Registered Nurse IOP PHP

Job Duties & Responsibilities:​

• Complete initial assessments and documents as required.

Collect, record, and analyze, within prescribed timeframe, pertinent data for admission

assessment according to Hospital policy, including:

• Patient strengths and limitations that can be addressed in reaching health goals.
• Cultural, spiritual, and ethnic factors that may impact on patient's course of treatment.
• Patient needs that are to be addressed at discharge.
• Medical/physical status.
• History of medication compliance, reactions, and current schedule; and
• Age-specific data regarding the patient's individual needs.

Involve patient's support systems (family, friends) in assessment and documentation

• Observe and document the patient's interaction with family and friends as it is pertinent to the patient's treatment.
• Obtain assessment data from support systems, when appropriate, regarding the patient's history and individual needs.

Act as an advocate for patients

• Explain patient's rights so they can understand and obtain appropriate signatures.
• Provide the patient with information and obtain their signature on necessary consents.
• Act as a patient advocate, use knowledge of patient rights and responsibilities, and protect patient's privacy and confidentiality.
• Assist in patient orientation process.
• Know and employ Hospital policies and procedures regarding unit safety, the necessity of gown/contraband search on admission, and carry out the process in a respectful manner.
• Remain sensitive to individual patient/family stressors upon admission while providing pertinent unit information.

Initiate and update treatment plan and documentation as required

• Participate in planning and modifying the patient's plan of care.
• Evaluate data obtained by others by reviewing patient's treatment plan and multi-disciplinary assessment for assigned patients.
• Participate in care conferences (staffings) and represent the nursing care component of the treatment plan to others at the staffing.
• Develop and interpret plan of care with the patient/family, updating it as indicated.
• Write clear, concise, and obtainable treatment goals on the treatment plan for each problem.
• Review the treatment plan as goals are achieved, changed, or updated.

On an ongoing basis, identify, interpret, and document information collected in nursing

interview, observation, physical assessment and diagnostic data, and confer with other

health care professionals, as appropriate

• Review current lab data and follow-up with doctor.
• Evaluate potential for falls and initiate fall precautions, as indicated.
• Identify potential for self-abuse, suicidality and/or assaultive behavior.
• Develop age-appropriate interventions for the patient's plan of care.
• Assess changes in patient status and document interventions accordingly.

Implement patient care

• Demonstrate safe and correct medication administration by:
• Accuracy in medication administration: right patient, right medication, right dose, right time, and right route.
• Maintaining current knowledge of the medication's purpose and effects for each patient, as demonstrated by correct documentation of medication, as well as observations about responses to medication.
• Accurately transcribing and implementing physician medication orders.
• Maintaining a continual awareness of monitoring the expected and unexpected medication efforts including adverse drug reactions, drug/drug or drug/food interactions, or other unexpected consequences of the medication.
• Regularly conducting and documenting patient education about medications.
• Maintaining current knowledge about new pharmacologic products, including new medications or medications with new uses/therapeutic action.

Identify potential patient care problems, abrupt changes, or impending instability in the

patient's condition, and exercise leadership to intervene appropriately and prevent

adverse patient outcomes

• Use appropriate de-escalation techniques: quiet room; locked seclusion; restraints.
• Re-evaluate safety level.
• Identify alcohol withdrawal syndrome.
• Identify extra pyramidal side-effects/neuroleptic malignant syndrome signs.
• Identify significant cardiac and/or respiratory symptoms requiring immediate medical intervention.

Identify health education needs of the patient/family that will be addressed before

discharge

• Implement age-appropriate teaching interventions to meet these educational needs.
• Document in the patient record and treatment plan.
• Organize patient care activities and interventions according to patient priorities and preferences, needs of the unit, and time constraints.
• Implement patient care based on established care plans, Hospital policies and procedures, and unit standards of care, incorporating the patient's age-specific and cultural needs, as appropriate.
• As requested, and contingent on qualified medical professional (QMP) designation, assure that all admissions, transfers, and other related patient care activities are delivered in accordance with Emergency Medical Treatment and Labor Act (EMTALA) and associated regulatory requirements.
• Adhere to the Nursing department and Hospital's standards of nursing practice and standards of patient care.
• Protect patients, visitors, and staff from environmental hazards by adhering to safety and infection control standards.
• Participate in continuing education and in-service programs to increase clinical competence and to meet professional needs and goals.
• Report information obtained from continuing education programs to unit staff.
• Attend 100% of required in-services, as scheduled.
• Participate in the Performance Improvement program on an ongoing basis.

Assist in the development and implementation of unit standards of care, such as:

• Safety level of patient
• Unit safety/hazardous items
• Kardex

Standard care plans

• Identify problems with unit systems, communication patterns, and unit reso.