RN - PRN

Reference #: 5001014087406

RN - PRNPOSITION SUMMARY: As a member of the Interdisciplinary Care Team (IDT), the Registered Nurse (RN) performs physical assessments and completes health histories; monitors the physical and psychological health of the client; interprets patient information; and makes critical decisions about needed actions. This nurse collaborates with the physician and other healthcare providers and educates clients, families, and staff.

This nurse practices within the scope of Pennsylvania's Nurse Practice Act and in accordance with Elwyn's policies and procedures and those of Elwyn's regulatory agencies.

DUTIES AND RESPONSIBILITIES

Complete a comprehensive nursing assessment upon admission/readmission and as changing health needs indicate

Complete a Quarterly Nursing Assessment every three (3) months that includes a review of systems, full body exam, skin checks, Braden Scale, and Fall Risk Assessment

Provide direct nursing care and clinical oversight of care delivery

Upon discharge, complete a Discharge Summary that includes all relevant medication, medical follow up, and pertinent health care information to provide for continuity of care

Present clinical data obtained through direct observation, interview, physical assessment and other reports to the IDT members; present information in a concise and organized manner

Set daily priorities in accordance with professional nursing judgment

Develop a health care plan for clients requiring 24/7 nursing care that will include specific nursing goals and directions for meeting the client's health care needs

Review and revise the health care plan at a minimum of every 90 days and incorporate data gathered through nursing assessments and communication with the IDT

Collaborate with Day and Work Services to ensure that the health care needs of the client are communicated and the necessary documentation forwarded

Collaborate with physicians, physical rehabilitation professionals, therapists, health care professionals and other members of the IDT to plan and implement the therapeutic program of care

Refer clients to physicians when assessment indicates further medical evaluation is required; facilitate transfer to the hospital/Emergency Department as needed

Complete hospital and Emergency Department transfer sheets including coping and forwarding the annual physical exam, last set of 90 Day Physician Orders, current Medication Administration Records (MARs), and other pertinent information to the receiving facility

Monitor weight and blood pressure measurements at a minimum of monthly and more frequently as indicated by nursing judgement or physician orders

Administer enteral tube feedings, blood glucose testing, nebulizer treatments, and skin care as ordered by the physician; use discretion during administration to provide as much client privacy as possible

Prepare and administer medication as ordered by the physician in accordance with Elwyn's medication policies and procedures; obtain verbal orders when necessary and transcribe the information as per policy

Document administration of prescribed medications and treatments on hard copy MARs or in an electronic format (eMARs); use discretion during administration to provide as much client privacy as possible

Instruct direct care staff on the administration and documentation of specific treatments including but not limited to topical creams and other over the counter (OTCs) agents

Evaluate the therapeutic effectiveness of medications and treatments and report any observed side effects and relevant laboratory values to the Health Care Coordinator/Charge Nurse; Contact the physician as directed

If using hard copy MARs, review the monthly MAR and validate that all medication and treatment orders are correct and update as needed; remove old MARs from the medication binder and replace with new MARs at the start of every month

Assess client progress with the self-administration of medication and work to actively promote increased independence in client function; assist with data collection related to medication goals

Complete monthly medication exchanges with the pharmacy provider; immediately reconcile identified issues

Administer and document immunizations as ordered by the physician; ensure that necessary consents have been completed prior to administration.

Prepare clients for medical appointments through communication and maintenance of NPO (nothing by mouth) status, procedural preps, and the administration of pre-sedation medication

Validate that all lab work has been completed as scheduled and document in the nursing progress note; if not completed, schedule follow up and document

Document all behavioral and physical changes in the client's status and other pertinent information in the nursing progress notes; document all changes from baseline status; document effectiveness of prescribed behavioral interventions and nursing actions

Contact family members/guardians to report any new injuries that require more than basic First Aid or as otherwise requested by the family

Communicate health issues to staff in the program's Alert Log

Document all relevant information in the MAR, nursing progress notes, and 24 Hour Change in Status Report

Communicate all pertinent client and unit information to the incoming nurses through written reports

Provide significant clinical and informational updates to the Charge Nurse throughout the shift; contact the Charge Nurse by phone (1) hour prior to the end of the shift to provide verbal report

Contribute nursing knowledge to the development and maintenance of a safe and therapeutic living environment; inspect the general living areas for present and potential hazards and report to the Unit Director, Health Care Coordinator, or Charge Nurse

Monitor for potential infectious disease among clients and staff and report to the Health Care Coordinator/Charge Nurse who will then report to the Director of Nursing, Campus

Provide response to emergencies and oversight of medical issues in the role of Charge Nurse as assigned

Provide clear and concise direction to Elwyn staff during a medical emergency and direct medical care provided; transfer care to the Emergency Medical Technicians (EMTs) upon their arrival

Order medical and nursing supplies for assigned unit; restock supplies upon arrival

Maintain medical equipment in proper working order in each assigned medication dispensary; clean equipment at least monthly and facilitate equipment repair as necessary

Assist with the training and orientation of new nursing employees

Provide nursing coverage to all units as needed; demonstrate flexibility, adaptability, and team work when nursing assignments must be modified

In the absence of the Health Care Coordinator, provide nursing leadership to the unit staff for medical issues that arise including but not limited to seizure episode, 26666 call, falls,

Ensure timely reporting of all injuries or occupational exposures to blood, body fluids, infectious materials and hazardous chemical in accordance with the facility's policies and procedures and OSHA guidelines; collaborate with Risk Management as needed

Adhere to Elwyn's policies and procedures related to HIPAA and the disclosure of health protected information

Complete all Elwyn mandatory educational requirements by the annual due date

Attend nursing meetings and in-services as required

Perform cardiopulmonary resuscitation (CPR), and crisis intervention using agency-trained protocols

Submit new/current Nursing License, CPR card, Driver's License, physical exam, and contact sheet on or before t