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Form of workJob Overview: Under the direction of supervisor and physician orders, performs nursing care duties to provide the best possible nursing care for each resident, which meets the guidelines set forth by the Department of Health and the Montana Mental Health Nursing Care Center.
Major Duties or Responsibilities:
- Perform Nursing Assessments 60%
- Completes routine (weekly/monthly) nursing assessments (admission care plan, skin, bowel, AIMS, behavior, ADL) on residents to determine health status deficits by utilizing standard nursing assessment forms and experienced judgment.
- Examines/assesses residents in emergencies to determine the extent of injuries by using experienced nursing judgement and completing incident/accident forms.
- Performs emergency/first aid treatment to injured residents to stabilize the resident and prevent further injury by exercising experienced nursing judgment and following current standard of care procedure and universal precautions.
- Performs routine treatments to residents to improve healing and prevent deterioration to the resident by administering entereal tube feedings, changing dressings, applying ointments, using experienced judgment, following current standard of care procedures and universal precautions.
- Draws blood from residents as ordered by a physician to provide a specimen for laboratory evaluation by using syringes, vials, turnicates and following universal precautions, if certified.
- Performs minor laboratory tests (urine, stool, specific gravity, glucose) to ascertain the resident's health status by using nursing judgment and following facility policy.
- Administers oxygen and breathing treatments to improve oxygen concentration in the blood, improve breathing by use of breathing apparatus following nursing procedures and facility policy.
- Admnisters heat treatments to reduce resident pain by assessing the need and following facility policy and procedure utilizing experienced judgement.
- Removes sutures/staples in postoperative residents to promote healing by utilizing experienced judgment and nursing training.
- Administers medicaions to residents as ordered by the physician to maintain the health status of the resident by following nursing protocols and facility policy.
- Monitors medication effects to detect both negative and positive responses by assessing the resident after medication administration and recording the effects in the medical record.
- Identifies possible drug allergies and interactions to prevent harmful effects to the resident by withholding medications when appropriate and reporting harmful effects to the physician.
- Procures medications when ordered by the physician outside of normal pharmacy hours to reduce sypmtoms and treat acute conditions by following facility policy.
- Implements standing physician orders to provide treatment to the resident at the discretion and judgment of the nurse.
- Maintains an accurate count of controlled medications to ensure proper usage by couting narcotics from shift to shift and signing for use following facility policy and procedure.
- Administers IV therapy to treat medical conditions by interpreting orders, using IV equipment inserting IV catheters, hanging solutions, and monitoring results (administering IV therapy must be within LPN guidelines and current certifications).
- Coordinates Care 20%
- Oversees care provided by resident care aides during shift to ensure residents receive the care as directed by the care plan by observing care provided to the resident, assisting with care as a teaching tool, and reporting significant care deficiencies to the nurse supervisor.
- Directs resident care aides to provide care to residents routinely and in emergent instances to ensure quality care is provided to the resident by communicating orally and in writing changes in care plan or physician orders.
- Obtains and records resident vital signs to maintain an accurate record to assess trends and determine health condition by use of themometers, scales, blood pressure devices, standard forms and using nursing training and experience.
- Notes subjective resident complaints and objective observations of the resident's condition to provide documentation of potential problem areas by writing accurate summaries in the medical record using nursing judgment and training.
- Provides a complete shift-to-shift report covering all significant nursing problems and interventions to maintain continuity of care by providing an oral report at shift exchange.
- Transcribes physician verbal, written, and phone orders in initiate medical interventions by following nursing practices, utilizing standard forms, and facility policy.
- Provides verbal and written resident information to Minimum Data Set nurses to complete mandatory federal resident assessments by answering questions and directing the MDS nurse to appropriate documentation.
- Maintains confidentiality of medical information to meet Federal and State standards by understanding Federal HIPAA guidelines and following facility policies.
- Provides Nursing Support to Physicians 10%
- Notifies physicans of potential medical problems to solicit physician orders and/or transport residents to a higher level of care by assessing residents and reporting information to the physician in a concise professional manner and be prepared to answer phsycian questions concerning medical problems.
- Communicates to rounding nurse and/or charge nurse any medical or psychiatric concerns, to be brought to phsycian rounding by rounding nurse.
- Other Duties 10%
- Assists resident, family and friends concerning the death and dying process to provide information that may make the transition better and more dignified for those concerned by answering questions and providing information about the process.
- Prepares deceased residents for the mortician to ensure the dignity of the deceased resident and to ensure appropriate infection control by following nursing protocols, facility policy, and universal precautions.
- Reports policy/procedure infractions of personnel immediately to preserve quality care for residents and a safe work environment for staff by following the chain of command.
- Maintains familiarity with Policy and Procedure Manual, the Safety Manual and Infection Control Manual, Nursing policies, and physician standing orders in order to provide quality care and a safe environment for the residents and staff by reviewing policies and standing orders.
Physical and Environmental Demands: Work requires frequent standing and walking with some bending. Critical physical demands: lift 50 pounds rarely; lift 15-20 pounds frequently; reach forward and below frequently; push/pull 60 pounts occasionally; push/pull 10-20 pounds occasionally. Must have the ability to transfer residents safely and effectively. Must have adequate sight, hearing, and speech to communicate with residents. Near visual acuity to read gauges, thermometers, etc. Exposure to blood and body fluids in Classification I, II, and III and unpleasant odors. Daily interaction with sometimes volatile and angry residents. HBV vaccination available.
Knowledge, Skills and Abilities (Behaviors):
Required for the first day of work:
- Knowledge of nursing, medications, and treatment planning.
- Knowledge of LPN's scope of practice and Administrative Rules of Montana
- Knowledge of patient's rights regarding medical treatment.
- Knowledge of current psychopharmacology.
- Skill in the use of the basic instruments and equipment of the nursing profession.
- Ability to plan and implement appropriate nursing care interventions.
- Ability to perform accurate and thorough work.
- Ability to provide patient assessment and appropriate documentation.
- Ability to communicate effectively, verbally and in writing.
- Ability to analyze, assemble, and organize information.
- Ability to proficiently utilize technology related to patient care information systems
Minimum Qualifications (Education and Experience):
- Must be a graduate of an accredited school of practical nursing.
- Must be currently licensed as a Practical Nurse inthe State of Montana.
- Must be BLS certified
