REGISTERED NURSE I ID-7797

DEFINITION:
This class provides professional nursing care and services to patients in a variety of settings.

CLASSIFICATION STANDARDS:
Positions allocable to this class typically report to higher-level nurses or providers. Incumbents apply recognized nursing principles and practices in providing professional nursing care and/or services under close supervision in a variety of settings. Duties are performed in accordance with specific instructions, departmental policies and procedures and established general written standards of nursing care. Positions are responsible for assessing, planning, implementing, and evaluating care as part of an interdisciplinary team. Incumbents serve as professional role models and may provide direction to others.  Nursing practice at this level demonstrates the application of basic assessment skills; independent judgment and action; and adherence to patient privacy, confidentiality, and security guidelines.

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Essential Job Functions

  • Follows established policies and procedures within their scope of practice.
  • Complies with licensing and accreditation standards and other regulatory requirements.
  • Conducts self-assessment of performance and identifies own learning needs.
  • Consistently seeks assistance and feedback regarding patient and clinical practice issues.
  • Accepts personal accountability and demonstrates initiative in continuing to develop nursing knowledge and skills.
  • Communicates and collaborates effectively as a member of an interdisciplinary healthcare team as needed.
  • Participates in patient care conferences, committee meetings, staff development, and education programs to increase or maintain professional competency.
  • Seeks experiences that reflect current clinical practice to achieve and enhance professional and clinical skills and competencies.
  • Remains up-to-date on current professional skills, trends, and issues.
  • Participates in performance improvement activities.
  • Maintains courteous and respectful relationships with patients, families, and co-workers.
  • Provides care in a non-judgmental, non-discriminatory manner.
  • Respects patient rights; adheres to and protects patient privacy, confidentiality, and security guidelines.
  • Completes and maintains accurate and legible documentation and records in a clear, concise, and timely manner.
  • Reports and may intervene in incidents involving patients, visitors, or employees.
  • Delegate, assign, and/or supervise the assigned work of others including Licensed Vocational Nurses (LVNs), nursing attendants, technicians, clerical staff, and students, as needed.
  • Participates in approved clinical investigations or research studies in accordance with departmental policies, as needed.
  • Participates in product evaluation and product standardization activities, as needed.
  • Participates in organization-wide committees and projects, as needed.

Assessment/Reassessment: An ongoing process which is continuous for the duration of the patient's stay. 

  • Interviews patient and other individuals to collect information. 
  • Observes physical condition including physically examining the patient.
  • Identifies economic, educational, and cultural barriers; patient values and beliefs; spiritual influences; and age specific and biophysical needs according to accepted standards of practice.
  • Reviews all available information, including medical records, patient history, and other documentation.   
  • Documents all findings and observations.
  • Initiates reassessment of patients as necessary when a patient is currently or potentially at physiologic, psychological, and psychosocial risk.
  • Recognizes deviations from baseline and interprets subtle changes in a patient's condition.

Planning: 

  • Formulates nursing care plans based upon assessment and in accordance with provider orders, procedures and/or protocols.
  • Identifies nursing care objectives.
  • Prioritizes patient care needs and activities as a member of an interdisciplinary patient care team.
  • Coordinates patient care in collaboration with other interdisciplinary patient care team members.
  • Establishes patient goals and treatment plans.
  • Modifies plans of patient care based on reassessment findings, specific patient care needs, and/or changes in interdisciplinary treatment plan. 
  • Assists in discharge planning needs.
  • Identifies appropriate tools and/or teaching methods for patient/family education.  

Implementation: 

  • Provides individualized and specialized nursing care and administers medications and treatments to patients as prescribed.
  • Observes patient's response to interventions and treatments and monitors for side effects of medication administration.
  • Recognizes and responds to changes in patient status timely and appropriately. Intervenes when situations call for immediate action.
  • Performs efficiently in emergency situations.
  • Provides patient/family education based on identified learning needs utilizing available teaching resources.
  • Counsels patients and care givers concerning patient care and treatment plans.
  • Communicates identified needs and patient responses to members of the interdisciplinary team.
  • Implements the integrated plan of care and coordinates patient care activities with members of the health care team.
  • Provides discharge teaching including aftercare instructions, medication administration, follow-up appointments, and appropriate contact information.
  • Recognizes safety hazards in the patient care environment and initiates timely and appropriate intervention.
  • Uses patient care equipment and devices safely; recognizes when equipment and devices are not functioning correctly and takes timely and appropriate action (e.g. removing malfunctioning equipment from patient care area).

Evaluation/Monitoring: 

  • Observes, evaluates, and communicates the effects of treatments and interventions.
  • Documents patient's response to treatment or nursing care.
  • Reassesses and revises plan of care in collaboration with other members of the health care team.
  • Coordinates delivery of patient care with other services and disciplines to achieve optimal patient outcomes.
  • Communicates with patients and care givers regarding changes in patient care and treatment plans.

Requirements

MINIMUM REQUIREMENTS:
A license to practice as a Registered Nurse issued by the California Board of Registered Nursing.*

REGISTERED NURSE I ID-7797

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