Delivers and ensures patient care by assessing and diagnosing patient's condition, developing plan of care and evaluating patient's response to care. Participates in patient education and discharge planning. Collaborates with, coordinates and guides designated care team members in planning patient care and achieving goals.
1. Develops and evaluates plan of care.
- Systematically and continuously assesses patient's knowledge base and physical, psychosocial and spiritual health through interviews, physical examinations and data collection.
- Consults with multidisciplinary health care team in regard to nursing assessment findings.
- Creates written, individualized plan of care based on priority of patient problems, anticipated length of stay, input from patient and family and other members of the health care team.
- Communicates pertinent information and changes in patient status to appropriate members of care team and other health care providers, as necessary.
- Collaborates with team members to make changes in plan of care, as necessary.
2. Provides and/or delegates patient care according to the plan of care and established protocols.
- Utilizes clinical resources in implementing patient care and provides rationale for patient care decisions.
- Conducts clinical rounds, provides emergency care and administers medications to patient.
- Operates equipment required for patient care according to manufacturer's recommendations.
- Performs and assists with procedures and treatments on unit including but not limited to changing dressings, feeding patients and providing pre/post operative care.
- Practices and monitors infection control standards.
- Promotes and provides patient safety in accordance with state and federal guidelines.
3. Documents patient care, as required on all appropriate forms.
- Enters date and time of entry and signs name in legible manner on patient's chart.
- Completes Nursing Admission Assessment 24 hours after admission.
- Documents patient's response to interventions and plan of care on the Progress Notes.
- Performs vital signs and pain score at least every four hours.
- Completes Transfer Assessments on patients transferred out of the unit and Perioperative Assessments on patients scheduled for surgery or procedures.
- Completes Frequent Observations and the Intake/Outtake Record according to established protocols.
- Initiates and completes health care referrals in collaboration with the interdisciplinary team.
4. Provides patient education.
- Identifies patients learning needs upon admission. Informs and educates patient and family to enable participation in their care and decision making.
- Develops and implements a teaching plan of care. Conducts patient teaching conferences. Documents patient teaching.
5. Participates in Quality Improvement process.
- Participates in developing and implementing of unit goals and objectives.
- Attends in-service programs on new products and equipment used on unit.
- Completes occurrence reports according to policy and unit-based audits, as assigned.
- Participates in identifying problems requiring investigation and in developing and implementing corrective action plans for the unit.
6. Participates in unit staff meetings and unit based clinical conferences, as scheduled. Represents the clinical unit on committees, as assigned. Submits annual record of continuing educations and self-assessment of clinical performance.
7. Performs the responsibilities of charge nurse and preceptor according to established protocols, as assigned.
8. Performs related duties, as required.