Registered Nurse Rehab

Position Responsibilities

• Successfully completed FIM Training program.
• Understands functional activities of daily living and is able to assess level at which patient performs specific activity.
• Doubles as a caregiver, documenting the patients level of function in terms of level of assistance needed.
• Able to provide education on rehab equipment.
• Able to provide education on safety precautions for patients with post hip surgery, knee surgery, back surgery, and CVA.

Assessment

• Performs initial vital signs and admission history to include introduction to patient and family.
• Assesses patient education needs on admission and daily.
• Assesses psychosocial needs specific to patient's age, growth, and development.
• Performs an accurate systems assessment at the beginning of each shift.
• Responds to diagnostic data and initiates appropriate action or intervention.

Planning

• Initiates an interdisciplinary plan of care within eight hours of admission.
• Establishes priorities for patient care based on patient needs as evidenced by completion of assigned duties within shift.

Implementation

• Verbalizes understanding of patient diagnosis and interdisciplinary plan of care.
• Safely and correctly initiates and documents nursing interventions in emergency situations.
• Performs 24-hour chart check at the beginning of each shift.
• Administers, observes, and documents intravenous therapy according to hospital policy.
• Administers medications within 30 minutes of scheduled time, observes and documents effectiveness, recognizes and reports adverse reactions immediately.
• Provides individualized instructions each shift to patient/significant other regarding the plan of care.
• Demonstrates safe and correct use of unit specific equipment.
• Ensures that each patient's general hygiene needs are met daily.
• Performs pre-operative and post-operative care and instruction for each assigned surgical patient during shift.
• Adheres to standard precautions including hand hygiene guidelines at all times.
• Documents specific patient valuables on designated form when received and immediately arranges for appropriate storage.
• Performs dressing changes using aseptic technique.
• Collections and labels specimens per policy when ordered by physician.
• Performs bedside glucose monitoring according to policy.
• Administers internal feedings via ng tube, g tube, and/or j tube.
• Reports all abnormal findings immediately to physician.
• Initiates wound and skin protocol upon identification of risk.
• Inserts intermittent or indwelling urinary catheter using aseptic technique.
• Administers oxygen therapy according to physician order.
• Transfers patients in/out of the unit in an efficient manner, by obtaining a complete and correct set of physician's orders.
• Completes documentation of transfer summary.
• Ensures appropriate completed referral forms accompany intra-facility transfers including giving/receiving of report.
• Demonstrates safe and correct use of restraints.

Evaluation

• Documents/reports patient responses or outcomes resulting from: nursing interventions, treatments/procedures, interpersonal interactions, and patient/family education.
• Evaluates and documents patient's progress towards established goals/objectives every shift.
• Updates/revises patient care problem list and individualized patient care standards based on patient/family responses, progress towards goals, and/or change in medical status every shift.
• Evaluates patient length of stay and related transfer/discharge planning needs based on anticipated problems, internal or community resources, and support systems.

Professional and Staff Development

• Obtains 100% of mandatory hospital and unit specific inservices annually, prior to evaluation date.
• Plans, presents, and documents unit inservice as required by level.
• Documents competency in clinical skills annually.
• Attends staff meetings as required.
• Uses established lines of communication for resolution of problems and interpersonal conflict.

Leadership

• Presents a minimum of 1 in-services and 2 patient care conferences.
• Attends 75% staff meetings.
• Functions as a Charge Nurse, possesses clinical knowledge of all patients on the unit, triage and assign beds to promote patient flow.
• Attends a Charge Nurse course.
• Serves as preceptor/clinical resource.
• Actively participates in unit based PI.