Under the general supervision of the Nurse Manager or Nurse Supervisor, provides assessment and implementation of direct nursing care to residents/patients.
Assessment, treatment and patient care responsibilities are delivered with a knowledge of patient growth and development and are appropriate to the ages of the patients served.
Identifies and documents initial observation and assessment of the patient's/resident's needs for immediate nursing action within twenty-four hours of admission.
Systematically and accurately assesses nursing needs of the patient in order to detect pertinent changes in the clinical picture.
Identifies appropriate foci.
Develops, plans, evaluates, and documents care based on this assessment.
Assesses, intervenes, and documents appropriately to meet patient's educational, psychosocial, and discharge planning needs with other disciplines.
Initiates appropriate referrals to other departments, services, and/or outside agencies for patient care.
Gives comprehensive patient/resident care.
Initiates and follows through with patient and family teaching.
Consults with unit nursing leadership regarding significant changes in patient's condition.
Collaborates with all members of the health care team to complete MDS/care planning in compliance with regulatory agency requirement.
Communicates relevant patient care information on shift to shift report.
Utilizes patient care standards in clinical practice.
Documents pertinent information regarding patient's response to treatment, progression toward goals in patient's chart. Revises Plan of Care as indicated.
Completes Admission/Transfer Summary Sheet and/or Discharge Summary.
Transcribes physician's orders in patient chart accurately and timely.
Seeks clarification of physician's orders that are unclear or inappropriate.
Interprets clinical data, notifies the physician promptly if immediate changes in management are indicated.
Administers intravenous medications in compliance with policies and procedures.
Titrates medicated infusions as per physician's prescriptives, protocols, standards.
Completes checks to ensure that emergency equipment is on hand and in good working order.
Recognizes reports malfunction/failure of equipment used in the area to Biomedical Engineering takes appropriate action to repair/replace such equipment (e.g., ventilators, cardiac monitors, defibrillators, suction apparatus, pumps, Doppler, oxygen tank, NIPP, & pacemaker).
Checks that all monitoring equipment, ventilator alarms are set according to standards.
Participates in patient care rounds by presenting findings on patients.
Applies principles of infection control and safety.
Assists in the orientation of new personnel.
Provides clinical supervision of LPNs, CNAs, and other ancillary staff.
Orients patient's family to new environment; develops rapport with patient's family.
Relieves the Nurse Manager as required.
Assists in data collection and analysis of Quality Assurance/CQI monitors; participates in implementation of follow up action.
Accurately and effectively utilizes the hospital computer system as it pertains to job responsibilities and in accordance with hospital policy.
Participates actively on quality improvement committees as assigned.
Assists other personnel as needed.
Keeps up-to-date with current trends pertinent to area of assignment.
Participates in continuing education activities; attends scheduled inservice programs; shares information gained at conferences with colleagues.
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