ASSESSMENT:
Interviews patient, family, significant others to formulate a nursing history.
Observes, identifies and collects data to identify nursing care needs of the patient and family.
Correlates the medical plan of care with the nursing plan of care.
Identifies and reports to the appropriate person(s) abnormal diagnostic data and clinical changes in the patient's condition.
Utilizes standard of care to anticipate potential patient care programs.
PLANNING:
Develops and/or updates individualized nursing care plan on each patient.
Documents patient problems and nursing care needs of the patient and family/significant others.
Actively involves patient and family/significant others in planning patient's care.
Develops short- and long-term goals for the patient and family/significant others. Identifies the need to involve other disciplines in the patient's care.
Initiates discharge planning upon admission.
IMPLEMENTATION:
Performs common nursing procedures as defined in Policy and Procedure Manual.
Implements changes in physicians' orders in a timely manner.
Explains treatments and procedures to patient and family/significant others.
Provides patient and family teaching.
Provides for the safety, cleanliness and comfort of the patient.
Initiates emergency procedures as needed within the scope of practice and hospital policy.
Sets priorities and provides nursing care based on the patients needs.
EVALUATION:
Evaluates the patient's response to nursing care.
Updates and revises care to be delivered as patients' needs change.
Appropriately communicates changes and care given to other members of the health care team.
Recognizes alternations in physiological, psychological and psychosocial status.
PROFESSIONAL GROWTH AND RESPONSIBILITY:
Assumes leadership role and delegates nursing care.
Assigns tasks appropriately and guides team members based on their skills and abilities.
Maintains awareness of legal aspects of hospital nursing.
Conducts patient care conferences.
Updates skills and knowledge and attends peers' patient care conferences.
Assists in orientation and/or acts as a preceptor for new personnel.
Sets goals and objectives with target dates.
Participates in patient care Quality Assurance programs.
UNIT SPECIFIC:
Manages patients as a team leader or primary care giver.
Demonstrates ability to assess patients' signs and symptoms with impending CVA, Pulmonary Edema, MI, CHF, PE, respiratory distress.
Assesses neurological status (including cognitive levels) in post head injured patients.
Maintains all intravenous lines and fluids (i.e., CVP, Hickman catheters, mini infusers hyperalimentation, dialysis catheter, etc.).
Clearly documents effectiveness of nursing care (i.e., pain management and response to treatments such as wound care).
Demonstrates basic computer entry skills.
Demonstrates knowledge and skills in application of various types of monitor leads.
Demonstrates knowledge and skills in recognizing and acting accordingly to life threatening arrhythmia's.
Demonstrates the philosophy of team concept.
Participates in group projects and staff meetings with suggestions that enhance the work environment and increase productivity.
Consistently contributes to team effort (e.g. assists co-workers when need is observed or upon request).
