Cheyenne Regional Medical Center
Cheyenne, WY, USA
ROLE SUMMARY The Registered Nurse assesses, plans, implements, evaluates and supervises individual patient care according to unit policies and procedures. Accepts responsibility for direction of co-workers in the implementation of care plans. May be required to work on other units according to distribution of staff and patients. CORE RESPONSIBILITIES Completes nursing assessment of patient and documents appropriately into patient chart. Develops and reviews and revises a plan of care, including a discharge plan, based upon the assessment of patient's needs. Implements medical and nursing orders per plan of care and documents appropriately. Evaluates patient's response to care. Engages in patient and family teaching as appropriate. Oversees staff assigned for providing patient care. Collaborates with leadership to assure the integration of the ANA’s Scope & Standards of Practice, assuring that these standards are identified as the measurement criteria for nursing practice on the unit. Unit specific orientation and ongoing training and competencies are assigned based on department role, scope of services, and organizational standards. Documents training and competencies in electronic format. DEPARTMENT/ROLE SPECIFIC RESPONSIBILITIES CHARGE NURSE: Responsible for coordination of patient care in collaboration with physicians and ancillary departments to achieve quality outcomes. Facilitates immediate and direct complaint intervention and resolution. Participates in ongoing evaluation of patients, assuring efficiency of communication with patients, follow-up and flow through the system. Performs daily rounds on the floors to assess patients and possible critical situations to determine patient care needs and outcomes. Assists in the identification and management of staff, patient, and family educational needs. Oversight of charging and documentation accuracy, including review and analysis of effectiveness of nursing interventions. Possess the authority to send employees home in the interest of safe patient care. ARU/TCU: Attends family conferences, patient care Conferences, and daily stand up meetings. CARE CLINIC, SAME DAY SURGERY, and PACU: Collaborates with the Clinical Nurse Manager to assure integration of ASPAN’s Standards of Perioperative Nursing Practice. CLINICAL EDUCATION: Instructs Nurse Residency or clinical certification classes as directed by the program director. Deliver clinical curriculum utilizing various methods. FORENSIC NURSING: Provides timely, non-judgmental, compassionate care to victims of trauma and violence, to include but not limited to Intimate Partner Violence, Child Abuse, Strangulation, Elder Abuse and Sexual Assault and Abuse. Follows established forensic nursing protocols. Triages and assesses patients, provides prophylaxis for pregnancy and STI’s, coordinates medical and psychological care, provides advocacy, community resource and law enforcement referrals. Performs complete head to toe physical, document patient history, collect forensic evidence including photographic documentation. Be available for call coverage according to forensic nursing protocol. Maintains forensic nursing competences and participate in quality assurance projects, community education and peer review. HOSPICE: Serves as patient case manager and focuses specifically on the physical, spiritual, and emotional needs of the patient and family in a nurturing and supportive role. Attends the first available hospice volunteer training after acceptance of employment. HOSPITALIST: Integrates health care for clients from pre-admission to post-discharge. The nurse functions in structured and unstructured health care settings. The nurse utilizes independent nursing judgment when integrating health care. Will have knowledge of and utilize appropriate age-related patient care protocols relating to the physical and psychological needs of adult and geriatric patients. MEDICAL IMAGING: Procedural Nurse: Provides IV moderate sedation and pain relief. Assists with biopsies, the placement of drains for abscesses, and the insertion of chest tubes. May assist with Peripheral Runoffs, PAS port placements and removals, Nephrostomy/Biliary tube placements, AV Fistulograms with and without angioplasty, IVC Filter placement and removal, Discograms and thrombolytic infusion therapy. VASCULAR ACCESS NURSE: Hard stick IVs, ultrasound guided IVs, PICC insertions, mid-line insertions, port accesses, and dressing changes. RESOURCE POOL: Floats within designated pod and clinical specialty. The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned. SKILLS, KNOWLEDGE, AND ABILITIES Demonstrates effective leadership and professional skills according to Standards of Care. Ability to assess a patient’s condition, formulate plan of care, select appropriate interventions, evaluate patient’s response to plan of care and to explain to patient/family about this process. Ability to assess, evaluate, explain, teach, problem solve using critical thinking; and perform calculations. Demonstrates excellent professional and clinical skills and utilization of the Nursing process of direct and indirect patient care which includes assessment, planning, implementation and evaluation of nursing care to meet patient needs and improve patient outcomes.