1.
Assesses the patient’s physiologic health status
·
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 patient 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 Decubitus 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;
·
Demonstrates
preparation of I.V. drips;
·
Administers and
documents medication correctly;
·
Administers IVP medication as per
department policy and procedure;
·
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.
*ADA Essential Functions
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