Registered Nurse
Department: Nursing
Reports To: CNO/Nurse Manager

Summary

The Registered Nurse (RN) is responsible for the health and well-being of patients assigned to their care. Utilizing critical thinking and decision-making skills, the RN supervises nursing staff (including paramedics, LPNs, nurse aides, unit clerks, etc.) during their shift. The RN provides medical/surgical and emergency nursing care to patients in accordance with Kimball Health Services policies and procedures. The RN works under the direct supervision of the Charge Nurse and is supervised by the Nursing Department Manager and the Chief Nursing Officer (CNO).

Essential Duties and Responsibilities

Includes but is not limited to:

General Patient Care:

• Review patient charts and become familiar with orders including medications, lab results, radiology orders, activity, diet, and consultation orders.
• Be knowledgeable regarding the patient's discharge plan.
• Ensure all ancillary nursing services (e.g., am/pm care, bathing, linens changed, daily weights, etc.) are completed.
• Explain procedures and treatments to patients, ensuring understanding and cooperation.
• Serve as a patient advocate by clarifying communications from hospital personnel.
• Follow all Universal Precautions and Blood-borne Pathogen protocols as outlined by hospital policy.
• Initiate isolation precautions as needed for patient, staff, and visitor safety.
• Ensure the availability of necessary supplies in nursing areas.
• Provide emotional and physical comfort and safety for patients and visitors.
• Respond to life-saving situations based on nursing standards, policies, procedures, and protocols.
• In the Emergency Room (ER), coordinate and implement appropriate protocols based on triage assessment.
• Conduct Mental Status Examinations (MSEs) when necessary.

Documentation:

• Begin the shift by receiving and attending report from staff who have worked the previous shift. Ask questions for clarification as needed.
• Document patient assessments, noting changes in condition, vital signs, weight, and level of consciousness. Report concerns directly to the provider on call.
• Review charts to verify medication orders, lab requests, radiology orders, and consults to ensure accuracy and completion.
• Verify and document medical providers' orders.
• Complete paperwork for new admissions, including signed consents, complete history, documentation of patient belongings, and orientation to room and nursing floor routines.
• Give a report to the oncoming shift that includes patient identifiers, assessment, situation (e.g., code status, recent changes), safety issues (e.g. Allergies, fall risks), background, and the next steps in the care plan.
• Ensure accurate and timely submission of billable supply charges to the administration office.

Medication Administration:

• Review the Medication Administration Record (MAR) to plan the shift's work and when medications are due for assigned patients.
• Administer prescribed medications and treatments according to approved nursing techniques.
• Ensure accurate narcotic count at the end of each shift.

Patient Assessment:

• Perform a complete physical assessment on each assigned patient at the beginning of the shift. Note changes in condition and notify the medical provider as necessary.
• Assess the patient’s room for safety issues or needed equipment (e.g., bedside commode, water glass, denture holder, etc.).
• Create or follow the Nursing Care Plan, including a patient education plan.
• Monitor the patient at least hourly for changes in condition and maintain awareness of comfort and safety needs.
• Report any changes in patient condition during the shift to the medical provider, patient care coordinator, and Charge Nurse.
• Triage patients presenting to the ER and determine the appropriate protocol.

Clinical Expertise and Staff Support:

• Share knowledge with staff and students as appropriate. Assist with orientation and education of new staff.
• Demonstrate critical thinking skills when making decisions that impact patients, families, staff, and others involved in patient care, considering how decisions will affect future shifts.

Supervisory Responsibilities

• Provide direct supervision of nursing staff during the shift.
• Utilize critical thinking skills to allocate staff and resources effectively.
• Assist nursing administration in ensuring appropriate staff coverage for future shifts according to staffing policies.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Education and/or Experience:
  • Graduate of an accredited Registered Nurse program.
  • Completion of or willingness to attend and complete Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Trauma Nurse Core Course (TNCC), Pediatric Advanced Life Support (PALS), and other relevant training as needed.
• Customer Service Skills:
  • Ability to communicate effectively, both verbally and in writing, with diverse individuals and groups from various cultural and social backgrounds.
  • Recognize, anticipate, and respond to the needs of customers in a caring, respectful manner, leading to satisfactory resolutions.
  • Relay pertinent information through appropriate documentation and communication to other health care providers.
  • Interact professionally with patients, families, directors, and nursing or medical staff, representing Kimball Health Services positively.
• Language Skills:
  • Must be able to read and write English, interpret safety rules, operating instructions, and procedure manuals, and write routine reports and correspondence.
  • Document clearly and effectively in patient charts using appropriate medical terminology and abbreviations.
  • Must be able to give verbal reports with relevant and accurate information to other health care providers.
• Mathematical Skills:
  • Ability to perform basic math operations (addition, subtraction, multiplication, and division) in all units of measure.
  • Ability to compute rates, ratios, and percentages and interpret bar graphs.
  • Complete drug calculations 
• Reasoning Ability:
  • Ability to define problems, collect data, establish facts, and draw valid conclusions.
  • Ability to identify the impact of decisions on others and interpret technical instructions in mathematical or diagram form, managing both abstract and concrete variables.
• Certificates, Licenses, Registrations:
  • Licensed Registered Nurse in the state of Nebraska without restriction.
  • Certification or ability to become certified in BLS, ACLS, PALS, and TNCC.

    

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Regularly required to stand, walk, sit, use hands to handle or feel, reach with hands and arms, climb, stoop, kneel, crouch, crawl, talk, hear, and taste or smell.
• Must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move up to 50 pounds.
• Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Occasionally exposed to moving mechanical parts, fumes or airborne particles, risk of electrical shock, radiation, physical abuse by patients, and infectious diseases.
• Noise level is usually quiet in the work environment.

HIPAA Compliance

As part of a federally mandated HIPAA compliance plan, the access classification for this job is:

• Unrestricted Access:
       A workforce member with unrestricted access will have full access to protected health information, including a patient’s entire record for accomplishing intended purposes.