Registered nurses (RNs) are the most highly trained in the field of nursing. They are responsible for the documentation of all aspects of a patient’s healthcare. It is up to the RN to make sure each patient is being cared for according to their respective treatment plan.
5 Clinical Practice Guidelines for RNs
Assessing the Health Status of Individuals in Their Care
A primary responsibility of an RN is to monitor the care and condition of the patients who are under their immediate care. They notify physicians of any changes in a patient’s condition and monitor a patient’s progress during the implementation of their treatment plan. In a hospital or facility setting, a registered nurse is available at all times to monitor a patient’s condition. If circumstances warrant, they must call in an attending physician or another healthcare professional to assist if a patient’s status becomes critical. It is their responsibility to maintain a close watch over all patients under their immediate care and to note any and all changes that occur during their shift.
Recording Data and Medical Information Pertinent to the Care of the Patient
Registered nurses (RNs) are required to document any changes in a patient’s status, when medications are dispensed and any other information required as part of their treatment plan. They must document everything down to the smallest detail so that the attending physician can read the chart and know exactly what is happening with the patient even if they have never seen the patient before. Reactions to medications must be noted, as well as improvements in the patient’s condition. Fluid outputs must be monitored as well as what the patient eats and their fluid intake.
Administering Medications and Evaluating Their Effectiveness
Registered nurses (RNs) are required to administer medications according to a patient’s treatment plan. They must document the time and dosage of each medication as it is given and note any side effects or adverse reactions a patient experiences. They are responsible for keeping a running inventory of all medications kept at their station during their shift. They must also account for all narcotics that are kept at their station.
Providing a Safe Environment for Staff and Their Patients
RNs are responsible for monitoring the safety of their unit. The safety of their staff and the patients they care for is of utmost importance. Containing infectious disease or making sure spills are cleaned up promptly both fall under the watchful eye of the RN who must make sure the staff and patients are protected from any variety of hazards that may occur in the facility. Patients who have a disorder, in which they have violent outbursts, must be monitored, and staff must know how to properly restrain the patient, so they cannot harm themselves or others.
Educating Patients on Their Treatment and Care Before, During and After Procedures
A registered nurse is responsible for making sure both patients and their caregivers understand an individual’s medications and treatment plan. They also educate patients on how best to avoid reinjuring a wound or preventing a condition from worsening. When a patient is released from the hospital, their caregivers must receive instructions on how to properly care for any bandages or administer any medications the patient may need. The patient must also receive instruction on how to prevent infection and how long their recovery might take.
A registered nurse has many responsibilities that fall within the clinical practice guidelines. It is their duty as the mediator between the patient and the physician to act as an advocate for the patient while enforcing the patient’s treatment plan as prescribed by the doctor. For all of their duties, they must constantly show compassion and care while maintaining a high level of professionalism.