· Conducts patient interview, explains policies and procedures to patient/significant others, reviews patient’s chart and answers questions correctly and courteously;
· Assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status;
· Determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate;
· Assesses level of pain and pain management;
· Communicates/documents patient’s physiologic health status and plan of care.
2. Assesses patient’s psychosocial health status
· Elicits perception of medical/nursing care and the expectation of care;
· Determines coping mechanism, knowledge level, and ability to comprehend;
· Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction;
· Communicates and documents psychological status and care plan; support group, counseling services, social services.
3. Identifies patient outcome
· Develops criteria for measurement of patient outcomes;
· Identifies actual/potential patient problems;
· Identifies patient’s need for teaching based on psychosocial and developmental assessment;
· Develops patient outcome statement (s) and establishes individualized patent goals.
4. Formulates the plan of care and establishes the priorities necessary to achieve expected outcome
· Identifies care activities and establishes the priorities necessary to achieve expected outcome;
· Coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome;
· Documents the plan of care and collaborates with physicians and other health team members.
5. Implements the plan of care
· Maintains constant vigilance over patients care to ensure that safety precautions/needs are followed. (Side rails up, call lights and bedside stand within reach, etc.);
· Exercises professional skills related to the plan of care;
· Reassesses patients as needed and appropriately revises plan of care;
· Correctly administers prescribed treatments;
· Correctly uses equipment necessary for patient care;
· Provides emotional support to patient and significant other;
· Applies scientific principles in performing procedures; carries them out safely, timely and efficiently;
· Makes accurate observations of patient’s conditions during treatments/procedures. Reports and records same as appropriate;
· Keeps accurate documentation of patient’s treatment, activity and condition, as well as patient’s responses to medical and nursing interventions;
· Uses appropriate methods of documentation according to departmental policy;
· Acts rapidly and effectively during any emergency situation, managing self, patients and other employees;
· Provides a calm, quiet, restful atmosphere. Communicates effectively with the patient’s family or caretakers;
· Participates in planning for discharge and coordinates referrals, as appropriate;
· Provides discharge instructions to patient and significant other.
6. Evaluates care provided for patient outcome
· Demonstrates ability to measure effectiveness of care provided and documents same;
· Performs variance analysis related to outcome data for performance improvement;
· Designs, implements, and evaluates systems to improve care in Unit;
· Keeps accurate documentation of patient’s treatment, activity and condition;
· Uses appropriate methods of documentation according to departmental policy.
7. Collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team
· Collaborates with the appropriate physician on patient’s plan of care;
· Accurately interprets and implements treatment regimen as prescribed by the Physician;
· Assists the Physician during treatments and/or diagnostic procedures;
· Keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient’s condition and/or treatments, as appropriate;
· Uses clinical judgment in delegating assignments to the Patient Care Associate, Support Care Associate and Clerical Service Associate in providing patient care, and ensures that assignments are completed in a timely fashion.
8. Performs grade I-IV Decubritus Care
· Performs preventive skin care measures
· Applies simple dressings, maintaining principles of aseptic technique;
· Applies warm & cold compresses, consistent with facility procedure;
· Performs irrigations, consistent with Facility procedure;
· Performs other procedures related to skin care, as necessary.
9. Administers medications correctly and safely
· Correctly identifies medication: action; dosage; side effects and implications for the patient;
· Meets standard on medication administration examination;
· Demonstrates preparation of local solutions;
· Administers and documents medication correctly;
· Educates patients and significant others related to drug and food interactions.
10. Participates in patient and family education
· Provides the patient with an explanation of his/her condition as indicated;
· Communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies;
· Recognizes and utilizes health teaching opportunities and resources /materials available for this teaching;
· Provides for early discharge planning and appropriate referrals for post-hospital care;
· Evaluates the effectiveness of teaching by feedback from patient/family and documents same.
11. Performs related duties, as required.