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...
- Rate: Not Specified
- Location: Santa Rosa, US-CA
- Type: Permanent
- Industry: Finance
- Recruiter: Front Porch
- Contact: Not Specified
- Email: to view click here
- Reference: 2582
- Posted: 2024-06-28 08:05:23 -
- View all Jobs from Front Porch
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