Responsibilities:
1. Assesses the patients physiologic health status
- 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.
2. Assesses patients 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 patients 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 patients conditions during treatments/procedures.Reports and records same as appropriate;
- Keeps accurate documentation of patients treatment, activity and condition, as well as patients 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 patients 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 patients 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 patients 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 patients 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.
Qualifications:
? Graduate from an accredited School of Nursing. Associates Degree in Nursing, required. Bachelors Degree in Nursing, preferred.
? Minimum 1-2 years of professional nursing experience in the related specialty.
? Current license to practice as a Registered Professional Nurse in New York State, required.
? BLS/ACLS/PALS/TNCC required, plus specialized certifications as needed.
