctly wastes used portions of controlled substances within a timely manner.
• Performs narcotic count according to hospital policy.
• Attaches patients name band, fall risk, allergy band etc. immediately after patient’s arrival and upon bands being removed.
• Ensures fall protocol is followed on each patient.

**Performs the evaluation phase of the nursing process.**

• Evaluates each assigned patients’ response to care each shift and as needed.

**Provides patient and family education.**

• Provides patient and/or family's education based on assessments and re-assessments each shift and as needed.
• Uses terminology appropriate to patient/family's knowledge base and age specific needs each shift.
• Re-assesses patient and family's learning needs and abilities each shift and as needed.
• Documents education provided including subject taught, method of teaching, who was taught, comprehension of information each shift.
• Provides and documents patient and family follow-up instructions at discharge.

**Demonstrates accountability to the nursing process through documentation.**

• Documents assessments at least every shift and as needed.
• Documents according to the plan of care at least once per shift and as needed.
• Documents clearly the implementation of specific intervention, including details of methods used, with the time of implementation and evaluation of patient response.
• Utilizes only approved abbreviations in patient documentation each shift.
• Documentation follows hospital and departmental policies for frequency and content.

**Maintains a safe and comfortable unit.**

• Ensures alarms on any assigned areas are audible to alert staff, each shift.
• Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem.
• Completes a requisition for repair and sends electronic work request before the end of the shift, pass on any issues to the next shift for follow up and provides a copy to the manager before the end of shift.
• Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification.