The Registered Nurse, RN provides professional nursing care and services to patients in a variety of settings.

Essential Job Functions

Assessment:

• Evaluation of the nature and extent of nursing issues presented by a patient for the purpose of patient care planning.
• Assessment includes identifying less obvious or common relationships in collected data and taking appropriate steps to mitigate their impact on the provision and quality of nursing services.
• In addition, at this level, assessment involves predicting diverse patient need for care, potential need for care, and the validation of data collected by others.
• At this level assessment involves recognizing subtle trends before explicit diagnostic signs are evident. Collects and analyzes data from multiple sources.
• Assesses, evaluates and documents the patients' physical, medical and psychosocial circumstances; identifies economic or cultural barriers and determines their influence on the provision of care; refers patients based on patients' needs and risk factors involved.
• Synthesizes all available patient information including observations by other health care team members and the patient's significant others and predicts variances from the expected trajectory.
• Initiates additional assessment and/or reassessment of patients as necessary when a patient is currently or potentially at physiologic, psychological, and psychosocial risk.
• Identifies and utilizes resources to facilitate the appropriate assessment of diverse populations, patients, and families.
• Develops collaborative partnerships with patient and family to obtain complete health history, including present illness, current health status, and past medical, psychosocial, spiritual and family histories; integrates patients' values and beliefs when providing care.
• Creates, validates, and/or improves tools to ensure assessment data is collected and documented.
• Utilizes collected data and experience to assess risk for instability and rapidly identify deviations from baseline.

Planning:

• Developing a plan of care based on the assessment process.
• The purpose is to collaborate with all involved in the care of the patient (interdisciplinary team, patient, and their significant others).
• At this level, incumbents develop a comprehensive plan of care and prescribe nursing interventions that move the patient closest to desired outcomes.
• Interventions are individualized and address both short- and long-term needs.
• Uses complex problem solving skills and experience to identify a broad range of options in the development of a plan of care with realistic outcomes which are congruent with interdisciplinary goals.
• As patient responds to interventions, expeditiously modifies and communicates the plan of care in collaboration with the interdisciplinary team including clinical pathways as appropriate; for patients on clinical pathways, identifies when a change in patient condition requires discontinuation of the pathway and communicates to the provider the need to change the plan of care.
• Evaluates and integrates the presence of high-risk factors, at-risk behaviors, and other concerns into the plan of care.
• Initiates and leads patient care conferences with interdisciplinary team.
• Integrates and anticipates interdisciplinary discharge planning needs into plan of care.
• Identifies appropriate tools and/or teaching methods for patient/family education.

Implementation:

• Interventions that a nurse performs for a patient, including treatments, procedures, medication administration, education, referrals, and discharge planning.
• At this level, incumbents lead others during situations which require immediate, independent interventions and for those which call for planned interventions.
• Also at this level, incumbents demonstrate adaptability and respond quickly and decisively to very complex situations.
• Provides individualized, specialized nursing care to patients and administers medications and treatments to patients as prescribed.