Job Abstract

Performs an age specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.

• Conducts patient interview, explains policies and procedures to patient/significant others, reviews patients 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 patients physiologic health status and plan of care.

• 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.

• Develops criteria for measurement of patient outcomes;
• Identifies actual/potential patient problems;
• Identifies patients need for teaching based on psychosocial and developmental assessment;
• Develops patient outcome statement (s) and establishes individualized patient goals.

• 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.