1) Registered Nurse in Nilai Medical Centre is a team member of the organization who is responsible for executing all aspects of care to patients as defined in the SOP for each unit and shall be held accountable for the patient outcomes under her / his care.
DUTIES AND RESPONSIBILITIES
1. Registered Nurse uses the Nursing Process to formulate and maintain individualized nursing care plans by :
1.1 Assessing Patient
1.1.1 Collects and contributes to a database (physiological, emotional, sociological, cultural, psychological and spiritual needs) from available resources (eg. Patient, family, doctors’ notes and others).
1.1.2 Identifies and documents change in health status which interferes with patient’s Activities of Daily Living (e.g. oxygen, nutrition, elimination, activity, safety, rest, sleep and psychological well-being).
1.2 Identifying Patient Problems
1.2.1 Establishes nursing goals and patient expected outcomes based on the list of problems with patient, family and significant others.
1.2.2 Confirms Nursing Diagnosis and develops individualized nursing care plans based upon the problem list and plan intervention that follows established nursing protocols.
1.3 Implementing the Nursing Interventions
1.3.1 Carries out individualized plans of care according to priority of needs and established nursing protocols.
1.3.2 Participates in the prescribed medical regime by preparing, assisting and providing follow-up care to patients undergoing diagnostic and / or therapeutic procedures.
1.3.3 Uses nursing knowledge, skills and protocols to assure an environment conducive to optimum restoration and maintenance of patient’s normal Activities of Daily Living (ADL).
1.3.4 Maintains and promotes all aspects of hygiene.
1.3.5 Maintains and promotes physical safety (e.g. implementation surgical aseptic techniques, administers prescribed medication safely etc.).
1.3.6 Maintains and promotes psychological safety through consideration of each individual’s worth and dignity and apply nursing measures in reducing common developmental and situational stress.
1.3.7 Measures basic physiological functions and report significant findings (e.g. vital signs, fluid intake and output, etc.).
1.4 Evaluating Planned Care
1.4.1 Uses nursing process components for evaluating and re-evaluating of individualized nursing care.
1.4.2 Participates with patients, families, significant other and members of nursing team in the evaluation of established patient’s goals. Identifies alternatives methods of meeting patient’s needs, modifies plan of care as necessary and document changes.
2. Registered Nurse is responsible for patient education, he / she shall:-
2.1 Assesses situations for need of information or support to maintain health.
2.2 Develops short-range teaching plans based upon long and short-range goals for individual patient.
2.3 Implements teaching plans that are specific to the patient’s level of development and knowledge.
2.4 Supports and reinforce the teaching plans of the other health professionals.
2.5 Evaluates the effectiveness of patient’s learning.
3. Maintains profession’s ethical and legal framework; be responsible for her / his nursing practice.
4. Assumes responsibility for self development and use resources for continued learning such as attending CNE Programme.
5. Consults with the Team Leader in the absence of Nurse Manager when patient’s problems are not within the scope of practice.
6. Ensures accurate nursing documentation and safe keeping / recording of DDA drugs.
7. Complies hospital’s Policies and Procedures including the general safety regulations for patient and staff.
8. Checks medical supplies, ward equipments ensuring availability and machinery are in good condition.
9. Establishes and maintain effective communication with patient’s, families, significant others and health team members.
10. Performs other duties as assigned by the superiors.